Rock River Health Care

In the surveyor’s words

From the most serious findings on record at Rock River Health Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Sep 13, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident's discharge hospital orders were followed for medication administration, and discharge procedures and appointments. The facility failed to assess and monitor a resident with a known vision impairment, and a known facial infection on antibiotic therapy. The facility failed to monitor and assess a central venous catheter site. This failure resulted in a resident with a vitreous hemorrhage having no surgical intervention and follow up care, and the resident continuing to complain of decreased vision, facial pain, and swelling. This applies to 1 of 17 residents (R59) reviewed for quality of care in the sample of 17. […]

• Immediate jeopardy, isolatedF880May 14, 2021

  I. Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering Person Under Investigation (PUI) resident rooms to prevent exposure to COVID-19 and failed to identify residents on transmission based precautions (TBP) for two of two residents (R320 & R318) reviewed for transmission based precautions. […]

• Actual harm, isolatedF692Dec 10, 2025

  Based on observation, interview and record review the facility failed to obtain accurate weights on a resident with a feeding tube (R14). The facility failed to weigh a resident (R14) as per the dietician's recommendations. The facility failed to notify the dietician of a resident's (R14) refusals of tube feedings. The facility failed to notify the dietician of missed or omitted tube feedings for R14. The facility failed to notify the dietician or nurse practitioner of R14's significant and continued weight loss in a timely manner. These failures contributed to R14 sustaining a significant weight loss. […]

• Actual harm, isolatedF600Mar 24, 2025

  Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 6. This failure resulted in R1 being kicked in the genitals and R2 being pushed to the ground and sustaining a fracture of his left femur. The findings include: R1's face sheet showed he was admitted to the facility 4/23/2021 with diagnoses to include acute kidney failure, obstructive uropathy, benign prostatic hyperplasia, and major depressive disorder. R1's medical record showed he had an inguinal hernia repair 3/13/25 and could return to normal activity 3/17/25. R1's 2/17/25 assessment showed he has no cognitive impairment and exhibits no behaviors. […]

• Actual harm, isolatedF697Oct 9, 2024

  Based on observation, interview and record review the facility failed to perform a pain assessment on R42 who was admitted for a left tibia and fibula fracture. They also failed to provide R42 with her prescribed hospital discharge pain medications, this failure resulted in R42 having to return to the hospital to be treated for uncontrolled pain for 1 of 2 residents (R42) reviewed for pain in the sample of 20. The findings include: On 10/07/24 at 9:00 AM, R42 was lying in bed with her left lower leg wrapped with an elastic dressing. On 10/07/24 at 9:01 AM, R42 said, I fell and broke my tibia and fibula close to the foot. I am currently non-weight bearing. The doctor told me he was going to wrap it for now and will eventually place me in a cast .a walking cast, I hope. […]