Inspection Reports for Rock River Healthcare

The inspection was conducted following a complaint alleging that staff searched a resident's personal belongings without permission and took money and personal items.

The facility failed to ensure a resident's right to be treated with respect and dignity and to retain and use personal possessions. Staff searched the resident's room and belongings without his consent while he was hospitalized, removed items including marijuana and money, and the resident reported missing $40. The facility lacked a policy on residents' rights and room searches.

The complaint involved a resident (R1) whose belongings were searched without permission while he was hospitalized. The resident reported missing $40 and felt violated. Staff smelled marijuana and searched the room without resident consent. The investigation found staff conducted the search without proper authorization or notification, and the facility lacked a policy on room searches.

The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment, specifically regarding room temperature control for residents.

The facility failed to maintain a comfortable temperature in one resident's room, with temperatures consistently above 81 degrees Fahrenheit due to malfunctioning air conditioning compressors and reliance on portable units during a heat wave.

The inspection was conducted to assess compliance with medication administration regulations and ensure residents are free from significant medication errors.

The facility failed to ensure one resident (R1) was free from significant medication errors, including missed doses and refusals of seizure medications, which contributed to a seizure event requiring emergency services. Documentation and medication administration practices were inconsistent, and the facility did not document medication card usage properly.

The inspection was conducted due to a complaint investigation regarding the facility's failure to identify a new skin alteration for a resident at risk for developing pressure wounds.

The facility failed to identify new open skin areas on a resident (R1) who is at risk for pressure wounds, despite the resident having two open areas identified during a primary care provider visit. The facility's records did not reflect these new wounds, and no new orders or assessments were documented.

The visit was complaint-related concerning the facility's failure to identify new pressure wounds on resident R1. The complaint was substantiated as the facility did not document or treat the new wounds identified during an external PCP visit.

The inspection was conducted to evaluate the facility's compliance with respiratory care standards, specifically regarding the maintenance and replacement of continuous positive airway pressure (CPAP) machines and supplies for residents using these devices.

The facility failed to maintain and replace CPAP machines and supplies appropriately for 5 of 5 residents reviewed. Several residents had old, unclean, or improperly maintained CPAP equipment, with no physician orders or care plan references for timely replacement of supplies. Staff were uncertain about cleaning protocols and replacement schedules, and the facility's policies lacked specific time frames for exchanging CPAP supplies.

The inspection was conducted due to a complaint investigation regarding physical abuse incidents involving two residents (R1 and R2) at the facility.

The facility failed to ensure residents were free from physical abuse, resulting in R1 being kicked in the genitals and R2 being pushed to the ground, sustaining a displaced fracture of his left femur. Multiple staff interviews confirmed the altercation and the facility's failure to prevent abuse.

The complaint investigation found substantiated physical abuse involving two residents. R1 was kicked in the genitals by R2, who was then pushed back by R1 causing R2 to fall and sustain a fractured femur.

The inspection was conducted to assess compliance with pharmaceutical services and infection prevention and control programs at Rock River Health Care.

The facility failed to ensure the accuracy of medication administration records for 3 residents due to undocumented medication administration, and failed to ensure staff followed enhanced barrier precautions by not wearing required PPE when emptying an indwelling urinary catheter drainage bag for 1 resident.

Routine inspection of Rock River Health Care to assess compliance with regulatory requirements related to resident dignity, safety, medication administration, staffing, nutrition, and pest control.

The facility was found deficient in multiple areas including failure to maintain resident dignity, clean and safe environment, appropriate wound and pain care, medication administration and monitoring, staffing requirements, pharmaceutical services, food service quality, hydration, and pest control.

The inspection was conducted to evaluate the facility's pharmaceutical services and medication administration practices, specifically to ensure residents received their scheduled medications and proper documentation was maintained.

The facility failed to ensure that two residents (R1 and R3) received their scheduled pain medications and failed to document medication administration properly on the Medication Administration Record (MAR). There were missed doses and blank MAR entries despite residents reporting they received medications, and staff admitted to not signing off on the MAR.

The inspection was conducted due to concerns regarding medication reconciliation and administration at Rock River Health Care, specifically focusing on whether residents received their prescribed medications as ordered.

