Deficiencies (last 3 years)
Deficiencies (over 3 years)
42.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
828% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
30 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding alleged misappropriation of property involving missing laptops reported by resident R11.
Complaint Details
The complaint involved resident R11 reporting two missing Apple laptops that were not followed up on to resolve the issue. No staff education was provided to prevent further misappropriation. The facility policy on abuse, neglect, and exploitation was not fully implemented. Interviews with staff and residents confirmed the missing laptops and lack of follow-up. A resolution was eventually agreed to replace one working computer, but the issue was delayed and not properly addressed initially.
Findings
The facility failed to thoroughly investigate the allegation of missing laptops and did not provide staff education to prevent further misappropriation. The missing laptops were not replaced promptly, and no corrective actions were implemented in a timely manner.
Deficiencies (1)
Failure to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated and resolved, including lack of staff education to prevent further incidents.
Report Facts
Number of residents interviewed: 17
Assessment reference date: Nov 3, 2025
Date of incident report: Oct 9, 2025
Date grievance filed: Oct 10, 2025
Date of survey completion: Dec 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Interviewed regarding missing laptops and follow-up actions |
| Certified Nursing Assistant-C | Certified Nursing Assistant | Interviewed about missing property procedures |
| Regional Clinical-E | Regional Clinical | Discussed resolution with resident R11 regarding missing computers |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jul 23, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide adequate supervision and assistive devices to prevent accidents related to smoking for residents, leading to immediate jeopardy.
Complaint Details
The complaint investigation was triggered by concerns about unsafe smoking practices leading to immediate jeopardy to resident health and safety. Immediate jeopardy was identified beginning 2025-07-10 and removed on 2025-07-16 after corrective actions.
Findings
The facility failed to ensure safe smoking practices for residents, including inadequate supervision, failure to assess risk, lack of smoking aprons, and unsafe smoking materials. Immediate jeopardy was identified but removed after the facility implemented an action plan. Additional deficiencies included inaccurate nurse staffing postings and lack of required training for non-nursing staff.
Deficiencies (7)
Failure to provide adequate supervision and assistive devices to prevent accidents related to smoking, resulting in immediate jeopardy.
Inaccurate nurse staffing postings that did not reflect actual hours worked or staff present.
Failure to provide medically related social services to help residents achieve the highest practicable quality of life, including lack of smoking cessation options.
Failure to ensure non-nursing staff received annual resident rights and facility responsibilities training.
Failure to ensure non-nursing staff received annual abuse, neglect, exploitation, and dementia training.
Failure to ensure non-nursing staff received annual Quality Assurance and Performance Improvement (QAPI) training.
Failure to ensure non-nursing staff received annual behavioral health training.
Report Facts
Residents reviewed for smoking supervision: 4
Date immediate jeopardy began: Jul 10, 2025
Date immediate jeopardy removed: Jul 16, 2025
Number of residents affected by staffing posting inaccuracies: 24
Number of non-nursing staff missing required trainings: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook-L | Cook | Non-nursing staff member who did not receive required annual trainings for resident rights, abuse prevention, QAPI, and behavioral health. |
| Housekeeping-M | Housekeeping Staff | Non-nursing staff member who did not receive required annual behavioral health training. |
| NHA A | Nursing Home Administrator | Responsible for ensuring non-nursing staff receive required training; interviewed regarding smoking safety and staffing postings. |
| LPN F | Licensed Practical Nurse / Unit Manager | Interviewed regarding smoking safety, burn holes in clothing, and facility procedures. |
| LPN/UM B | Licensed Practical Nurse / Unit Manager | Interviewed regarding smoking safety assessments and monitoring. |
| Scheduler K | Scheduler | Interviewed regarding nurse staffing postings and schedule discrepancies. |
| RN/MDS Coordinator G | RN/MDS Coordinator | Interviewed regarding smoking assessments and expectations. |
Inspection Report
Routine
Census: 30
Deficiencies: 5
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, staffing, infection control, and immunization practices at Rock River Nursing & Rehab.
Findings
The facility was found deficient in multiple areas including failure to re-evaluate physical restraint use, inadequate investigation of alleged staff abuse, insufficient nursing staffing levels, ineffective infection prevention and control program including lack of a qualified infection preventionist and incomplete water management program, improper medication administration practices, and failure to ensure residents were offered or documented immunizations.
Deficiencies (5)
Failure to provide ongoing re-evaluation of the need for a seatbelt restraint for resident R24.
Failure to conduct a thorough investigation of alleged staff abuse and failure to notify law enforcement.
Insufficient nursing staff to meet resident needs, including times with only one nurse for 30 residents.
Failure to implement an effective infection prevention and control program, including lack of a qualified infection preventionist, incomplete water management program, and improper medication administration.
Failure to ensure residents were offered or documented refusal of influenza and pneumococcal vaccinations as required.
