Rocky River Gardens Rehab and Nursing Ctr

Inspectors wroteBased on medical record review, policy review, and interviews, the facility failed to provide written notice of an immediate facility-initiated discharge to the resident and/or the resident's representative when the facility determined the resident would not be permitted to return following hospitalization. This affected one resident (Resident #1) reviewed for transfer and discharge requirements Findings Include: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, other chorea, and psychosis. Review of facility census records revealed Resident #1 was transferred and discharged to the hospital on [DATE] due to suicidal behaviors. Further review of the medical record revealed the facility conducted a care conference by telephone with Resident #1's responsible party on 06/29/26. [...]

Inspectors wroteBased on medical record review, the facility failed to coordinate the comprehensive assessment and care-planning process with the recommendations identified in a Level II Preadmission Screening and Resident Review (PASRR). This affected one (Resident #1) of three residents reviewed for PASRR requirements. The facility census was 83.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to maintain infection control practices to include Enhanced Barrier Precautions (EBP) for one resident, (#84) of one resident reviewed for EBP and the facility failed to ensure aerosol masks and tubings were changed timely and stored appropriately for four residents, (#56, #59, #78 and #84), of four residents reviewed for aerosol treatments. The facility also failed to ensure a Continous Positive Airway Pressure (CPAP) mask and tubing was appropriately stored for Resident #84. This had the potential to affect an additional five residents, (#51, #56, #59, #83, and #85) who also received EBP (on the same floor Resident #84 resided) and 15 residents, (#8, #11, #19, #22, #34, #38, #44, #53, #54, #59, #61, #63, #66, #78, and #81) who received aerosol treatments. The facility census was 86.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms were homelike and clean. This affected two residents, (#34 and #84's) of four reviewed for homelike environment. The facility census was 86.1. Record review for Resident #34 revealed an admission date of 01/23/26. Diagnosis included schizoaffective disorder and basil cell carcinoma of the skin. Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 was severely cognitively impaired. Resident #34 was frequently incontinent of bowel and bladder, required partial/moderate assistance for bed mobility, chair/bed to chair transfer, toilet transfer and toileting hygiene. Resident #34 received wound care with dressing changes. Observation on 06/30/26 at 3:40 P.M. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to assist two residents, (#70 and #84) who had been incontinent in a timely manner. This affected two of two residents reviewed for for incontinence care and had the potential to affect an additional 38 residents (#1, #2, #3, #4, #6, #8, #10, #11, #14, #15, #16, #25, #26, #27, #29, #30, #34, #37, #38, #42, #44, #45, #54, #55, #56, #57, #58, #61, #66, #67, #68, #71, #72, #77, #79, #80, #85, and #88) identified by the facility who were incontinent of bowel and or blabber. The facility census was 86.1. Record review for Resident #70 revealed an admission date of 05/26/25. Diagnoses included Chronic Obstructive Pulmonary Disease (COPD), muscle weakness and need for assistants with personal care. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure concerns related to Resident #90's care was addressed timely with resolution. This affected one resident (Resident #90) out of three residents reviewed for resident rights. Facility census was 87.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure infection control practices were maintained during care for Resident #34 and #52. This had the potential to affect all residents in the facility. The facility census was 91.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to provide timely incontinence care for Resident #48 and #96, and failed to ensure Resident #18, #50, 64 and #87 received showers/bathing as scheduled. This affected six residents (Resident #18, #48, #50, #64, #87 and #96) of seven residents reviewed for assistance with activities of daily living (ADL). The facility census was 91.

Inspectors wroteBased on observation, interview, and review of the facility policy the facility failed to ensure medications were stored in a safe, secure manner. This had the potential to affect all 32 residents residing on the second floor excluding five residents (#3, #23, #40, #60 and #70) the facility identified as needing assistance with mobility, and 45 residents residing on the third floor excluding six residents ( #2, #41, #51, #52, #74, and #77) the facility identified as requiring assistance with mobility. The facility census was 91.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure water temperatures were maintained as required for 45 residents (Resident #1, #2, #6, #7, #9, #11, #13, #14, #15, #17, #18, #16, #24, #25, #29, #30, #31, #32, #33, #37, #41, #42, #44, #46, #47, #48, #49, #50, #51, #52, #53, #59, #61, #65, #71, #73, #74, #77, #81, #82, #83, #85, #88, #91, and #93) on the third floor and rooms were clean and maintained for Resident #7, #39 and #73. This affected 46 residents of 91 residents residing in the facility. The facility census was 91.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy revealed the facility failed to ensure interventions for fall prevention were in place for Resident #84 and #50. This affected two residents (#84 and #50) of three residents reviewed for falls. The facility census was 91.

