A list of the most recent deficiencies for Rock River Gardens. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-16 | 2024-01-17 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-10 | 2023-05-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-10 | 2023-05-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-04-10 | 2023-05-19 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-10 | 2023-05-19 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-10 | 2023-04-28 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-10 | 2023-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-10 | 2023-04-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-10 | 2023-04-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-10 | 2023-04-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-10 | 2023-04-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-10 | 2023-04-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-10 | 2023-04-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-10 | 2023-04-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-10 | 2023-04-19 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-10 | 2023-04-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-10 | 2023-04-12 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-10 | 2023-04-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-10 | 2023-04-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-06 | 2023-04-10 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-06 | 2023-04-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2023-04-10 | 2023-04-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-04-10 | 2023-04-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-10 | 2023-04-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-02-01 | 2022-03-01 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-02-01 | 2022-02-28 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-02-17 | 2022-02-25 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-02-17 | 2022-02-25 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-01 | 2022-02-14 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2022-02-01 | 2022-02-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-02-01 | 2022-02-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-01 | 2022-02-11 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-02-01 | 2022-02-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-02-01 | 2022-02-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-02-01 | 2022-02-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-01 | 2022-02-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-01 | 2022-02-01 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-01 | 2022-02-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-02-01 | 2022-02-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-11 | 2022-01-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-01-11 | 2022-01-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-11 | 2022-01-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-04 | 2021-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-16 | 2021-05-25 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-03-04 | 2021-03-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-03-04 | 2021-03-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-03-04 | 2021-03-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-04 | 2021-03-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-03-04 | 2021-03-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-04 | 2021-03-23 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2021-03-04 | 2021-03-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Establish methods for sharing information. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-03-04 | 2021-03-22 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-03-04 | 2021-03-21 | N |
| Develop a communication plan. | Fire Safety | 2021-03-04 | 2021-03-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-03-04 | 2021-03-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-02-16 | 2021-03-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-02-16 | 2021-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-16 | 2021-03-15 | N |