Report Facts
Residents census: 30
Residents requiring Hoyer lift: 12
Residents requiring two person assistance: 6
Residents with full code status: 22
Staffing levels: 1
Staffing levels: 1
Infection surveillance: 3
Infection surveillance: 4
Infection surveillance: 4
Infection surveillance: 7
Infection surveillance: 2
Infection surveillance: 3
Infection surveillance: 2
Infection surveillance: 6
Infection surveillance: 6
Infection surveillance: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Named as Infection Preventionist and involved in medication administration and staffing issues |
| NHA-A | Nursing Home Administrator | Interviewed regarding staffing, infection control, and immunization deficiencies |
| Scheduler-Q | Interviewed about staffing changes and call-ins | |
| Dietary Director-R | Interviewed about dietary staffing changes | |
| Medication Tech-MT-K | Interviewed about restraint use | |
| Medication Tech-MT-L | Interviewed about staffing shortages | |
| Ombudsman-T | Interviewed about staffing concerns | |
| Assistant Director of Nursing-ADON-F | Interviewed about staffing and infection control training | |
| CNA-I | Certified Nursing Assistant | Interviewed regarding abuse allegation |
| CNA-O | Certified Nursing Assistant | Interviewed about staffing concerns |
| VPCS-J | Vice President of Clinical Services | Interviewed about infection control program and surveillance |
| DOM-N | Director of Maintenance | Interviewed about water management program |
Inspection Report
Census: 30
Deficiencies: 12
Date: Apr 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, infection control, staffing, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, inadequate re-evaluation of physical restraints, lack of baseline care plans, failure to provide appropriate treatment and care, inadequate pressure ulcer care, insufficient supervision to prevent accidents, inadequate staffing levels, failure to monitor for adverse medication effects, incomplete infection prevention and control program, lack of designated qualified infection preventionist, and failure to ensure residents were offered appropriate vaccinations. Several residents experienced harm or potential harm due to these deficiencies.
Deficiencies (12)
Failure to allow resident to participate in the development and implementation of person-centered plan of care.
Failure to provide ongoing re-evaluation of the need for a seatbelt restraint for a resident in a wheelchair.
Failure to develop and implement a baseline care plan within 48 hours of admission.
Failure to provide appropriate treatment and care according to orders, resident preferences and goals, resulting in immediate jeopardy related to unrecognized depression and weight loss, and failure to conduct neuro checks after a fall.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift.
Failure to ensure each resident’s drug regimen is free from unnecessary drugs by not monitoring for adverse reactions of high-risk medications.
Failure to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications and lack of care plan and side effect monitoring for psychotropic medication use.
Failure to provide and implement an effective infection prevention and control program, including lack of a qualified infection preventionist, incomplete water management program, inadequate infection surveillance and control measures, and improper medication administration technique.
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations, resulting in residents not being offered or documented as receiving vaccines.
Failure to ensure a safe and protected designated smoking area for residents who smoke.
Report Facts
Residents requiring Hoyer lift: 12
Residents requiring two person assistance: 6
Residents requiring one person assistance: 4
Residents independent: 8
Residents requiring pureed diet: 2
Residents requiring mechanical soft diet: 6
Residents requiring staff member to feed: 2
Residents requiring staff member to cue to eat: 2
Residents requiring staff member to set up meal tray and cut/prepare food: 1
Residents with full code status: 22
Residents at risk for elopement: 3
Residents at risk for falling: 10
Residents incontinent of urine and/or bowels: 14
Residents requiring bed pan for toileting assistance: 4
Residents on census day: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON-B | Director of Nursing | Interviewed and involved in multiple findings including infection prevention, staffing, medication monitoring, and care planning |
| NHA-A | Nursing Home Administrator | Interviewed and involved in staffing and infection prevention findings |
| SW-D | Social Worker | Interviewed regarding care planning and psychotropic medication care plan responsibilities |
| WC RN-E | Wound Care Registered Nurse | Interviewed and observed providing wound care |
| WC PA-G | Wound Care Physician Assistant | Interviewed regarding wound care and diagnosis |
| MT-L | Medication Technician | Interviewed regarding staffing and pressure injury care |
| LPN-W | Licensed Practical Nurse | Interviewed regarding fall investigation |
| Scheduler-Q | Scheduler | Interviewed regarding staffing changes |
| Dietary Director-R | Dietary Director | Interviewed regarding staffing changes |
| Ombudsman-T | Ombudsman | Interviewed regarding staffing concerns |
| RN-P | Registered Nurse | Interviewed regarding psychotropic medication care plan |
| LPN-V | Licensed Practical Nurse | Interviewed regarding psychotropic medication care plan |
Inspection Report
Deficiencies: 13
Date: Jan 15, 2025
Visit Reason
The inspection was conducted to investigate multiple regulatory compliance concerns including medication administration, resident safety, environmental conditions, staff training, and facility management.
Findings
The facility had multiple deficiencies including failure to notify physicians of medication delays, inadequate medication administration timeliness, failure to maintain comfortable temperatures due to HVAC issues, incomplete investigations of resident-to-resident altercations, failure to follow physician orders for monitoring and treatment, incomplete staff competencies and training, and failure of the governing body to ensure proper facility management.
Deficiencies (13)
Failure to notify residents' physicians and representatives of medication delays and changes in condition for 2 residents (R3 and R4).
Heating unit supplying the north side of the facility was not fully operational, resulting in temperatures below 71 degrees Fahrenheit affecting 14 residents.
Resident-to-resident altercation was not thoroughly investigated, lacking staff and resident interviews and education to prevent future incidents.
Failure to provide appropriate treatment and care according to physician orders for 4 residents (R3, R5, R10, and R13), including seizure management, medication administration, wound care, and surgical referrals.
Failure to provide adequate supervision and assistance to prevent a fall for resident R6 during bed bath.
Failure to ensure nurses and nurse aides completed required competencies after hire, including Licensed Practical Nurse (LPN)-K lacking competency documentation.
Failure to complete performance reviews for 4 of 5 Certified Nursing Assistants (CNAs) reviewed.
Failure to provide pharmaceutical services to meet the needs of residents, including delayed medication orders and lack of medication availability for seizure management.
Failure to maintain resident R5's medical record in accordance with accepted professional standards, including multiple blank treatment administration record dates without explanation.
Medication error rate exceeded 5 percent, including undated insulin vial for R2 and failure to check vital signs prior to medication administration for R16.
Failure of the facility governing body to ensure proper management and operation of the facility, including failure to maintain HVAC system resulting in prolonged heating issues affecting residents.
Failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards for resident R5.
Failure to provide required annual training for Certified Nursing Assistants (CNAs) on effective communication, resident rights, abuse and neglect, QAPI, infection control, compliance and ethics, and behavioral health.