Inspectors wroteBased on interviews, record reviews, and review of the facility policy, the facility failed to ensure accurate and complete documentation for Resident #50 and Resident #64. This affected two residents (#50 and #64) of eleven residents reviewed for records. The facility census was 91.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed record review, review of hospital records, review of a protective order, review of a police report, facility policy review and interview, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent an unauthorized leave of absence (LOA) for Resident #200, who was under adult protection services (APS) with a guardian and guardian directive which prohibited Resident #200's husband from taking the resident off facility premises or into his vehicle. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] at approximately 6:00 P.M. [...]

Inspectors wroteBased on interview, record review and review of the facility policy, the facility did not ensure appropriate monitoring of Resident #201's ability to urinate and/or signs of urinary discomfort after the removal of an indwelling urinary catheter (a hollow flexible tube that collects urine from the bladder and leads to a drainage bag). This finding affected one (Resident #201) of three residents reviewed for urinary catheters. The facility census was 97.

Inspectors wroteBased on observation, medical record review, review of the facility investigation, hospital record review, review of the facility root cause analysis, review of facility policy and interviews, the facility failed to provide adequate supervision and monitor WanderGuard (wearable device to help keep residents at risk of wandering safe) functioning for Resident #69, a resident with a history of exit seeking behavior to prevent elopement. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on 10/08/24 at approximately 7:44 P.M. when Resident #69 eloped from the facility without staff knowledge, through a smoking patio exit door and traveled from Ohio (OH) to Wisconsin (WI), under unknown circumstances. Resident #69 was not seen by facility staff for nearly three hours before he was discovered missing at approximately 10:30 P.M. [...]

Inspectors wroteBased on closed medical record review, video footage with audio review, emergency medical services (EMS) run sheet review, hospital record review, interviews, and review of the facility's Change in a Residents' Condition or Status policy and procedure and Abuse, Neglect, Exploitation and Misappropriation policy and procedure, the facility failed to provide adequate and necessary care and services to prevent neglect involving Resident #101. This resulted in Immediate Jeopardy, including actual harm and subsequent death beginning on [DATE] at 7:03 P.M. when an incident of neglect occurred when the facility failed to prevent a fall with injury (rib fracture), to ensure timely and appropriate treatment was provided immediately post fall, to timely identify an acute change in condition and obtain immediate medical care. Review of video footage with audio dated [DATE] timed 7:03 P.M. [...]

Inspectors wroteBased on interview, review of video footage with audio and review of the facility's Resident Rights policy, the facility failed to ensure residents were treated with respect and dignity. This affected one of three residents observed for dignity during care, Resident #101. The facility census was 99.

Inspectors wroteBased observation, interview, and facility policy review the facility failed to keep medication in a secured environment, and failed to discard expired tuberculin solution. This had the potential to affect all 110 residents in the facility. The facility census was 110. Findings Include: 1. Observation on [DATE] at 11:15 A.M. revealed the second-floor medication room door was ajar and not latched completely allowing the door to be pushed open without the use of the door handle. The door handle was part of a code locking system with the number 7 button stuck enabling the door to be unlocked. Observation on [DATE] at 11:20 A.M. revealed the third-floor medication room door was closed but not locked. By turning the door handle it opened the door without having to enter the code to unlock the door. Observation on [DATE] at 3:26 P.M. [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure foods were labeled, dated and not retained when expired. This had the potential to affect 106 residents receiving food from the facility's kitchen as four residents (Residents #19, #41, #74 and #103) were ordered nothing-by-mouth (NPO). The facility census was 110.

Inspectors wroteBased on interview and record review the facility failed to ensure resident funds were disbursed as required and in a timely manner after death. This affected one resident (Resident #120) of five residents reviewed for resident funds. The facility census was 110.

