Inspection Reports for Rocky River Gardens Rehabilitation & Nursing Center
OH
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
97 residents
Based on a December 2024 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 2
Date: Dec 4, 2024
Visit Reason
The investigation was triggered by a complaint related to the facility's failure to provide adequate supervision and individualized interventions to prevent an unauthorized leave of absence for Resident #200, who was under adult protective services with a guardian directive prohibiting her husband from taking her off facility premises.
Complaint Details
The complaint investigation found that Resident #200 was taken off facility premises by her husband in violation of a guardian directive, resulting in her death. The facility failed to monitor leave of absence sign-out and adequately supervise the resident. The investigation also found failure to monitor Resident #201's urinary function after catheter removal, leading to urinary retention and infection.
Findings
The facility failed to prevent Resident #200's husband from taking her off premises, resulting in the resident's death by gunshot wound. The facility also failed to adequately supervise the resident during leave of absence and did not implement care plans or interventions to monitor visitation restrictions. Additionally, the facility failed to monitor Resident #201's urinary function after catheter removal, resulting in urinary retention and infection.
Deficiencies (2)
Failure to protect Resident #200 from unauthorized leave and inadequate supervision leading to resident's death.
Failure to ensure appropriate monitoring of Resident #201's ability to urinate and signs of urinary discomfort after catheter removal.
Report Facts
Residents with guardians: 24
Facility census: 97
Duration without documented urination: 14.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #300 | Licensed Practical Nurse | Notified DON of Resident #200 missing and contacted police |
| DON | Director of Nursing | Involved in notification and investigation of Resident #200's unauthorized leave and death |
| Physician #302 | Physician | Notified about Resident #200 missing and death |
| APS Guardian #320 | Adult Protective Services Guardian | Temporary guardian for Resident #200 with visitation restrictions |
| Receptionist #618 | Receptionist | Responsible for monitoring Resident #200's visitation and LOA status |
| RN #589 | Registered Nurse | Removed Resident #201's urinary catheter and provided education |
| RN #585 | Registered Nurse | Authored SBAR and readmission progress notes for Resident #201 |
| CNA #571 | Certified Nursing Assistant | Interviewed regarding Resident #200's visitation and supervision |
| CNA #611 | Certified Nursing Assistant | Interviewed regarding Resident #200's visitation and supervision |
| CNA #588 | Certified Nursing Assistant | Interviewed regarding Resident #200's visitation and supervision |
| LPN #580 | Licensed Practical Nurse | Interviewed regarding Resident #200's visitation and supervision |
| [NAME] President of Operations | President of Operations | Verified documentation and investigation details |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Date: Oct 8, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #69 eloped from the facility without staff knowledge, resulting in immediate jeopardy to resident health and safety.
Complaint Details
The complaint investigation was triggered by Resident #69 eloping from the facility on 10/08/24 at approximately 7:44 P.M. The resident was missing for over two days and was found in Wisconsin on 10/11/24. The investigation found the facility failed to ensure the WanderGuard was functional and adequate supervision was provided. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Findings
The facility failed to provide adequate supervision and ensure the functionality of the WanderGuard device for Resident #69, who eloped from the facility and traveled approximately 425 miles to Wisconsin. The resident missed critical medical treatments during this time. The facility implemented corrective actions including staff education, increased supervision, and audits of WanderGuard functionality.
Deficiencies (1)
Failure to provide adequate supervision and ensure functional WanderGuard for Resident #69, resulting in elopement and immediate jeopardy.