Report Facts
Medication errors: 2
Residents affected by heating issue: 14
Residents reviewed for staff training: 5
Residents reviewed for medication and care: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-E | Licensed Practical Nurse | Named in medication delay and resident-to-resident altercation findings |
| LPN/UM-F | Licensed Practical Nurse/Unit Manager | Named in medication administration and notification findings |
| NHA-A | Nursing Home Administrator | Named in heating issue and resident-to-resident altercation findings |
| DON-B | Director of Nursing | Named in heating issue, medication administration, and staff training findings |
| CNA-H | Certified Nursing Assistant | Named in resident-to-resident altercation and staff training findings |
| MD-I | Maintenance Director | Named in heating unit failure and temperature monitoring findings |
Inspection Report
Routine
Deficiencies: 20
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, environment, staffing, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were informed and participated in medication changes, inadequate care planning and discharge planning, insufficient staffing leading to delayed call light responses, medication administration errors including unqualified staff administering medications and late medication passes, lack of proper infection control practices, environmental cleanliness issues, pest control deficiencies, and failure to provide trauma-informed care and individualized behavioral interventions.
Deficiencies (20)
Residents were not fully informed or involved in medication changes, including psychotropic medications and pain management.
Residents were not provided the opportunity to participate in the development and implementation of their person-centered plan of care.
Facility failed to reasonably accommodate resident needs and preferences, including removal of air conditioning unit without explanation.
Residents were not given prior written notice of room changes including reasons and options.
Facility restricted a resident's friend from visitation without explanation or strategies to maintain visits.
Resident's representative was not notified timely of significant changes including hospital transfer.
Facility environment was not clean or homelike; shared bathroom had fecal matter on walls and floor, paint damage in resident room, and outdoor areas littered with trash and abandoned wheelchair.
Care plan was not reviewed and revised by interdisciplinary team to reflect resident's assessed needs, including fall prevention interventions.
Residents did not receive assistance to maintain ability to perform activities of daily living, including inconsistent showering.
Residents who were unable to perform activities of daily living did not consistently receive necessary care to maintain good grooming.
Residents did not consistently receive treatment and care according to orders, including follow-up of colonoscopy results, monitoring of cellulitis, medication administration, and pain and bed rail assessments.
Residents did not receive adequate supervision to prevent accidents; gait belt was not used during transfer of a large resident.
Facility did not have sufficient nursing staff with appropriate competencies; unqualified medication aide administered medications.
Garbage and refuse were not properly disposed of in outside receptacles; litter and debris were observed around dumpsters.
Facility did not develop and implement effective discharge planning to meet resident goals and needs.
Facility did not comprehensively assess and provide trauma-informed care and individualized behavioral interventions for a resident with PTSD and other psychiatric diagnoses.
Medication error rate was 53.33%, including late medication administration and incomplete medication passes.
Facility did not maintain an effective infection prevention and control program; staff failed to wear appropriate PPE and perform hand hygiene during care of residents on enhanced barrier precautions.
Facility did not maintain an effective pest control program; flies were observed throughout the facility and pest control services were not provided in June and July 2024.
Residents experienced long call light response times due to insufficient staffing; some call lights were unanswered for over two hours.
Report Facts
Medication error rate: 53.33
Facility census: 62
Empty beds: 33
Residents not showered as preferred: 12
Residents not showered weekly: 3
Medication administration omissions: 6
Medication administration omissions: 7
Medication administration omissions: 5
Medication administration omissions: 1
Medication administration omissions: 1
Call light wait time: 3
Call light wait time: 2
Call light wait time: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-F | Certified Nursing Assistant | Observed administering medications without recent training or certification; pulled from CNA duties to pass medications |
| Regional Director of Clinical Operations-C | Interviewed regarding concerns about psychotropic medication prescribing and discharge planning | |
| Nursing Home Administrator-A | Nursing Home Administrator | Interviewed regarding staffing, medication administration, discharge planning, and pest control issues |
| Director of Nursing-B | Director of Nursing | Interviewed regarding medication administration, staffing, infection control, and discharge planning |
| Social Worker-D | Social Worker | Interviewed regarding discharge planning and behavioral interventions |
| Certified Nursing Assistant-K | Certified Nursing Assistant | Observed transferring resident without gait belt |
| Medication Technician-MT-F | Medication Technician | Observed administering medication late to resident |
| Licensed Practical Nurse-P | Licensed Practical Nurse | Left shift early leading to medication administration confusion |
| Registered Nurse-I | Registered Nurse | Interviewed regarding medication administration and notification of resident representative |
| Certified Nursing Assistant-J | Certified Nursing Assistant | Interviewed regarding transfers and PPE use |
| Certified Nursing Assistant-L | Certified Nursing Assistant | Observed not wearing gown during enhanced barrier precaution care |
| Director of Maintenance-G | Director of Maintenance | Interviewed regarding pest control and environmental cleaning |
| Housekeeping Director-H | Housekeeping Director | Interviewed regarding environmental cleaning responsibilities |
| Activity Director-E | Activity Director | Interviewed regarding visitation restrictions |
| Social Worker-SW-D | Social Worker | Interviewed regarding visitation restrictions and discharge planning |
| Nurse Practitioner-APNP-DD | Advanced Practice Nurse Practitioner | Conducted psychiatric evaluation and recommended medication and facility change |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 87
Deficiencies: 1
Date: Jul 16, 2024
Visit Reason
Surveyors entered the facility on 7/16/24 to investigate alleged concerns that the governing body has not been paying accounts and amounts were owed to multiple vendors associated with the facility operations.
Complaint Details
The visit was complaint-related, investigating concerns about unpaid vendor accounts and financial arrears affecting facility operations.