The facility failed to ensure medications were properly reconciled and administered for 4 of 4 residents reviewed, with multiple medications not signed off as given on 5/12/24. Medications were found still in the medication cart after the scheduled administration time, and staff acknowledged issues with signing off medications and potential confusion due to duplicate medication packaging.

The investigation was complaint-related, focusing on medication administration errors and reconciliation failures. The complaint was substantiated as multiple medications were found not administered or not signed off, and staff confirmed issues with medication pass and documentation.

The inspection was conducted to evaluate the facility's catheter care practices and to ensure appropriate care for residents who are continent or incontinent of bowel/bladder, including prevention of urinary tract infections.

The facility failed to provide catheter care in a manner to prevent cross contamination for 1 of 3 residents reviewed. Specifically, improper wiping technique, failure to wipe catheter tubing, placing the urine collection bag on the floor, and not changing gloves after touching the floor were observed.

The inspection was conducted due to a complaint regarding the facility's failure to follow the dietitian's recommendation for free water flushes for a resident with a gastrostomy tube, which resulted in dehydration and hospitalization.

The facility failed to provide the recommended free water flushes of 200 ml every 6 hours to resident R1, leading to dehydration and hospitalization. Documentation showed delays and inconsistencies in administering the recommended hydration, despite medical and dietitian orders.

The complaint investigation found that the facility did not implement the dietitian's recommendation for free water flushes, causing resident R1 to become dehydrated and hospitalized. The deficiency was substantiated with evidence from interviews, record reviews, and hospital documentation.

The inspection was conducted due to a complaint investigation regarding the facility's failure to update fall interventions and fall assessments after a resident experienced a fall.

The facility failed to update fall interventions and assessments for resident R1 after a fall on 9/13/23. The fall care plan was not revised promptly, and no post-fall assessment was completed after the incident, contrary to facility policy requiring immediate intervention updates to prevent further falls.

The complaint investigation found that the facility did not update fall interventions or conduct a post-fall assessment for resident R1 after a fall on 9/13/23. The fall care plan was only updated on 9/19/23, the day of the inspection, which was later than required by policy.

The inspection was conducted due to complaint investigations related to allegations of financial abuse, failure to follow discharge orders, medication administration, pressure ulcer care, fall prevention, smoking safety, nutritional care, medication labeling, infection control, and vaccination policies.

The facility failed to investigate an alleged financial abuse case, did not follow discharge hospital orders for medication and appointments, missed medication doses, failed to monitor and assess a resident's central venous catheter, did not provide appropriate pressure ulcer care, failed to implement fall interventions and smoking safety precautions, did not provide nutritional supplements timely, failed to label insulin pens properly, did not implement enhanced barrier precautions, and failed to offer pneumococcal vaccination series per CDC guidelines.

The complaint investigation included allegations of financial abuse, failure to follow discharge orders, medication administration errors, pressure ulcer care deficiencies, fall prevention failures, smoking safety issues, nutritional care inadequacies, medication labeling errors, infection control program deficiencies, and vaccination policy failures.

The inspection was conducted due to concerns about the facility's failure to reassess and update care plans for residents with behavioral management issues following verbal altercations among residents and staff.

The facility failed to update care plans and document follow-up interventions for three residents (R1, R2, R3) involved in multiple verbal altercations and exhibited behavioral issues. Despite incidents involving aggressive and inappropriate behaviors, no updated care plans or counseling were documented, and staff reported limited ability to manage these behaviors effectively.

The investigation was complaint-related, focusing on behavioral management failures. The report notes multiple incidents of verbal altercations involving residents R1, R2, and R3, with no adequate follow-up or updated care plans documented. The complaint was substantiated by observations, interviews, and record reviews.

The inspection was conducted based on complaints and concerns regarding wound care, resident supervision, medication administration, and food preparation consistency at Rock River Health Care.

The facility failed to ensure proper wound assessment and treatment for two residents, adequate supervision to prevent wandering into other residents' rooms, proper monitoring during medication administration, and appropriate food preparation for residents requiring pureed diets.

The complaint investigation found substantiated issues including failure to assess and treat wounds timely, inadequate supervision of a wandering resident leading to entry into other residents' rooms, failure to monitor medication administration properly, and failure to prepare pureed food to the required consistency.