Report Facts
Facility census: 101
Distance traveled by resident: 425
Staff educated: 113
Resident Trust Fund withdrawals: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #811 | Registered Nurse | Assigned nurse on 10/08/24 who witnessed Resident #69 leaving and initiated search and police notification |
| RDO #800 | Regional Director of Operations | Notified of Immediate Jeopardy and involved in root cause analysis and corrective actions |
| RDCS #801 | Regional Director of Clinical Services | Notified of Immediate Jeopardy and involved in review of WanderGuard orders and care plans |
| DON | Director of Nursing | Instructed staff during elopement incident and led staff education on elopement policy and interventions |
| Administrator | Facility Administrator | Involved in search efforts, root cause analysis, and corrective action implementation |
| LPN #812 | Licensed Practical Nurse | Received notification of Resident #69 found in Wisconsin and notified facility leadership |
| STNA #815 | State Tested Nursing Assistant | Assigned to Resident #69's unit during elopement shift and reported resident was agitated and independent |
| STNA #816 | State Tested Nursing Assistant | Supervised nighttime smoke break and reported no alarm or tampering with smoking patio door |
| PM #822 | Program Manager | Volunteer guardian program manager who provided information about Resident #69's history and elopement |
| PP #802 | Primary Physician | Notified of Resident #69 missing and provided medical background |
| DOM #804 | Director of Maintenance | Checked WanderGuard sensors and smoking patio door functionality |
Inspection Report
Complaint Investigation
Census: 99
Deficiencies: 2
Date: Jul 22, 2024
Visit Reason
The investigation was conducted due to complaints regarding neglect and failure to provide adequate care to Resident #101, who fell from bed and subsequently died. The visit focused on assessing compliance with resident rights, abuse prevention, and proper care protocols.
Complaint Details
The complaint investigation was triggered by allegations of neglect involving Resident #101, including failure to prevent a fall, failure to provide timely medical care post-fall, and failure to monitor the resident properly, resulting in immediate jeopardy and death. The investigation included review of video footage, medical records, interviews, and facility policies. The complaint numbers investigated were OH00155612, OH0055552, and OH00155548.
Findings
The facility failed to ensure Resident #101 was treated with dignity and respect, failed to prevent a fall resulting in injury, and failed to provide timely and appropriate post-fall care including neurological checks. The neglect resulted in immediate jeopardy and the resident's subsequent death. Staff education and corrective actions were implemented following the incident.
Deficiencies (2)
Failed to honor resident's right to dignity and respect, resulting in neglect during care.
Failed to protect resident from neglect, including failure to prevent fall, provide timely treatment, and identify acute change in condition.
Report Facts
Facility census: 99
Residents requiring two-person assistance: 7
Residents sampled: 4
Residents affected: 1
Time of fall incident: 1903
Time EMS called: 631
Time resident expired: 749
Employees mentioned
| Name | Title | Context |
|---|---|---|
| STNA #400 | State Tested Nursing Assistant | Named in neglect and fall incident; failed to provide two-person assistance as ordered; terminated following investigation |
| LPN #150 | Licensed Practical Nurse | Failed to identify change in condition and provide timely intervention; suspended pending investigation |
| LPN #205 | Licensed Practical Nurse | Responded to fall incident; assisted resident back to bed; notified family and EMS |
| RDCS #401 | Regional Director of Clinical Services | Led root cause analysis and education; involved in investigation and corrective actions |
| DON | Director of Nursing | Received notification of fall; involved in investigation and corrective actions |
| ADON | Assistant Director of Nursing | Participated in root cause analysis and staff education |
| SS #134 | Social Services | Communicated with resident's family; involved in investigation |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 10
Date: Apr 12, 2024
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to timely disburse resident funds after death, incomplete significant change assessments, inaccurate Minimum Data Set (MDS) assessments, inadequate pressure ulcer care, failure to timely address pharmacy recommendations, improper use and monitoring of psychotropic medications, medication administration errors, unsecured medication storage, improper labeling and storage of medications, failure to discard expired tuberculin solution, improper food labeling and storage, and inaccurate documentation of resident weights.
Deficiencies (10)
Failed to ensure resident funds were disbursed as required and in a timely manner after death.
Failed to ensure a significant change Minimum Data Set (MDS) 3.0 assessment was completed for Resident #14.
Failed to accurately complete Minimum Data Set (MDS) assessments for Residents #5, #14, and #90.
Failed to ensure a skin assessment upon admission was timely obtained for Resident #11.
Failed to ensure pharmacy recommendations were timely addressed for Residents #90 and #109.
Failed to assess and monitor the use of a necessary antipsychotic medication for Resident #10.
Failed to maintain a medication administration error rate of less than 5%, with errors in crushing soft gel capsules.
Failed to keep medication in a secured environment and failed to discard expired tuberculin solution.
Failed to ensure foods were labeled, dated, and not retained when expired in resident refrigerators.
Failed to ensure accurate documentation of a resident's weight in the medical record.
