Inspection Reports for
Rock River Healthcare

The facility failed to ensure a resident's right to be treated with respect and dignity when staff searched a resident's belongings without consent, removing contraband items and causing the resident to feel violated. The facility did not provide a policy on residents' rights and conducting room searches upon request.

The facility failed to maintain a comfortable temperature in one resident's room due to malfunctioning air conditioning compressors during a heat wave.

The facility failed to ensure a resident was free from significant medication errors, affecting one of three residents reviewed.

The facility failed to identify and document new skin alterations for one resident at risk for pressure wounds, resulting in minimal harm or potential for actual harm. The facility's wound policy promotes a systemic approach to wound care and monitoring.

The facility failed to maintain and replace CPAP machines and supplies appropriately for 5 residents, with no clear policy time frames for exchanging masks, tubing, or water tanks. Staff and practitioners acknowledged the need for timely replacement to reduce infection risks.

The facility failed to protect residents from physical abuse, resulting in actual harm to two residents. Resident R1 was kicked in the genitals and Resident R2 was pushed to the ground sustaining a fractured left femur.

The facility was cited for failing to ensure accurate medication administration records for three residents and for not following enhanced barrier precautions during catheter care.

The facility was found to have multiple deficiencies including failure to maintain resident dignity, safe environment, appropriate wound and pain care, adequate RN staffing, medication management, food service, hydration, and pest control.

The facility failed to ensure two residents received scheduled pain medications and failed to document medication administration properly on the MAR for two residents.

The facility failed to ensure medications were reconciled for 4 of 4 residents reviewed. Medications were found still in the medication cart from the prior day, and nurses failed to sign off administration on the MAR. The facility acknowledged issues with medication pass and documentation.

The facility failed to provide catheter care in a manner to prevent cross contamination for one of three residents reviewed.

The facility failed to follow the dietitian's recommendation for free water flushes for one resident with a gastrostomy tube, resulting in dehydration and hospitalization.

The facility failed to update fall interventions and assessments promptly after a resident fall, increasing the risk of further falls. The facility's policy requires post-fall assessments and immediate new interventions if the fall prevention plan fails.

The facility was found to have multiple deficiencies including failure to investigate financial abuse allegations, failure to follow discharge orders and monitor a resident with vision impairment and infection, inadequate pressure ulcer care, failure to implement fall interventions and smoking safety, failure to provide nutritional supplements and assessments, improper medication labeling, failure to implement enhanced barrier precautions, and failure to offer pneumococcal vaccinations per CDC guidelines.

The facility failed to reassess and update care plans for behavioral management for three residents following verbal altercations and incidents. Multiple incidents of verbal aggression and threats were documented without appropriate follow-up or updated interventions.

The facility was cited for multiple deficiencies including failure to provide appropriate wound care for two residents, inadequate supervision of a wandering resident, failure to monitor medication administration, and failure to provide pureed food with proper consistency.