Findings
The facility's governing body failed to fulfill responsibilities including establishing and implementing policies and procedures regarding facility operations and fiscal management. Vendor accounts were in arrears totaling over 1.5 million dollars, risking disruption of services and care for residents. Observations included facility maintenance issues and supply management concerns.
Deficiencies (1)
Failure to establish a governing body legally responsible for managing and operating the facility and appointing a properly licensed administrator.
Report Facts
Residents present: 53
Total licensed capacity: 87
Number of vendors with outstanding balances: 60
Total outstanding vendor balances: 1500000
Outstanding balance - Northwest Environmental: 2386.35
Outstanding balance - AlixaRx: 532696.32
Outstanding balance - Lifescan Labs of Illinois: 3731.79
Outstanding balance - HR Revolution: 1715
Outstanding balance - Point Click Care Technologies Inc: 18713.02
Outstanding balance - Sysco Baraboo: 35004.26
Outstanding balance - RL Specialty: 2116.4
Outstanding balance - Innovative Supply Group: 1137.26
Outstanding balance - All STAT Portable WI: 686
Outstanding balance - Relias LLC: 1970.89
Outstanding balance - Twin Med: 15137.92
Outstanding balance - Integrity Senior Health: 4500
Outstanding balance - [NAME] Bus Company: 3871.75
Outstanding balance - Sterling Therapy Solutions: 26916
Outstanding balance - Synapse Health: 4166.91
Outstanding balance - Wisconsin Department of Health Services: 636420
Outstanding balance - Centers for Medicare & Medicaid Services (CMS): 60333
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA-A | Nursing Home Administrator | Provided census and capacity information, discussed facility finances and vendor changes |
| CSS-E | Central Supply/Scheduling Staff | Discussed supply ordering and staffing agency use |
| BOM/HR-D | Business Office Manager/Human Resources Staff | Described accounts payable process and vendor interactions |
| DON-B | Director of Nursing | Discussed pharmacy and lab vendor changes, therapy services |
| DAR-G | Director of Accounts Receivable | Discussed outstanding balances with Northwest Environmental |
| Employee-H | Spoke about HR Revolution outstanding balance and payments | |
| AR-L | Accounts Receivable | Discussed outstanding balance with Point Click Care Technologies |
| DOC-R | Director of Credit | Discussed line of credit and payments with Sysco Baraboo |
| Staff-I | Confirmed RL Specialty account current | |
| Employee-J | Clarified Innovative Supply Group outstanding balance | |
| Employee-K | Discussed Innovative Supply Group account status | |
| Employee-M | Spoke about All STAT Portable WI account status | |
| Employee-N | Discussed Relias LLC outstanding balance and suspension letter | |
| APD-O | Account Payable Director | Discussed Twin Med account and payments |
| Physician-S | Physician | Discussed Integrity Senior Health payments and outstanding balances |
| Employee-P | Discussed [NAME] Bus Company outstanding balance and service hold | |
| APR-Q | Accounts Payable Representative | Discussed Synapse Health DME services and payment plan |
| Governing Body/Owner-F | Owner | Provided vendor aging report and discussed payments and plans |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 12, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, treatment, discharge planning, wound care, infection control, and complaint investigations.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of treatment changes, delayed grievance resolution, inadequate discharge planning for several residents, failure to provide appropriate treatment and care according to orders and care plans, insufficient pressure ulcer care, lack of proper diabetic foot care, and failure to maintain infection prevention and control protocols during wound care.
Deficiencies (7)
Failure to notify resident representative of treatment changes for resident R51.
Failure to promptly resolve a grievance for resident R51.
Failure to develop and implement effective discharge planning for residents R304, R305, and R303.
Failure to provide appropriate treatment and care according to orders and care plans for residents R301, R51, and R303.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for residents R6 and R51.
Failure to provide appropriate foot care including diabetic foot monitoring for residents R303 and R51.
Failure to maintain infection prevention and control program during wound care for residents R301 and R51.
Report Facts
Treatment completion date discrepancy: 2
Air mattress weight setting: 660
Air mattress weight setting: 220
Pressure injury measurement: 0.4
Pressure injury measurement: 4
Grievance delay: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-F | Licensed Practical Nurse | Observed performing wound care without proper hand hygiene and PPE; involved in treatment of residents R301 and R51. |
| LPN Nurse Supervisor/Wound Nurse-E | Licensed Practical Nurse Nurse Supervisor/Wound Nurse | Involved in wound care assessments and treatment discussions for residents R51 and R6. |
| RN-G | Registered Nurse | Interviewed regarding notification of resident representative and diabetic foot care. |
| SSD-D | Social Services Director | Involved in grievance handling, discharge planning, and communication with resident representatives. |
| NHA-A | Nursing Home Administrator | Interviewed regarding grievance process, discharge planning, and wound care oversight. |
| DON-B | Director of Nursing | Interviewed regarding wound care, discharge planning, and infection control. |
| Wound NP-I | Wound Nurse Practitioner | Performed wound assessments and treatments for residents R6 and R51. |
| TD-J | Therapy Director | Interviewed regarding therapy involvement in discharge planning and weight bearing status. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 25, 2024
Visit Reason
The inspection was conducted due to an allegation of misappropriation of narcotics involving a staff nurse and a resident, as well as other compliance concerns including failure to provide CPR per resident directive, pressure ulcer care deficiencies, pharmaceutical service issues, fluid restriction diet errors, food safety violations, and infection control program deficiencies.
Complaint Details
The complaint investigation was triggered by an allegation of narcotic misappropriation involving a staff nurse removing Oxycodone for a resident (R28) without proper authorization or documentation. The facility failed to conduct a thorough investigation, including not interviewing the resident. Additional complaints involved failure to provide CPR per a resident's directive, pressure ulcer care, pharmaceutical services, diet management, food safety, and infection control.
