Rock Creek Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Rock Creek Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF760Apr 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 11 residents (Resident #1) reviewed for medication errors. The facility failed to ensure Resident #1's hospital discharge orders were implemented to include enoxaparin (a medication commonly known as Lovenox, an anticoagulant medication used to prevent and treat DVT (deep vein thrombosis, a serious condition where a blood clot forms in a deep vein, usually in the legs, causing pain, swelling and redness) and pulmonary embolism (a life-threatening condition that occurs when a blood clot blocks an artery of the lung) after surgery or in patients with limited mobility), cefuroxime (an antibiotic medication commonly known as Ceftin used to treat… […]

• Immediate jeopardy, isolatedF689Dec 13, 2024

  Based on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure CNA A properly transferred Resident #1 via mechanical lift (a device designed to help caregivers transfer patients) on 12/11/224 resulting in Resident #1 having a significant laceration to her scalp with exposure to underlying skull. The noncompliance was identified as PNC. The IJ began on 12/11/24 and ended on 12/11/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death. Findings include: 1. […]

• Immediate jeopardy, isolatedF692Apr 1, 2022

  Based on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to Resident, consistent with the resident's comprehensive assessment for 1 of 15 Residents (Resident #108) reviewed for weight loss. The facility did not follow dietary recommendations or implement physicians' orders to prevent Resident #108 from having significant weight loss. […]

• Immediate jeopardy, isolatedF580Apr 16, 2021

  Based on interview and record review, the facility failed to consult with the physician regarding a change in condition for 1 of 5 residents reviewed for change of condition. (Resident #2) The facility failed to notify the physician, of Resident #2's multiple blood sugar readings of less than 70 mg/dl. An Immediate Jeopardy (IJ) was identified at 9:00 a.m. on 4/16/21. While the IJ was removed on 4/16/21, the facility remained out of compliance a severity level of actual harm that is not Immediate Jeopardy and a scope of isolated due to the facility's ongoing evaluation of the effectiveness of the corrective systems. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 9:00 a.m. on 4/16/21. […]

• Immediate jeopardy, isolatedF600Apr 16, 2021

  Based on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 2 of 7 (Residents #1 and #6) residents reviewed for abuse. The facility failed to protect Resident #1 and Resident #6 from being threatened and verbally abused by LVN H, a night shift staff. Resident #1 reported multiple times to the Social Worker and Administrator that LVN H was threatening and verbally abuse, but the facility failed to take any actions to protect the resident. Resident #1 became fearful, lost sleep, and was sleeping with a cane for protection. An Immediate Jeopardy (IJ) situation was identified on 4/16/21. […]