Inspectors wroteBased on record review and interview the facility failed to ensure a significant change Minimum Data Set (MDS) 3.0 assessment was completed for Resident #14. This affected one resident (#14) of 25 residents reviewed for MDS assessments. The facility census was 110.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately complete [NAME] Data Set (MDS) assessments for Resident #5, #14 and #90. This affected three residents (Residents #5, #14, and #90) out of 25 residents reviewed for accurate [NAME] Data Set (MDS) assessments. The facility census was 110. Findings Include: 1. A record review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE] with the diagnoses including high blood pressure, Chronic Obstructive Pulmonary Disease (COPD), history of falls with multiple fractures of the lumbar vertebrae, thoracic vertebrae, and skull. Resident #5 required assistance from staff, was cognitively intact and ambulated with a front wheeled walker and stand by assist of staff. [...]

Inspectors wroteBased on record review, and interview the facility failed to ensure a skin assessment upon admission was timely obtained for the accurate initial assessment of skin impairment for Resident #11. This affected one resident (Resident #11) out of four residents reviewed for pressure ulcers. The facility census was 110. Findings Include: A record review for Resident #11 revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, heart failure, peripheral vascular disease (PVD), and Alzheimer's disease. Resident #11 had intact cognition and requires assistance from staff for personal hygiene cares, dressing, and transfers. [...]

Inspectors wroteBased on record review, interview, and review of policy and procedure, the facility failed to ensure pharmacy recommendations were timely addressed for Resident #90 and #109. This affected two residents (#90 and #109) of five residents reviewed for unnecessary medications. The facility census was 110.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess and monitor the use of a necessary antipsychotic medication. This affected one resident (Resident #10) out of five residents reviewed for unnecessary medications. The facility census was 110. Findings Include: Observation on 04/10/24 at 10:15 A.M. revealed Resident #10 resting quietly in bed. Further observations on 04/11/24 at 2:25 P.M. and on 04/12/24 at 11:25 A.M. revealed Resident #10 resting quietly in bed with no behaviors observed. A review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE] with the following diagnoses including Chronic Obstructive Pulmonary Disease (COPD), heart failure, high blood pressure, and Alzheimer's Disease. Resident #10 had impaired cognition and was dependent on staff for all personal hygiene cares, transfers and dressing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication administration error rate of less than 5%. The facility had 37 opportunities for medication error with two medication errors occurring resulting in a medication error rate of 5.41%. This affected one resident (Resident #46) out of four residents observed for medication administration. The facility census was 110. Findings Include: Medication administration observation on 04/11/24 at 7:25 A.M. revealed Licensed Practical Nurse (LPN) #476 preparing morning medication for Resident #46. LPN #476 placed the tablets into a medication pouch to be crushed and poured into a medication cup. LPN #476 took a soft gel capsule of Omega 3 Fish Oil and placed it in a separate pouch to crush and pour the liquid into the medication cup. [...]

Inspectors wroteBased on record review, interview, and review of policy and procedure, the facility failed to ensure accurate documentation of a resident's weight in the medical record. This affected one resident (#107) of three residents (#41, #114, and #107) reviewed for nutrition. The facility census was 110.

Inspectors wroteBased on observation, staff interview, and review of a company price quote document, the facility failed to maintain the parking lot in a safe manner. This had the potential to affect all 110 residents residing in the facility. The facility census was 110.

Inspectors wroteBased on observations, resident interviews, staff interviews, medical record review, admission agreement review, smoking policy review, review of the Secured Unit Agreement, and resident rights policy review, the facility failed to ensure residents were free from involuntary seclusion when cognitively intact residents were not afforded the opportunity to go outside without an escort of staff or interference. This resulted in actual psychosocial harm for two Residents (#57 and #252) were not allowed to freely go outside at will. This resulted in cognitively intact Resident #57 expressing wanting to leave the facility and was told by staff he could not leave. The resident was so distraught and resorted to physically removing the screen from his window, taking his wheeled walker and oxygen tank through the window, and leaving the facility to go to the store. [...]