Findings
The facility failed to thoroughly investigate an allegation of narcotic misappropriation, did not provide CPR per a resident's advance directive resulting in immediate jeopardy, failed to provide appropriate pressure ulcer care leading to a Stage IV pressure injury requiring surgical debridement, did not ensure pharmaceutical services met resident needs including medication administration documentation, failed to include fluid restriction on a resident's diet card, held cold foods at unsafe temperatures, and did not maintain an effective infection prevention and control program with multiple sanitation and hygiene violations observed.
Deficiencies (7)
Failure to thoroughly investigate an allegation of misappropriation of Oxycodone for resident R28 by a staff nurse.
Failure to provide CPR per resident R55's advance directive resulting in immediate jeopardy to resident health or safety.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for resident R6, resulting in progression to a Stage IV pressure injury requiring surgical debridement.
Failure to provide pharmaceutical services to meet the needs of resident R28, including accurate medication administration and documentation.
Failure to ensure resident R51's fluid restriction was included on the diet card, risking improper fluid intake.
Failure to ensure cold foods were held at safe temperatures before serving to residents, risking foodborne illness.
Failure to maintain an infection prevention and control program, including improper handling of dirty linen, contaminated food trays, housekeeping during meal service, and inadequate hand hygiene.
Report Facts
Medication doses removed: 2
Fluid restriction: 2000
Cold food temperature: 55.3
Cold food temperature: 57.5
Cold food temperature: 36.6
Pressure injury size: 2.19
Pressure injury size: 3.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-BB | Licensed Practical Nurse | Named in narcotic removal and medication administration finding for resident R28 |
| Former Staff Nurse-CC | Staff Nurse | Named in narcotic removal allegation and investigation for resident R28 |
| Nursing Home Administrator-A | Nursing Home Administrator | Involved in narcotic misappropriation investigation and communication with surveyors |
| DON-B | Director of Nursing | Interviewed regarding narcotic removal and CPR incident |
| RN Unit Manager-L | Registered Nurse Unit Manager | Interviewed regarding narcotic removal and wound care |
| Pharmacist-AA | Pharmacist | Reviewed medication removal logs for narcotics |
| RN-Q | Registered Nurse | Involved in CPR incident with resident R55 |
| Hospice RN-S | Hospice Registered Nurse | Involved in communication regarding resident R55's code status and death |
| DM-E | Dietary Manager | Interviewed regarding diet card and food safety issues |
| Cook-J | Cook | Interviewed and observed regarding food temperature issues |
| Laundry-FF | Laundry Staff | Observed storing clean linen with oxygen tanks and soiled laundry |
| CNA-Z | Certified Nursing Assistant | Observed handling dirty linen and resident care with poor infection control practices |
| Regional Clinical Director-N | Regional Clinical Director | Reported education provided regarding dirty linen on floors |
Inspection Report
Routine
Deficiencies: 15
Date: Apr 25, 2024
Visit Reason
The inspection was a routine survey of Rock River Nursing & Rehab to assess compliance with regulatory requirements including resident rights, medication administration, infection control, care planning, staffing, and other areas of care.
Findings
The facility was found deficient in multiple areas including failure to ensure signed advance directives, incomplete investigation of narcotic misappropriation, lack of timely transfer and bed-hold notices, incomplete care planning for dialysis, failure to provide CPR per resident directive, inadequate pressure ulcer care, unsafe smoking practices, significant weight loss without proper monitoring, insufficient nursing staff on night shifts, incomplete psychotropic medication monitoring, improper medication storage, failure to maintain infection control practices, and failure to ensure fluid restriction information on diet cards.
Deficiencies (15)
Facility did not ensure the medical record contained signed advance directive election forms for 1 of 14 residents reviewed (R6).
Facility did not have evidence an allegation of misappropriation of narcotics was thoroughly investigated for 1 resident (R28).
Facility did not provide written transfer notices and bed-hold information to residents and/or representatives for multiple residents (R11, R105, R22, R7).
Facility did not develop a comprehensive plan of care for a resident on dialysis (R11).
Facility failed to provide CPR per resident directive for 1 resident (R55), resulting in immediate jeopardy that was later removed.
Facility did not ensure residents with pressure injuries received necessary treatment and services consistent with professional standards to promote healing and prevent new pressure injuries (R6).
Facility did not ensure the environment remained free of hazards for 1 resident (R6) related to smoking safety assessments and enforcement of smoking policy.
Facility did not ensure residents maintained acceptable nutritional status and failed to implement dietician recommendations for weight loss monitoring for 1 resident (R32).
Facility did not ensure sufficient nursing staff was available on night shifts, with only one nurse present on multiple occasions.
Facility did not ensure residents receiving psychotropic medication received adequate monitoring and documentation of indications for use (R34 and R7).
Facility failed to provide pharmaceutical services to meet the needs of a resident (R28) related to medication administration and documentation.
Facility failed to ensure one wound treatment cart was locked when left unattended.
Facility failed to ensure diet card for one resident (R51) included information regarding physician ordered fluid restriction.
Facility failed to ensure cold foods were held at an acceptable temperature for 29 sampled residents.
Facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment, including proper handling of linens, meal trays, and housekeeping during meal service.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 54
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 29
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-BB | Licensed Practical Nurse | Named in narcotic misappropriation investigation and medication removal |
| Former Staff Nurse-CC | Staff Nurse | Named in narcotic misappropriation investigation |
| Social Worker SW-G | Social Worker | Interviewed regarding advance directives and transfer notices |
| Director of Nursing DON-B | Director of Nursing | Interviewed regarding multiple findings including advance directives, narcotic investigation, transfer notices, staffing, psychotropic medication monitoring, wound care |
| RN Unit Manager-L | Registered Nurse Unit Manager | Interviewed regarding narcotic medication administration and wound care |
| Nursing Home Administrator NHA-A | Nursing Home Administrator | Interviewed regarding narcotic investigation, transfer notices, medication administration |
| Pharmacist-AA | Pharmacist | Interviewed regarding narcotic medication removal |
| Pharmacist-GG | Pharmacist | Interviewed regarding psychotropic medication review |
| RN-Q | Registered Nurse | Named in failure to provide CPR per resident directive |
| Hospice RN-S | Hospice Registered Nurse | Named in failure to provide CPR per resident directive |
| Regional Dietician-X | Dietician | Interviewed regarding weight loss monitoring |
| Cook-J | Cook | Interviewed regarding cold food temperature |
| Dietary Manager DM-E | Dietary Manager | Interviewed regarding diet card and cold food temperature |
| Laundry-FF | Laundry Staff | Interviewed regarding infection control and linen storage |
| Wound Nurse/LPN-I | Licensed Practical Nurse/Wound Nurse | Interviewed regarding wound treatment cart locking |
| Central Supply Coordinator CS-D | Central Supply Coordinator | Interviewed regarding wound treatment cart locking |
| Housekeeper Director-H | Housekeeping Director | Interviewed regarding housekeeping during meal service |
| CNA-Z | Certified Nursing Assistant | Observed and interviewed regarding infection control and dirty linen handling |
| Medication Technician Med Tech-Y | Medication Technician | Observed during medication pass with infection control concerns |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 7, 2024
Visit Reason
The inspection was conducted in response to complaints regarding failure to provide timely assistance with bed mobility to a resident, and failure to provide pain medication in a timely manner as ordered.
Complaint Details
The complaint involved Resident 1 (R1) who called for assistance to be repositioned in bed but did not receive timely help, leading her to call the police. The police incident report confirmed the resident was left unattended for nearly two hours. Resident 3 (R3) experienced increased pain due to delayed administration of a fentanyl patch, which was not applied on the scheduled date. Both incidents were substantiated by interviews and record reviews.
Findings
The facility failed to provide timely assistance to reposition a resident in bed, resulting in prolonged discomfort and pain. Additionally, the facility failed to administer a fentanyl patch pain medication on schedule, causing increased pain for the resident.
Deficiencies (2)
Failed to provide timely assistance to reposition a resident dependent on staff for bed mobility, resulting in the resident waiting nearly two hours for help.
Failed to provide pain medication (fentanyl patch) in a timely manner as ordered, with a two-day delay in administration.
Report Facts
Deficiencies cited: 2
Wait time for repositioning: 2
Pain medication delay: 2
BIMS score: 15
Pain intensity rating: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Named in findings related to delayed repositioning assistance and pain medication administration |
| LPN1 | Licensed Practical Nurse | Named in findings related to failure to administer fentanyl patch as ordered |
| CNA1 | Certified Nursing Assistant | Named in findings related to delayed repositioning assistance |
| CNA4 | Certified Nursing Assistant | Named in findings related to resident pain observation and communication |
| PO1 | Police Officer | Involved in incident responding to resident call for help |
| DON | Director of Nursing | Interviewed regarding staff response expectations and in-service training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 21, 2024
Visit Reason
The inspection was conducted to investigate a complaint regarding failure to follow physician orders for resident care, specifically the application of mineral oil and leg wraps for one sampled resident.
Complaint Details
The visit was complaint-related, investigating failure to follow physician orders for resident R7. The complaint was substantiated based on observations, interviews, and record review.
Findings
The facility failed to ensure physician orders were followed for one of twelve sampled residents (R7). Observations and interviews confirmed that mineral oil and bilateral Velcro leg wraps were not applied as ordered by the physician.
Deficiencies (1)
Failure to provide appropriate treatment and care according to physician orders for resident R7, specifically not applying mineral oil and bilateral Velcro leg wraps as ordered.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Confirmed during interview that resident R7 did not have leg wraps applied as ordered. |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, notification of changes, life support orders, accident prevention, food safety, and dietary services at Rock River Nursing & Rehab.
Findings
The facility was found deficient in multiple areas including failure to provide written notice of rules regarding heating food brought in from outside, failure to notify a resident's representative of changes in condition and new medication, lack of a signed DNR order, inadequate investigation of resident falls, provision of food at unsafe temperatures, and improper food handling and sanitation practices in the kitchen.
Deficiencies (6)
Facility did not always provide orally and in writing, in a language residents can understand, the notice of rules and services prior to or upon admission, specifically regarding heating food brought in from outside sources.
Facility did not notify a resident's representative when there was a change of condition or new medication involving one resident receiving hospice care.
Facility did not ensure a Do Not Resuscitate (DNR) order was signed by the physician on file for one resident.
Facility did not ensure a safe environment free from accident hazards and adequate supervision to prevent falls for one resident, including failure to conduct root cause analysis of falls.
Facility did not provide residents with meals that were palatable and at an appetizing temperature, with reports of cold and improperly cooked food.
