Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

ROCK CREEK OF OTTAWA

OTTAWA, KS · 75 certified beds · Last Life Safety survey January 30, 2025

CMS Certification Number 175332 · first certified January 1995

Ownership

Operated by THE ENSIGN GROUP · For profit - Corporation

  • Ownership changed November 1, 2018 (change of ownership)from OTTAWA RETIREMENT VILLAGE, INC.
20
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
4
Tags cited more than once
Across separate surveys
9
Inspection & testing records
Of the citations on file

Position within KS

20 citations — more than 23% of the 296 certified nursing homes in KS. Compared within KS rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: September 2026 to December 2026. This facility’s last Life Safety survey was January 2025. Facilities in KS are typically surveyed 20–22 months after the last one (median 21), measured over 298 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in KS, and nationally. Surveyors differ markedly between states, so the KS figure is the meaningful one.

This facility20KS median27National median11
Citations on file over three years, compared
MeasureCitations
This facility20
Median facility in KS27
Median facility nationally11

Survey history

Citations at each Life Safety survey
92021-0862023-0352025-01
Citations at each Life Safety survey
Survey dateCitations
August 9, 20219
March 29, 20236
January 30, 20255

Most-cited tags

Most-cited tags at this facility
K-09203K-03722K-03532K-03452K-07531K-03471K-07121K-02221
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0920Ensure proper usage of power strips and extension cords.32025-01-30
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22023-03-29
K-0353Inspect, test, and maintain automatic sprinkler systems.22023-03-29
K-0345Have approved installation, maintenance and testing program for fire alarm systems.22023-03-29
K-0753Have restrictions on the use of highly flammable decorations.12025-01-30
K-0347Properly provide smoke detection systems in areas open to corridors.12021-08-09
K-0712Have simulated fire drills held at unexpected times.12023-03-29
K-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.12021-08-09

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 9
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Miscellaneous Deficiencies 3
  • Egress Deficiencies 2
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies9
Gas, Vacuum, and Electrical Systems Deficiencies4
Miscellaneous Deficiencies3
Egress Deficiencies2
Services Deficiencies1
Construction Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 30, 2025 — 5 citations

Citations issued on January 30, 2025
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (March 25, 2025)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (March 25, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (March 25, 2025)
K-0753Have restrictions on the use of highly flammable decorations.Deficient, Provider has date of correction (March 25, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (March 25, 2025)

March 29, 2023 — 6 citations

Citations issued on March 29, 2023
TagWhat the surveyor checksStatus
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (May 12, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (May 12, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (May 12, 2023)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (May 12, 2023)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (May 12, 2023)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (May 12, 2023)

August 9, 2021 — 9 citations

Citations issued on August 9, 2021
TagWhat the surveyor checksStatus
K-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.Deficient, Provider has date of correction (October 21, 2021)
K-0293Have properly located and lighted "Exit" signs.Deficient, Provider has date of correction (October 21, 2021)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (October 21, 2021)
K-0347Properly provide smoke detection systems in areas open to corridors.Deficient, Provider has date of correction (October 21, 2021)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 21, 2021)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 21, 2021)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (October 21, 2021)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 21, 2021)
K-0930Ensure proper storage of liquid oxygen.Deficient, Provider has date of correction (October 21, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.