Report Facts
Facility census: 110
Medication administration opportunities: 37
Medication errors: 2
Medication error rate: 5.41
Residents reviewed for MDS assessments: 25
Residents affected by MDS assessment inaccuracies: 3
Residents reviewed for unnecessary medications: 5
Residents affected by pharmacy recommendation delays: 2
Residents reviewed for pressure ulcers: 4
Residents affected by pressure ulcer care deficiency: 1
Residents reviewed for nutrition: 3
Resident #107 weights recorded: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager #405 | Business Office Manager | Interviewed regarding resident funds disbursal delay for Resident #120 |
| MDS Registered Nurse #540 | Registered Nurse | Interviewed regarding MDS assessment inaccuracies and hospice coding errors |
| Licensed Practical Nurse #478 | Licensed Practical Nurse | Interviewed regarding restraint use on Resident #90 |
| Licensed Practical Nurse #409 | Licensed Practical Nurse | Authored progress note documenting Resident #5's head hematoma |
| Licensed Practical Nurse #442 | Licensed Practical Nurse | Authored progress note documenting Resident #5's fall in bathroom |
| LPN #419 | Wound Nurse Licensed Practical Nurse | Interviewed regarding lack of admission skin assessment for Resident #11 |
| Regional Director of Clinical Services #538 | Regional Director of Clinical Services | Interviewed regarding pharmacy recommendation response delays |
| Director of Nursing | Director of Nursing | Interviewed regarding psychotropic medication use and resident weight documentation |
| Licensed Practical Nurse #476 | Licensed Practical Nurse | Observed and interviewed regarding medication administration errors crushing soft gel capsules |
| Licensed Practical Nurse #534 | Licensed Practical Nurse | Interviewed regarding medication room door lock issues |
| State Tested Nursing Assistant #418 | State Tested Nursing Assistant | Observed entering medication room without escort |
| Licensed Practical Nurse #475 | Licensed Practical Nurse | Interviewed regarding expired tuberculin solution vials without opened dates |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding expired tuberculin solution vials without opened dates |
| Registered Dietitian #541 | Registered Dietitian | Interviewed regarding resident #107 weight documentation and accuracy |
| Licensed Practical Nurse #436 | Licensed Practical Nurse | Interviewed regarding resident #107 weight documentation and accuracy |
| Food Service Director #440 | Food Service Director | Interviewed regarding expired foods and refrigerator cleaning |
Inspection Report
Complaint Investigation
Census: 110
Deficiencies: 1
Date: Dec 15, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain the parking lot in a safe manner.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00148014.
Findings
Observations revealed several potholes and significantly damaged pavement in both the front and back parking lots, including sunken areas with standing water and cracked pavement. The Maintenance Director confirmed the damage and stated that repair quotes had been obtained but not approved by the corporate office.
Deficiencies (1)
Failure to maintain the parking lot in a safe manner, including potholes, sunken areas, and cracked pavement.
Report Facts
Repair quote amount: 56800
Facility census: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding the condition of the parking lots and repair quotes. |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 2
Date: Jun 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding involuntary seclusion and residents not being allowed to go outside without an escort or supervision.
Complaint Details
This deficiency represents non-compliance investigated under Complaint number OHO0143495.
Findings
The facility failed to ensure cognitively intact residents were free from involuntary seclusion by restricting their ability to go outside unescorted, resulting in actual psychosocial harm to several residents. The facility also confined some residents to a secured nursing unit without appropriate justification. Additionally, the facility failed to ensure safe administration of IV fluids due to incomplete physician orders.
Deficiencies (2)
Failed to protect residents from involuntary seclusion by not allowing cognitively intact residents to go outside without escort or interference.
Failed to ensure safe administration of IV fluids due to incomplete physician orders lacking time frame and saline concentration.
