Rock River Health Care

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's seizures were documented in the resident's medical records for 1 of 3 residents (R1) reviewed for medical records in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with an order for a Urology consult received an evaluation by a urologist for 1 of 3 residents (R1) reviewed for care and services in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's safety during care to 1 of 3 residents (R1) reviewed for safety in the sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain accurate weights on a resident with a feeding tube (R14). The facility failed to weigh a resident (R14) as per the dietician's recommendations. The facility failed to notify the dietician of a resident's (R14) refusals of tube feedings. The facility failed to notify the dietician of missed or omitted tube feedings for R14. The facility failed to notify the dietician or nurse practitioner of R14's significant and continued weight loss in a timely manner. These failures contributed to R14 sustaining a significant weight loss. These failures apply to 1 of 7 residents (R14) reviewed for weight loss in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a certified dietary manager was employed as food service director. This has the potential to effect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure hand hygiene was performed after touching a garbage can lid and performing other tasks. This has the potential to effect all residents that receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the pureed pork was a smooth consistency. This applies to 4 of 4 residents (R38, R41, R40, R69) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a Level 2 Preadmission Screening and Resident Review (PASRR) interview was completed as requested for a resident admitted with known mental illness. This applies to 1 of 7 residents (R4) reviewed for PASRRs in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR) evaluation was resubmitted before expiration of the 60 day approval. This applies to 1 of 8 residents (R71) reviewed for PASRRs in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to schedule a doctor's appointment for a resident. This failure applies to 1 of 19 residents (R7) reviewed for quality of care in the sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure low air loss mattress settings were programmed to effectively off-load areas of pressure for residents with pressure injuries for 3 of 8 residents (R14, R11, R3) reviewed for pressure injuries in the sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered by the physician. There were 30 opportunities with 12 medication errors resulting in a 40% medication error rate. These failures apply to 2 of 3 residents (R23, R47) observed in the medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents medications were securely stored and inaccessible to residents for 2 of 19 residents (R43, R59) reviewed for medication storage in the sample of 19.

Inspectors wroteBased on observation and interview the facility failed to ensure a resident and their personal property was treated with respect. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a comfortable temperature by not keep a resident's room below 81 degrees Fahrenheit for 1 of 3 residents (R1) reviewed for comfortable homelike environment in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from significant medication error. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify a new skin alteration for a resident who is at risk for developing pressure wounds which applies to 1 of 3 residents (R1) reviewed for pressure wounds in a sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident's continuous positive airway pressure (CPAP) machines or supplies which applies to 5 of 5 residents (R1, R2, R3, R4, R5) reviewed for respiratory treatments in a sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from physical abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 6. This failure resulted in R1 being kicked in the genitals and R2 being pushed to the ground and sustaining a fracture of his left femur.

Inspectors wroteBased on interview and record review the facility failed to ensure the accuracy of medication administration records (MAR) for 3 of 3 residents (R1, R2, and R3) reviewed for pharmacy services in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff followed enhanced barrier precautions by not wearing the required personal protective equipment (PPE) when emptying an indwelling urinary catheter drainage bag for 1 of 2 residents (R1) reviewed for infection control in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to perform a pain assessment on R42 who was admitted for a left tibia and fibula fracture. They also failed to provide R42 with her prescribed hospital discharge pain medications, this failure resulted in R42 having to return to the hospital to be treated for uncontrolled pain for 1 of 2 residents (R42) reviewed for pain in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to have an RN (Registered Nurse) for 8 hours per day 7 days a week. This applies to all 74 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the recipe and menu for the noon meal. This applies to all 74 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure controlled substances were double locked. This applies to 4 of 4 residents (R11, R14, R34, & R62) reviewed for controlled substances in the sample of 20.