Facility did not ensure food was stored, prepared, and served in accordance with professional standards, including dirty floors, unclean slicer, lack of facial hair restraints, inadequate dish machine temperature verification, improper thermometer cleaning, and poor glove use and hand hygiene by kitchen staff.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 11
Residents affected: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook-S | Observed not cleaning thermometer between food items, improper glove use, and not wearing facial hair restraint | |
| LPN-E | Licensed Practical Nurse | Interviewed regarding facility policy on heating food brought in from outside sources |
| CNA-G | Certified Nursing Assistant | Interviewed regarding heating food brought in from outside sources |
| LPN-F | Licensed Practical Nurse | Interviewed regarding heating food brought in from outside sources |
| DON-B | Director of Nursing | Interviewed regarding heating food policy and notification of resident representative |
| NHA-A | Nursing Home Administrator | Interviewed regarding heating food policy and DNR order discrepancy |
| RDCO-C | Regional Director of Clinical Operations | Interviewed regarding notification of resident representative and DNR order discrepancy |
| RN-D | Registered Nurse | Interviewed regarding contact with resident's family and notification procedures |
| RN-I | Registered Nurse | Interviewed regarding resident's code status and diet consistency |
| CNA-K | Certified Nursing Assistant | Interviewed regarding resident's fall risk and supervision |
| RD-J | Registered Dietician | Interviewed regarding diet orders and communication of diet changes |
| DMR-U | Director of Medical Records | Observed passing out drinks and described procedures |
| CNA-N | Certified Nursing Assistant | Interviewed regarding communication of diet modifications |
| DM-P | Dietary Manager | Interviewed regarding kitchen sanitation and dish machine temperature monitoring |
| Cook-R | Interviewed regarding dish machine temperature monitoring | |
| DA-Q | Dietary Aide | Observed placing dirty dishes in dish machine |
| CNA-T | Certified Nursing Assistant | Interviewed regarding meal tray service |
Inspection Report
Deficiencies: 17
Date: Oct 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, medication administration, care and services, environment, staffing, therapy services, food services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to ensure residents were treated with dignity and respect, improper medication administration, inadequate staffing, poor environmental cleanliness, failure to provide appropriate therapy services, improper food service practices, and inadequate infection control measures.
Deficiencies (17)
Staff entered residents' rooms without knocking, violating residents' rights to dignity and respect.
Residents were allowed to self-administer medications without proper clinical appropriateness or physician orders.
Facility failed to maintain personal and medical records private and confidential; medication cart left unlocked with resident information visible.
Facility did not provide a safe, clean, comfortable, and homelike environment; multiple residents reported unclean rooms, sticky bedside tables, clutter, and long call light wait times.
Facility failed to follow grievance process and did not promptly resolve or document grievances for multiple residents.
Facility failed to ensure proper assessment and monitoring of physical restraints; resident with seatbelt in wheelchair was not assessed for restraint use.
Facility failed to provide treatment and care according to orders, resident preferences, and professional standards; wound care was delayed and improperly performed, and communication with managed care organization was poor.
Facility failed to ensure adequate nursing staff to meet resident needs; multiple residents reported long call light wait times, unmet toileting needs, and insufficient assistance.
Facility failed to ensure adequate supervision and safety to prevent accidents; resident with seizure disorder and anticoagulation therapy had multiple falls with head injuries and inadequate fall prevention interventions.
Facility failed to ensure residents received diet and fluids consistent with physician orders; residents received wrong diet textures and inappropriate liquids.
Facility failed to ensure medication error rates were below 5%; multiple residents received medications outside the ordered time window without proper documentation or physician notification.
Facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures; multiple residents and test trays had cold or unpalatable food and beverages.
Facility failed to provide special eating equipment and utensils as indicated in residents' plans of care; residents were observed using inappropriate plates and lacked adaptive utensils.
Facility failed to procure food from approved sources and maintain proper storage and sanitation; staff served expired milk, did not use hair restraints, and had uncovered garbage cans near food preparation areas.
Facility failed to properly dispose of garbage; dumpsters were overflowing with garbage bags on the ground, creating an unsanitary and unhomelike environment.
Facility failed to provide or get specialized rehabilitative services as required; residents with physician orders for physical therapy did not receive timely evaluations or therapy services.
Facility failed to provide and implement an infection prevention and control program; staff did not perform hand hygiene appropriately during wound care and peri care.
Report Facts
Medication opportunities late: 8
Medication opportunities late: 6
Medication opportunities late: 10
Medication opportunities late: 8
Falls: 13
Showers received: 2
Showers received: 1
Shower wait time: 6
Call light wait time: 3
Call light wait time: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA K | Certified Nursing Assistant | Named in dignity violation for entering rooms without knocking and peri care hand hygiene violation |
| LPN N | Licensed Practical Nurse | Named in dignity violation for entering room without knocking |
| IDON B | Interim Director of Nursing | Interviewed regarding multiple deficiencies including dignity, medication administration, staffing, fall prevention, and infection control |
| LPN M | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors and wound care |
| RN C | Registered Nurse | Observed providing wound care with improper hand hygiene and technique |
| UM S | Unit Manager | Interviewed regarding fall prevention and wound care |
| DTS V | Director of Therapy Services | Interviewed regarding lack of therapy services |
| NHA A | Nursing Home Administrator | Interviewed regarding multiple deficiencies including staffing, grievances, food service, and therapy |
| CNA F | Certified Nursing Assistant | Named in staffing and diet texture deficiencies |
| DM E | Dietary Manager | Interviewed regarding food temperatures, diet textures, and adaptive equipment |
| CNA EE | Certified Nursing Assistant | Reported residents left in soiled briefs and staffing concerns |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 21, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide written notice for room changes and inadequate supervision and assessment to prevent elopement for certain residents.
Complaint Details
The complaint investigation focused on allegations that the facility did not provide written notice for room changes to residents and their families, and failed to provide adequate supervision and assessments to prevent elopement for residents at risk. The investigation substantiated these concerns.
Findings
The facility failed to provide prior written notice for room changes to residents and their families, and did not ensure adequate supervision and assessment to prevent elopement for residents at risk. Additionally, deficiencies were found in respiratory care related to lack of physician orders and care plans for oxygen and CPAP use.
Deficiencies (3)
Failure to provide prior written notice including reasons for room changes to residents R2 and R6 and their families.
Failure to ensure adequate supervision and assessments to prevent accidents and elopement for residents R1 and R5 at risk for elopement.
Failure to provide necessary physician orders, care plans, and monitoring for oxygen and CPAP use for residents R2, R3, and R4.
