Cycle 1
Health 2025-01-30 · Fire 2025-01-30
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ottawa, KS
Rock Creek Of Ottawa
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1100 W 15th Street, Ottawa, KS
(785) 242-5399
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
75
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1995-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.67 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.69 · national 2.35
Total nurse hours
3.81
All reported nurse hours · state 4.07 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.43
Weekend nurse staffing · state 3.58 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,344
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9933
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.92
Baseline 25.30% · Performance 20.82% · Measure score 4.92 · Achievement 1.32 · Improvement 4.92
Healthcare-associated infections
5.89
Baseline 9.73% · Performance 6.71% · Measure score 5.89 · Achievement 3.77 · Improvement 5.89
Total nurse turnover
1.82
Baseline 58.75% · Performance 56.25% · Measure score 1.82 · Achievement 1.82 · Improvement 0.24
Adjusted total nurse staffing
3.52
Baseline 4.05 hours · Performance 4.08 hours · Measure score 3.52 · Achievement 3.52 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 218 · Observed rate 10.55% · Lower 95% interval 7.67% |
| Discharge to community | 61.65% |
50.57%
11.1 pts better
|
Better than the National Rate · Eligible stays 190 · Observed rate 57.89% · Lower 95% interval 54.96% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 88.81% |
95.27%
6.5 pts worse
|
Numerator 127 · Denominator 143 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 143 |
| Discharge self-care score | 64.6% |
53.69%
10.9 pts better
|
Numerator 73 · Denominator 113 |
| Discharge mobility score | 52.21% |
50.94%
1.3 pts better
|
Numerator 59 · Denominator 113 |
| Pressure ulcers or injuries, new or worsened | 4.2% |
2.29%
1.9 pts worse
|
Numerator 6 · Denominator 143 · Adjusted rate 5.27% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 122 · Observed rate 5.74% · Lower 95% interval 4.24% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 141 |
| Staff flu vaccination coverage | 14.44% |
42%
27.6 pts worse
|
Numerator 27 · Denominator 187 |
| Discharge function score | 65.49% |
56.45%
9 pts better
|
Numerator 74 · Denominator 113 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 57 · Denominator 57 |
| Transfer of health information to patient | 97.96% |
96.28%
1.7 pts better
|
Numerator 48 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 50.63% |
25.2%
25.4 pts better
|
Numerator 40 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.8%
6.9 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.4% · Q3 98.1% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.5%
4.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
4.4%
0.3 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 4.8% · Q3 3.7% · Q4 3.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.0% |
5.6%
28.4 pts worse
|
11.4%
22.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 24.5% · Q3 42.9% · Q4 50.0% · 4Q avg 34.0% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.0%
0.4 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.2% · Q3 4.3% · Q4 7.5% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
23.2%
2.7 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 26.4% · Q3 26.0% · Q4 23.6% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
19.8%
13.2 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 9.8% · Q3 7.5% · Q4 2.3% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.6% |
18.4%
6.8 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.4% |
18.8%
4.4 pts better
|
14.9%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 17.3% · Q3 12.2% · Q4 14.8% · 4Q avg 14.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
1.8%
0.1 pts better
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.8% · Q4 1.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.2% |
23.2%
10 pts worse
|
19.8%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 39.3% · Q3 32.3% · Q4 20.9% · 4Q avg 33.2% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
4.6%
0.9 pts better
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 3.9% · Q3 5.0% · Q4 4.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
75.6%
22.3 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 98.9% · Q3 98.2% · Q4 97.2% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
11.7%
0.2 pts worse
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.2% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
2.2%
1 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 1.4% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.7% |
73.5%
15.2 pts better
|
79.7%
9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
23.0%
3.4 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 25.2% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-29 · Fire 2023-03-29
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-08-09 · Fire 2021-08-09
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-30
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-01-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-01-30
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-03-25
F · Potential for more than minimal harm
2025-01-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-01-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-03-25
F · Potential for more than minimal harm
2023-03-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-12
F · Potential for more than minimal harm
2023-03-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-12
D · Potential for more than minimal harm
2023-03-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-12
F · Potential for more than minimal harm
2021-08-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-10-21
F · Potential for more than minimal harm
2021-08-09
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2021-10-21
F · Potential for more than minimal harm
2021-08-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-21
F · Potential for more than minimal harm
2021-08-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-10-21
E · Potential for more than minimal harm
2021-08-09
K222 · Egress Deficiencies
Fire Safety
Add 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.
Corrected 2021-10-21
E · Potential for more than minimal harm
2021-08-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-10-21
E · Potential for more than minimal harm
2021-08-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-10-21
E · Potential for more than minimal harm
2021-08-09
K930 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2021-10-21
D · Potential for more than minimal harm
2021-08-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-10-21
Inspection history
Recent health citations
G · Actual harm
2026-01-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-10
F · Potential for more than minimal harm
2025-01-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-30
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-07
D · Potential for more than minimal harm
2023-12-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-03-29
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-29
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-29
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-27
F · Potential for more than minimal harm
2021-08-09
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2021-08-31
E · Potential for more than minimal harm
2021-08-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-08-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-08-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-08-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-31
D · Potential for more than minimal harm
2021-08-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-31
Penalties and ownership
What sits behind the stars
Ownership
Gateway Healthcare LLC
5% Or Greater Direct Ownership Interest · Organization
Bohrer, Tracy
Operational/Managerial Control · Individual
Bohrer, Tracy
W-2 Managing Employee · Individual
Bunker, Derek
Corporate Officer · Individual
Burnam, Soon
Corporate Officer · Individual
Guschl, James
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Baldwin Healthcare & Rehab Center, LLC
Baldwin City, KS
5-star overall rating with 4-star inspections with 10 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Wellsville Manor
Wellsville, KS
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Richmond Healthcare & Rehab Center
Richmond, KS
1-star overall rating with 2-star inspections with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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