Report Facts
Facility census: 103
Residents reviewed for involuntary seclusion: 37
Residents affected by involuntary seclusion deficiency: 4
Residents who smoked: 18
Sodium level: 162
Residents reviewed for IV orders: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Practitioner #628 | Certified Nurse Practitioner | Interviewed regarding incomplete IV fluid orders and elevated sodium level in Resident #73. |
| Director of Nursing | Director of Nursing | Confirmed incomplete IV fluid orders and sodium level for Resident #73; confirmed residents were not allowed outside without escort. |
| Administrator | Administrator | Provided information on facility lockdown, escort policy, and smoking break changes. |
| Social Worker #598 | Social Worker | Reported residents upset about inability to go outside without escort. |
| Activities Director #503 | Activities Director | Reported residents needed escort to go outside and no staff available at times. |
| State Tested Nursing Assistant (STNA) #436, #570, #589, #585 | State Tested Nursing Assistant | Provided information on escort requirements and secured unit policies. |
| Licensed Practical Nurse (LPN) #550, #575 | Licensed Practical Nurse | Provided information on escort requirements and secured unit policies. |
| Environmental Service Director #502 | Environmental Service Director | Reported timing of smoking policy changes and outside access restrictions. |
| Regional Director of Operations #616 | Regional Director of Operations | Reported Resident #24 moving off secured nursing unit. |
Inspection Report
Complaint Investigation
Census: 103
Deficiencies: 12
Date: Jun 14, 2023
Visit Reason
The inspection was conducted based on complaints alleging failures in resident care including advanced directives documentation, involuntary seclusion, care planning, bathing assistance, pressure ulcer care, fall supervision, medication regimen review, weight monitoring, IV fluid administration, and hospice care coordination.
Complaint Details
The complaint investigation number OHO0143495 included allegations of failures in resident care such as advanced directives documentation, involuntary seclusion, care planning, bathing assistance, pressure ulcer care, fall supervision, medication regimen review, weight monitoring, IV fluid administration, and hospice care coordination.
Findings
The facility failed to accurately document and update residents' advanced directives, improperly restricted cognitively intact residents' freedom to go outside unescorted, failed to develop and implement complete care plans, did not provide scheduled bathing/showers for dependent residents, failed to timely assess and treat pressure ulcers, did not provide adequate supervision to prevent a fall with injury, failed to complete monthly medication regimen reviews, did not ensure gradual dose reductions for psychotropic medications, failed to coordinate hospice care effectively, and did not maintain infection control during wound care.
Deficiencies (12)
Failed to ensure a resident's advanced directives were accurately recorded throughout the medical record.
Failed to ensure residents were free from involuntary seclusion when cognitively intact residents were not allowed to go outside without escort, causing psychosocial harm.
Failed to develop and implement complete care plans that meet all residents' needs, including for newly amputated toes and pain management.
Failed to provide bathing/showers for dependent residents as scheduled.
Failed to timely assess newly identified pressure ulcers and seek treatment.
Failed to provide adequate supervision and proper footwear to prevent a fall with injury and failed to complete a thorough fall investigation.
Failed to ensure monthly and weekly weights were completed and monitored for residents.
Failed to ensure physician orders for intravenous fluids included time frame and solution percentage.
Failed to ensure a licensed pharmacist performed monthly medication regimen reviews.
Failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications and failed to limit PRN use.
Failed to coordinate care with hospice services in providing care for residents receiving hospice.
Failed to maintain infection control practices during wound dressing changes.
Report Facts
Facility census: 103
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #611 | Registered Nurse | Charge nurse for Resident #35, involved in advanced directives finding |
| Director of Nursing | Director of Nursing | Confirmed advanced directives discrepancy and other findings |
| Social Worker #598 | Social Worker | Interviewed regarding residents not allowed outside without escort |
| Administrator | Administrator | Interviewed regarding facility lockdown and resident supervision outside |
| Activities Director #503 | Activities Director | Interviewed regarding resident preferences and escort policy |
| RN #596 | Registered Nurse | Completed elopement reviews |
| STNA #589 | State Tested Nursing Assistant | Interviewed regarding secured unit and resident supervision |
| LPN #550 | Licensed Practical Nurse | Interviewed regarding secured unit residents and wanderguard use |
| Nurse Practitioner #612 | Nurse Practitioner | Interviewed regarding secured unit appropriateness and weight loss |
| Registered Pharmacist #614 | Registered Pharmacist | Completed consultant pharmacist recommendations |
| Regional Nurse #617 | Regional Nurse | Interviewed regarding fall investigation and wound care |
| Wound Care Nurse LPN #563 | Licensed Practical Nurse | Provided wound care and involved in infection control deficiency |
| Hospice Nurse RN #623 | Hospice Nurse | Interviewed regarding hospice care coordination for Resident #35 |
| Hospice RN #624 | Hospice Nurse | Interviewed regarding hospice care coordination for Resident #80 |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 1
Date: Apr 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to administer rapid-acting insulin in a timely manner to residents requiring insulin daily.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00140218.