Inspectors wroteBased on record review, facility policy and procedure review and interview, the facility failed to provide Resident #30 adequate supervision and ensure proper footwear while ambulating to prevent a fall with injury. The facility also failed to complete a thorough fall investigation following the fall with injury. Actual harm occurred on 02/23/23 when Resident #30, who was severely cognitively impaired, at risk for falls and required (staff) supervision with ambulation fell while ambulating independently and sustained a fractured right clavicle and right hip requiring surgical intervention. This affected one (#30) of three residents reviewed for falls. The facility census was 103.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure each resident's Gradual Dose reduction (GDR) recommendations from the pharmacist was followed up by their physician. This affected four (#3, #30, #24, and #69) of the five residents reviewed for unnecessary medications. The facility identified 31 residents on psychotropic medications. The facility census was 103.

Inspectors wroteBased on medical record review, staff interview, and review of policy, the facility failed to ensure a resident's advanced directives were accurately recorded throughout the medical record. This affected one (#35) of three residents reviewed for advance directives. The facility census was 103.

Inspectors wroteBased on record reviews, resident interviews and staff interviews, the facility failed to ensure care plans reflected resident needs. This affected three (#57, #14, and #252) of 32 resident records reviewed. The facility census was 103.

Inspectors wroteBased on observation, staff interviews, record review, and review of policy, the facility failed to provide bathing/showers for two dependent residents. This affected two (#35 and #73) of three residents reviewed for bathing/showers. The facility census was 103.

Inspectors wroteBased on observations, medical record review, staff interviews, and policy review, the facility failed to timely assess newly identified skin areas and seek new treatment. This affected one (#80) of two residents reviewed for pressure ulcers. The facility identified four residents with pressure ulcers. The facility census was 103.

Inspectors wroteBased on observation, staff interview, record review, and review of policy, the facility failed to ensure monthly and weekly weights were completed and monitored for residents. This affected two (#73 and #3) of three residents reviewed for weight loss. The facility census was 103.

Inspectors wroteBased on record review, staff interview, and review of policy, the facility failed to ensure physician orders included the time frame intravenous fluids were to be administered and the percentage of the solution to be administered. This affected one resident (#73) of three residents reviewed for physician orders. The census was 103.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a licensed pharmacist completed monthly medication review (MMR). This affected two (#14 and #69) of the five residents reviewed for unnecessary medications. The facility census was 103.

Inspectors wroteBased on record review, hospice staff interviews and staff interview, the facility failed to coordinate care with hospice services in providing care for residents. This affected two (#35 and #80) of three residents reviewed who received hospice services. The facility census was 103.

Inspectors wroteBased on observation, staff interview, record review, and review of policy, the facility failed to maintain infection control practiced during a wound dressing change. This affected one (#80) of two residents observed during wound dressing changes. The facility census was 103.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive assessments were accurate. This finding affected four (Residents #7, Resident #21, Resident #40 and Resident #103) of seven resident records reviewed for Pre-admission Screen - Resident Review (PAS-RR). The facility census was 99.

Inspectors wroteBased on observation, facility policy review and staff interviews, the facility failed to ensure timely disposition of unused medications. This affected one of three medication storage rooms in the facility. The census was 99.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity was maintained during medication administration. This effected one (Resident #50) of three Residents (#50, #54 and #60) residents observed for glucose testing and insulin administration. The facility census was 99.

Inspectors wroteBased on medical record review, policy review, resident and staff interviews, the facility failed to ensure one (Resident #96) of 16 residents whom were interviewed, had the right to self-administer medications. The facility census was 99.

Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to ensure two of three sampled residents (Resident #31 and #67) were provided interdisciplinary meetings (care conferences) quarterly with each assessment. The facility census is 99.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure one (Resident #31) of five residents pharmacy recommendations were completed when approved by the physician. The facility census was 99.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure laboratory testing was completed when ordered by a physician. This affected one (Resident #67) of five residents reviewed for unnecessary medications. The facility census was 99.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to ensure diagnostic testing was completed when ordered by a physician. This affected one (Resident #67) of five residents reviewed for unnecessary medications. The facility census was 99.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure infection control practice was maintained during blood glucose testing for Resident #60. This effected one of two (Residents #54 and #60) residents observed for glucose testing. The facility census was 99.