Rock Creek of Ottawa

In the surveyor’s words

From the most serious findings on record at Rock Creek of Ottawa, in the surveyor’s own words.

• Actual harm, isolatedF689Jan 27, 2026

  The facility documented a census of 69 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure an environment free from accident hazards for Resident (R) 1, who required staff assistance and a mechanical lift for safe transfers. As a result, R1 sustained a humerus (upper arm bone) fracture of her left arm. Findings included:- The Electronic Medical Record (EMR) for R1 documented diagnoses of morbid (severe) obesity (BMI-Body Mass Index of 40 or greater, or a BMI of 35 or greater with one or more serious health conditions), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and… […]

• No harm, potential for more than minimal, widespreadF812Jan 30, 2025

  The facility identified a census of 72 residents. The facility had one main kitchen and one dining room. Based on observation, record review, and interview, the facility failed to ensure food was properly stored. The facility failed to ensure that the freezer was in proper working condition. The facility failed to ensure freezer temperatures remained at the required temperatures. The facility failed to ensure food temperatures were logged to ensure appropriate temperatures were reached before serving. Findings included: - Upon entry to the kitchen on 01/28/245 at 07:20 AM, it was observed and noted: In the server refrigerator, a half-gallon container of cottage cheese was over half empty and lacked an open date on the outside of the container. […]

• No harm, potential for more than minimal, widespreadF812Mar 29, 2023

  The facility reported a census of 72 residents. Based on observation, interview and record review, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility, as exhibited by the failure to store and label food in the refrigerator, maintain a clean refrigerator for the resident's foods and failure to utilize pasteurized eggs (a process which kills harmful bacteria) for resident's who request soft-cooked eggs for breakfast. Findings included: - During an environmental tour on 03/28/23 at 07:36 AM, the following areas of concern were noted: 1. Dietary Staff BB failed to utilize pasteurized eggs when she cooked and served six to eight soft-cooked eggs to residents. 2. […]

• No harm, potential for more than minimal, widespreadF727Aug 9, 2021

  The facility reported a census of 61 residents. Based on interview and record review the facility failed to use the services of a registered nurse for eight consecutive hours a day, on four days in a three-month period between 05/01/21 to 07/31/21. Findings Included: - Review of the facility schedules, from 05/01/21 to 08/09/21, daily staff postings, and hours worked summaries revealed the following: 1. A facility staffing schedule titled When to Work.Com dated 05/08/21, which scheduled a registered nurse on the 02:00PM to 10:00 PM shift. A facility staff posting sheet titled Nurse Staff information dated 05/08/21 documented one registered nurse for the 02:00PM to 10:00 PM shift. A Labor Hours Summary Report dated 05/08/21 documented 4.88 registered nurse hours. 2. […]

• No harm, potential for more than minimal, patternF761Jan 30, 2025

  The facility identified a census of 72 residents. The sample included 19 residents, four medication carts, and two medication rooms. Based on observation, record review, and interviews, the facility failed to properly store medications in two of the four medication carts. The facility also failed to label medication in one of the two medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - During the initial tour on 01/28/25 at 07:10 AM, a medication cart on the [NAME] hallway was unlocked and unattended in the hallway. On 01/28/25 at 07:19 AM, the second medication cart on the [NAME] hallway was unlocked and unattended. […]