Rock Creek Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Jun 7, 2021

  Based on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development and worsening of pressure injuries for one (#3) of three residents reviewed for pressure injuries out of five sample residents. Record review and interviews revealed the facility had multiple systemic failures in its management of pressure injuries. These included the failure to timely assess and monitor for pressure injuries, prevent the development and worsening of Resident #3's avoidable pressure injuries, and effectively educate the clinical staff on the use and monitoring of contracture devices. […]

• Actual harm, isolatedF600May 20, 2026

  Based on observations, record review, and interviews the facility failed to ensure two (#25 and #35) of eight out of 24 sample residents were kept free from abuse.Specifically, the facility failed to: -Protect Resident #25 from verbal abuse from Resident #3 on 12/15/25 and 12/21/25, which caused psychosocial distress for Resident #25; and,-Protect Resident #35 from verbal abuse from Resident #3 on 12/23/25 and 12/31/25, which caused Resident #35 to become tearful after both incidents. […]

• Actual harm, isolatedF689Dec 11, 2025

  Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accident hazards received adequate supervision out of four sample residents.Resident #1, who was dependent on facility staff for wheelchair mobility, sustained a fall from her wheelchair on [DATE], which resulted in a cervical spine fracture.During the facility's investigation of the fall, it was discovered that staff failed to attach the foot pedals to Resident #1's wheelchair. As a result, Resident #1 was unable to rest her feet on the foot pedals while being transported. […]

• Actual harm, isolatedF689Feb 8, 2024

  Based on observations, interviews and record review, the facility failed to ensure the environment was free of accidents and hazards for two (#16 and #4) of four residents reviewed for falls out of 17 sample residents. Resident #16, who was at high risk for falls, sustained 17 falls from 9/4/23 to 1/31/24. The facility failed to ensure fall interventions were implemented after each fall and implement effective interventions when they were added. The resident, who required maximum assistance with toileting according to her care plan, often fell trying to go to the bathroom. […]

• No harm, potential for more than minimal, widespreadF812May 20, 2026

  Based on observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to:-Maintain the kitchen in a sanitary condition;-Maintain the ice machine in a sanitary condition; and,-Ensure food items were properly covered, labeled, dated and discarded within appropriate use-by timeframes.Findings include:I. Failure to maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 5/27/26, read in pertinent part, The physical facilities shall be cleaned as often as necessary to keep them clean. (6-501.12) Equipment food-contact surfaces and utensils shall be clean to sight and touch. […]