Report Facts
Residents affected by room change notice deficiency: 2
Residents affected by elopement supervision deficiency: 2
Residents affected by respiratory care deficiency: 3
Elopement evaluation score for R1 on 3/6/23: 9
Elopement evaluation score for R5 on 3/20/23: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admissions Coordinator G | Admissions Coordinator | Responsible for coordinating room changes and issuing written notices; admitted not providing written notices for R2 and R6. |
| Social Worker V | Social Worker | Interviewed regarding room change coordination. |
| Director of Nursing B | Director of Nursing | Interviewed regarding elopement monitoring and wanderguard policies. |
| Nursing Home Administrator A | Nursing Home Administrator | Informed of concerns regarding room changes and elopement supervision. |
| RN J | Registered Nurse | Interviewed about CPAP care and elopement monitoring. |
| RN Manager-K | Registered Nurse Manager | Interviewed about elopement monitoring responsibilities. |
| MD-S | Maintenance Director | Responsible for door and wanderguard alarm checks. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Feb 15, 2023
Visit Reason
The inspection was conducted due to complaints involving alleged abuse, neglect, and medication errors at Rock River Nursing & Rehab.
Complaint Details
The complaint investigation involved allegations of abuse, neglect, and medication errors. The nurse was arrested for possession of narcotics while on duty but the facility failed to report this timely. A dietary manager was alleged to have harassed a resident, including inappropriate entry into the resident's room and issuing a restraining order against the resident. The facility's investigation was incomplete as not all residents and staff were interviewed. A resident (R412) did not receive prescribed Diltiazem due to medication unavailability, resulting in hospitalization for atrial flutter with rapid ventricular response.
Findings
The facility failed to timely report an alleged nurse arrest for possession of narcotics, did not conduct a thorough investigation into resident harassment allegations involving a dietary manager, and failed to ensure a resident received prescribed medication resulting in hospitalization.
Deficiencies (3)
Failure to timely report alleged abuse involving a nurse arrested for possession of narcotics.
Failure to respond appropriately to alleged violations including inadequate investigation of harassment allegations by dietary manager against resident.
Failure to ensure residents were free from significant medication errors; resident did not receive Diltiazem as ordered resulting in hospitalization.
Report Facts
Allegations of abuse reviewed: 7
Facility self-reports reviewed: 4
Residents interviewed: 5
Staff interviewed: 3
Diltiazem doses not administered: 3
Diltiazem dose: 240
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse-H | Nurse | Arrested for possession of narcotics while on duty |
| Director of Nursing (DON)-B | Director of Nursing | Interviewed regarding nurse arrest incident and medication error |
| Dietary Manager (DM)-L | Dietary Manager | Alleged to have harassed resident R37 and issued restraining order; terminated |
| Certified Nursing Assistant (CNA)-N | Certified Nursing Assistant | Witness to harassment incident and served restraining order to resident |
| Medication Technician (Med Tech)-C | Medication Technician | Reported medication unavailability for Diltiazem |
| Registered Nurse (RN)-D | Registered Nurse | Reported medication unavailability and administration issues for Diltiazem |
| Consultant-P | Consultant | Involved in preparing facility self-reports and interviewed about investigation |
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Interviewed regarding investigations and notified of medication error |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jan 14, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to protect residents from sexual abuse by another resident, failure to check employee credentials, failure to follow physician orders for insulin use, improper use of psychotropic medications, food safety violations, improper garbage disposal, failure to maintain accurate medical records, and infection prevention and control deficiencies.
Complaint Details
The complaint investigation revealed substantiated findings of sexual abuse by a resident, failure to verify employee credentials, medication administration errors, prolonged use of psychotropic medications without assessment, food safety violations, improper garbage disposal, incomplete medical records, and infection control breaches.
Findings
The facility failed to protect residents from sexual abuse by another resident, failed to verify credentials of newly hired staff, failed to notify physicians of high blood sugar readings and administer medications as ordered, allowed prolonged use of PRN psychotropic medication without proper assessment, failed to follow food safety and garbage disposal protocols, did not maintain complete medical records for wound care treatments, and failed to implement proper infection prevention and control practices including PPE use and wound care procedures.
Deficiencies (8)
Failure to protect residents from sexual abuse by another resident resulting in psychosocial harm.
Failure to check state professional licensure credentials and nurse aide abuse registry before hiring.
Failure to notify physician of blood sugar readings over 401 mg/dL and failure to provide medications as ordered.
Failure to ensure PRN psychotropic medication was not given for prolonged duration without physician assessment.
Failure to ensure food safety requirements including proper storage, dating, and hair restraints in kitchen.
Failure to ensure garbage and refuse was disposed of properly with closed dumpster lids.
Failure to maintain accurate and complete medical records for wound care treatments.
Failure to implement infection prevention and control program including proper PPE use and wound care procedures.
Report Facts
Residents affected: 2
Blood sugar readings over 401 mg/dL: 15
Lorazepam administration: 4
Wound care missed dates: 20
Food items with expired or missing dates: 10
Dumpster lids open: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Named in relation to sexual abuse incident and credential verification failure. |
| Director of Nursing B | Director of Nursing | Named in relation to sexual abuse incident, credential verification failure, medication administration, and infection control deficiencies. |
| LPN F | Licensed Practical Nurse | Named in relation to failure to notify physician of blood sugar readings and medication administration errors. |
| RN Y | Registered Nurse | Named in relation to medication administration errors and psychotropic medication use. |
| RN G | Registered Nurse | Named in relation to medication administration errors and wound care deficiencies. |
| Dietary Manager Q | Dietary Manager | Named in relation to food safety violations and hair restraint noncompliance. |
| CNA E | Certified Nursing Assistant | Named in relation to infection control PPE noncompliance. |
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