Rockwell Park Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Rockwell Park Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 29, 2024

  Based on observations, record review, resident, physician, and staff interview the facility failed to protect a severely cognitively impaired resident from the right to be free from physical abuse (Resident #5). Resident #5 experienced physical abuse twice on [DATE] when before bingo Resident #4 placed her arm around the Resident #5's neck, and pulled her forward, and then on the same day, placed Resident #5 in a chokehold with her arm while she was seated in her wheelchair. Resident #5 was held in the chokehold position which caused the resident to gasp and her face to become red. In addition, the facility failed to protect a severely cognitively impaired resident from the right to be free from sexual abuse (Resident #3). […]

• Immediate jeopardy, patternF600Sep 29, 2022

  Based on observation, record reviews and resident, staff, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to protect residents' rights to be free from physical and/or emotional abuse for 4 of 4 residents sampled. The abuse occurred on 4 separate occasions. The [AGE] year-old resident (Resident # 1) had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 pushed an [AGE] year-old male resident (Resident #4) to the floor in July, 2022, followed by Resident #1 grabbing the wrist of a [AGE] year-old female resident (Resident # 6) causing a bruise in August, 2022, then punched a [AGE] year-old male resident (Resident # 2) in the chest, September, 2022, and intimidated and threatened physical harm through verbal communication to a [AGE] year-old male… […]

• Immediate jeopardy, patternF610Sep 29, 2022

  Based on resident and staff interviews, record review and policy review, the facility failed to thoroughly investigate abuse and protect the residents from further abuse for three (3) of 4 residents reviewed for abuse (Resident #2, Resident #4, and Resident #6). Specifically, when Resident #1 began exhibiting verbally and physically aggressive behaviors directed towards others in July 2022, the facility failed to implement effective measures to prevent further abuse due to all interventions placed during investigations by the facility were temporary and their discontinuation left other residents at risk for potential of abuse. […]

• Immediate jeopardy, patternF686Nov 10, 2021

  Based on record review, observation and interviews with resident, staff, guardian, Wound Family Nurse Practitioner and physician, the facility failed to: assess and document wounds consistently; provide wound treatments as ordered; and provide pressure relief from equipment that operated in accordance with manufacturer ' s instructions. These failures led to the development of new wounds, wounds that worsened in size and became infected (#6 and #15), and wounds that resulted in hospital interventions. These problems affected 2 of 3 sampled residents with pressure ulcers. […]

• Immediate jeopardy, patternF725Nov 10, 2021

  Based on record review, observation and interviews of the residents, staff, guardian, and medical staff, the facility failed to provide sufficient nursing staff to 1.) ensure residents received consistent pressure ulcer wound care as ordered and pressure ulcer prevention. for 2 of 3 sampled residents (#6 and #15). 2.) Avoid significant medication errors for 3 of 3 sampled residents reviewed for medication administration (#12, #13 and #14); and 3.) Provide activities of daily living to a resident dependent on staff for nail care and hair washing for 1 of 3 sampled residents (#6). Immediate Jeopardy began on 9/22/21 when there was insufficient staff to carry out wound treatments.for Residents #6 and 15 who both had significant decline to their wounds. […]