Inspectors wroteBased on observation and interview the facility failed to provide the residents with an appetizing and appealing meal for 8 of 8 (R16, R32, R35, R45, R56, R66, R69, & R72) residents reviewed for appearance, palatability and preferred temperature in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to provide residents with available drinks when requested by the resident for 6 of 11 residents (R2, R12, R17, R24, R31, and R27) reviewed for drinks available to meet needs/hydration in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to dress a resident in a dignified manner. This applies to 1 of 20 (R2) residents reviewed for dignity in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a clean, clutter free shower, and maintain a resident's room in need of repairs. This applies to 2 of 20 (R48, R39) residents reviewed for clean comfortable homelike environment in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to provide wound care for R56's stage 4 pressure ulcer on the weekend shift for 1 of 5 residents (R56) reviewed for pressure ulcers in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to supervise residents to prevent a resident from giving food to another resident on a specialized diet for 1 of 20 residents (R38) reviewed for safety supervision in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor a resident (R20) while taking their medications and failed to provide and/or document provision of medication to a resident (R33) on the MAR (Medication Reconciliation Record). This applies to 2 of 5 (R20, R33) reviewed for mediations in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to report and keep a resident's room free of bugs/pest. This applies to 1 of 20 residents (R43) reviewed for pest control in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received their scheduled/routine pain medication and failed to document that medications were given on the Medication Administration Record (MAR) for 2 of 3 residents (R1 and R3) reviewed for pharmacy services in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were reconciled for 4 of 4 residents (R2, R3, R4 and R5) reviewed for pharmacy services in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide catheter care in a manner to prevent cross contamination. This applies to 1 of 3 residents (R3) reviewed for catheter care in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the dietitian's recommendation for free water flushes for a resident with a gastrostomy tube (g-tube) for 1 of 1 resident (R1) reviewed for g-tubes in the sample of 3. This failure resulted in R1 becoming dehydrated, requiring hosptilization.

Inspectors wroteBased on interview and record review the facility failed to ensure fall interventions and fall assessments were updated after a resident experienced a fall for one of three residents (R1) reviewed for falls in the sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's discharge hospital orders were followed for medication administration, and discharge procedures and appointments. The facility failed to assess and monitor a resident with a known vision impairment, and a known facial infection on antibiotic therapy. The facility failed to monitor and assess a central venous catheter site. This failure resulted in a resident with a vitreous hemorrhage having no surgical intervention and follow up care, and the resident continuing to complain of decreased vision, facial pain, and swelling. This applies to 1 of 17 residents (R59) reviewed for quality of care in the sample of 17. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/12/23 when R59 was re-admitted to the facility with a vitreous hemorrhage. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Enhanced Barrier Precautions were implemented and failed to develop an Enhanced Barrier Precautions Policy and Procedures. The facility's Resident Census and Conditions Report (CMS) dated 9/11/23 show there were 67 residents residing at the facility. This report also shows that there are 2 residents with indwelling catheters and 5 residents with pressure ulcers. None of these residents were placed on Enhanced Barrier Precautions. R59, a resident in this facility with a central intravenous catheter was not placed on Enhanced Barrier Precautions. On 9/11/23 at 12:33 PM, V3 (Infection Control) said the facility has not implemented Enhanced Barrier Precautions. V3 said she does not know anything about this and no one has told me about that. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to investigate an alleged allegation of financial abuse for 1 of 17 residents (R50) reviewed for abuse in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure prescribed treatment orders were in place for residents with pressure ulcers and failed to ensure pressure relieving interventions were in place. This applies to 2 of 6 residents (R17, R45) reviewed for pressure ulcers in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall interventions for a resident with a history of falls (R16) and failed to ensure safety smoking precautions were in place for a resident (R38). These failures apply to two of seventeen residents reviewed for safety and supervision in the sample of seventeen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nutritional supplements were provided to residents with significant weight loss and failed to ensure a nutritional assessment was performed for a resident who was re-admitted to the facility with multiple wounds and history of significant weight loss. This applies to 2 of 17 residents (R46, R62) reviewed for weight loss in the sample of 17.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure insulin pens were labeled and dated when opened. This applies to 2 of 4 residents (R40, R44) reviewed for medication labeling in the sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to offer pneumococcal vaccination series per CDC guidelines for 2 of 5 residents (R14, R38) reviewed for immunizations in the sample of 17