Findings
The facility failed to administer rapid-acting insulin at the appropriate time before meals for two residents, which was confirmed through medical record reviews, medication administration records, and staff interviews. The facility policy on insulin administration provided limited guidance on timing.
Deficiencies (1)
Failure to administer rapid-acting insulin in a timely manner according to physician orders and best practices.
Report Facts
Residents requiring insulin daily: 15
Residents affected: 2
Facility census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #204 | Interviewed regarding insulin administration timing | |
| Registered Nurse (RN) #205 | Interviewed regarding insulin administration timing | |
| Licensed Practical Nurse (LPN) #206 | Interviewed regarding insulin administration timing | |
| Licensed Practical Nurse (LPN) #207 | Interviewed regarding insulin administration timing | |
| Licensed Practical Nurse (LPN) #208 | Verified insulin administration times | |
| Regional Director of Clinical Services (RDCS) #210 | Informed of insulin administration concerns and provided guidance | |
| Assistant Director of Nursing (ADON) #211 | Informed of insulin administration concerns | |
| Administrator | Informed of insulin administration concerns |
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 1
Date: Jan 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the improper storage of medications at inappropriate temperatures in the third-floor medication room.
Complaint Details
This deficiency represents noncompliance investigated under Complaint Number OH00136761.
Findings
The facility failed to ensure medications were stored at the appropriate temperatures in the third-floor medication refrigerator, which was found at 52 degrees Fahrenheit, exceeding the recommended 35.6 to 46.4 degrees Fahrenheit. This affected two residents with insulin medications and had the potential to affect an additional 31 residents on the third floor.
Deficiencies (1)
Failure to ensure medications were stored at appropriate temperatures in the third-floor medication room refrigerator.
Report Facts
Facility census: 97
Novolin pens for Resident #52: 4
Novolog pens for Resident #71: 8
Medication refrigerator temperature: 52
Medication refrigerator last logged temperature: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #109 | Verified medication refrigerator temperature and inventory | |
| Director of Nursing (DON) | Provided information on proper insulin storage temperatures |
Inspection Report
Annual Inspection
Census: 99
Deficiencies: 9
Date: Dec 5, 2019
Visit Reason
The inspection was conducted as a comprehensive annual survey of Rocky River Gardens Rehab and Nursing Center to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during medication administration, failure to allow residents to self-administer medications when clinically appropriate, inaccurate resident assessments, incomplete care plan meetings, improper medication disposal, incomplete pharmacy recommendations, and failure to complete ordered laboratory and diagnostic tests. Infection control practices were also found lacking during glucose testing.
Deficiencies (9)
Failed to ensure dignity was maintained during medication administration affecting Resident #50.
Failed to allow Resident #96 the right to self-administer medications despite being cognitively intact.
Failed to ensure comprehensive assessments were accurate for Residents #7, #21, #40, and #103.
Failed to provide quarterly interdisciplinary care plan meetings for Residents #31 and #67.
Failed to ensure timely disposition of unused medications in one medication storage room.
Failed to ensure pharmacy recommendations for Resident #31 were completed when approved by physician.
Failed to ensure laboratory testing was completed as ordered for Resident #67.
Failed to ensure diagnostic testing (mammogram) was completed as ordered for Resident #67.
Failed to maintain infection control practices during blood glucose testing for Resident #60.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Facility census: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #255 | Licensed Practical Nurse | Named in findings related to dignity failure during medication administration and infection control breach during glucose testing |
| LSW #211 | Licensed Social Worker | Interviewed regarding medication self-administration policy and MDS assessment completion |
| DON | Director of Nursing | Interviewed regarding medication self-administration assessments and facility policy |
| RN #213 | MDS Registered Nurse | Interviewed regarding inaccurate assessments and care plan meetings |
| RN #207 | Registered Nurse | Interviewed regarding medication disposal practices |
| LPN #208 | Licensed Practical Nurse | Interviewed regarding incomplete pharmacy recommendations, laboratory and diagnostic testing |
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