Rocky River Gardens Rehab and Nursing CTR

In the surveyor’s words

From the most serious findings on record at Rocky River Gardens Rehab and Nursing CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 4, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, closed record review, review of hospital records, review of a protective order, review of a police report, facility policy review and interview, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent an unauthorized leave of absence (LOA) for Resident #200, who was under adult protection services (APS) with a guardian and guardian directive which prohibited Resident #200's husband from taking the resident off facility premises or into his vehicle. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] at approximately 6:00 P.M. […]

• Immediate jeopardy, isolatedF689Oct 23, 2024

  Based on observation, medical record review, review of the facility investigation, hospital record review, review of the facility root cause analysis, review of facility policy and interviews, the facility failed to provide adequate supervision and monitor WanderGuard (wearable device to help keep residents at risk of wandering safe) functioning for Resident #69, a resident with a history of exit seeking behavior to prevent elopement. This resulted in Immediate Jeopardy and the potential for serious harm, injury and/or death on [DATE] at approximately 7:44 P.M. when Resident #69 eloped from the facility without staff knowledge, through a smoking patio exit door and traveled from Ohio (OH) to Wisconsin (WI), under unknown circumstances. […]

• Immediate jeopardy, isolatedF600Jul 22, 2024

  Based on closed medical record review, video footage with audio review, emergency medical services (EMS) run sheet review, hospital record review, interviews, and review of the facility's Change in a Residents' Condition or Status policy and procedure and Abuse, Neglect, Exploitation and Misappropriation policy and procedure, the facility failed to provide adequate and necessary care and services to prevent neglect involving Resident #101. This resulted in Immediate Jeopardy, including actual harm and subsequent death beginning on [DATE] at 7:03 P.M. […]

• Actual harm, isolatedF603Jun 14, 2023

  Based on observations, resident interviews, staff interviews, medical record review, admission agreement review, smoking policy review, review of the Secured Unit Agreement, and resident rights policy review, the facility failed to ensure residents were free from involuntary seclusion when cognitively intact residents were not afforded the opportunity to go outside without an escort of staff or interference. This resulted in actual psychosocial harm for two Residents (#57 and #252) were not allowed to freely go outside at will. This resulted in cognitively intact Resident #57 expressing wanting to leave the facility and was told by staff he could not leave. […]

• Actual harm, isolatedF689Jun 14, 2023

  Based on record review, facility policy and procedure review and interview, the facility failed to provide Resident #30 adequate supervision and ensure proper footwear while ambulating to prevent a fall with injury. The facility also failed to complete a thorough fall investigation following the fall with injury. Actual harm occurred on 02/23/23 when Resident #30, who was severely cognitively impaired, at risk for falls and required (staff) supervision with ambulation fell while ambulating independently and sustained a fractured right clavicle and right hip requiring surgical intervention. This affected one (#30) of three residents reviewed for falls. […]