Rock River Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at Rock River Nursing & Rehab, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Aug 31, 2022

  Based on observation, interview, and record review, the facility did not follow proper sanitation in accordance with professional standards for food service safety to ensure dishes and utensils were properly sanitized by the facility's dishwashing machine. This had the potential to affect 51 of 53 Residents who receive nutrition orally from food prepared in the kitchen. The wash and rinse temperatures did not meet manufacturer's minimum recommendations for proper washing and rinsing. The facility did not consistently check temperatures and did not [MEDICATION(S)] when temperatures were below minimum wash and rinse temperatures for proper sanitization of dishes and utensils. […]

• Immediate jeopardy, patternF689Jul 23, 2025

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (R2, R3, R8 and R11) reviewed for smoking. The failure to prevent and assess a residents risk for injury related to smoking and not ensuring smoking materials are contained to prevent injury created a finding of Immediate Jeopardy beginning on 7/10/25.Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 4 of 4 residents (R3, R8, R11 and R2) reviewed for supervision with smoking. […]

• Immediate jeopardy, isolatedF684Apr 17, 2025

  Based on interview and record review, the facility did not ensure 2 of 12 residents (R25 and R19) reviewed received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. *R25 has a history of depression and receives medication to treat depression. The facility did not have a care plan, with resident specific interventions in place, upon R25's admission to the facility. R25 displayed multiple behaviors of depression including social isolation, refusals of care, refusal of multiple meals, and meal intake was low since R25's admission. R25's primary Nurse Practitioner (NP)-H, was not notified of R25's low meal intake. […]

• Immediate jeopardy, isolatedF684Jan 15, 2025

  Based on interview and record review, the facility did not ensure residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 4 (R5, R3, R10, and R13) of 21 sample Residents. On [DATE], R5 experienced a seizure, which was a change of condition for R5, as R5 had not a seizure previously. The facility did not ensure that R5 was assessed to determine the etiology of the seizure, did not develop a seizure care plan and did not monitor R5 closely for seizures. R5 experienced another seizure on [DATE]. Following a seizure on [DATE], Lorazepam 0.5 mg every two hours as needed for seizure activity was ordered. This order was not picked up until [DATE]. […]

• Immediate jeopardy, isolatedF755Jan 15, 2025

  Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for 3 (R5, R4, and R3) of 6 residents. On [DATE], R5 experienced a seizure, which was a change of condition for R5. On [DATE], R5 received a physician order for Lorazepam 0.5 mg (milligrams) every 4 hours as needed for comfort medication. This order was not picked up by the facility until [DATE]. R5 experienced another seizure on [DATE]. Following the seizure on [DATE], Lorazepam 0.5 mg every two hours as needed for seizure activity was ordered. This order was not picked up until [DATE]. On [DATE], R5 received an order for Levetiracetam 500 mg (an anti-seizure medication): Give 1 tablet by mouth two times a day for seizures. […]