Inspection visit
Inspection
31 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 31 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure resident funds were disbursed as required and in a
timely manner after death. This affected one resident (Resident #120) of five residents reviewed for resident
funds. The facility census was 110.
Residents Affected - Few
Findings include:
Review of Resident #120's medical record revealed an admission date of [DATE] and diagnoses including
paranoid schizophrenia, unspecified psychosis, major depressive disorder, schizophrenia unspecified,
unspecified severe protein-calorie malnutrition, psychotic disorder with hallucinations due to known
physiological condition and history of COVID-19.
Review of a Minimum Data Set (MDS) 3.0 dated [DATE] revealed Resident #120 expired in the facility.
Review of a nurses' note dated [DATE] revealed Resident #120 expired in the facility.
Review of Resident #120's resident fund statement revealed as of [DATE], Resident #120 had an ending
balance of $1069.28. There was no evidence of final disbursal for review.
Interview on [DATE] at 4:25 P.M. with Business Office Manager (BOM) #405 revealed she contacted
Resident #120's guardian a week after she died regarding the funds and he had said he would contact the
family. BOM #405 stated she never heard anything back after that. BOM #405 verified Resident #120's
resident funds were not disbursed within 30 days as required after her death.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 15
Event ID:
365392
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0637
Assess the resident when there is a significant change in condition
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview the facility failed to ensure a significant change Minimum Data Set (MDS) 3.0
assessment was completed for Resident #14. This affected one resident (#14) of 25 residents reviewed for
MDS assessments. The facility census was 110.
Residents Affected - Few
Findings include:
Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses
including dementia with behavioral disturbance, diabetes, high blood pressure, anxiety, and depression.
Review of the physician orders for Resident #14 revealed the resident was admitted to hospice services on
02/20/24 for dementia with behavioral disturbance.
Review of the comprehensive annual MDS 3.0 assessment, dated 03/11/24 for Resident #14 under Section
J, Health Conditions, revealed the resident was severely cognitively impaired and did not have a life
expectancy of less than six months but was receiving hospice services.
Interview with MDS Registered Nurse (RN) #540 on 04/12/24 at 11:50 A.M. confirmed Resident #14 was
receiving hospice services and Section J was coded incorrectly because a significant change assessment
was not completed after the resident was admitted to hospice on 02/20/24. MDS RN #540 stated it was
missed when she completed an MDS audit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 2 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of
the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including
dementia with behavioral disturbance, diabetes, high blood pressure, anxiety, and depression.
Residents Affected - Few
Review of the physician orders for Resident #14 revealed the resident was admitted to hospice services on
02/20/24 for dementia with behavioral disturbance.
Review of the comprehensive annual Minimum Data Set (MDS) 3.0 assessment, dated 03/11/24, for
Resident #14 under Section J, Health Conditions, revealed the resident was severely cognitively impaired
and did not have a life expectancy of less than six months but was receiving hospice services. Section M,
Skin conditions, revealed the resident had no pressure ulcers but also had one Stage two pressure ulcer to
the left buttock.
Interview with MDS Registered Nurse (RN) #540 on 04/12/24 at 11:50 A.M. confirmed Resident #14 was
receiving hospice services and that the resident had a pressure ulcer to her left buttock MDS RN #540
confirmed Section J and Section M of the MDS assessment were coded incorrectly.
3. Review of the medical record for Resident #90 revealed an admission date of 06/24/21. Diagnoses
included Alzheimer's disease, dementia with behavioral disturbance, and post-traumatic stress disorder
(PTSD).
Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #90 had impaired cognition.
The assessment also indicated physical restraints were used less than daily.
Observation on 04/10/24 at 8:49 A.M. of Resident #90 revealed the resident was sitting in the dining room
and no restraints were observed. Attempted interview at this time with Resident #90 revealed Resident #90
was noninterviewable.
Interview on 04/11/24 at 11:57 A.M. with Licensed Practical Nurse (LPN) #478 revealed she had never
Resident #90 with any restraints.
Interview on 04/11/24 at 12:15 P.M. with MDS Registered Nurse (RN) #540 stated they did not have any
residents on restraints in the facility. MDS RN #540 stated she accidentally marked that restraints were
used on Resident #90's 01/01/24 quarterly MDS assessment.
Based on observation, interview, and record review the facility failed to accurately complete [NAME] Data
Set (MDS) assessments for Resident #5, #14 and #90. This affected three residents (Residents #5, #14,
and #90) out of 25 residents reviewed for accurate [NAME] Data Set (MDS) assessments. The facility
census was 110.
Findings Include:
1. A record review of Resident #5's medical record revealed Resident #5 was admitted to the facility on
[DATE] with the diagnoses including high blood pressure, Chronic Obstructive Pulmonary Disease (COPD),
history of falls with multiple fractures of the lumbar vertebrae, thoracic vertebrae, and skull. Resident #5
required assistance from staff, was cognitively intact and ambulated with a front wheeled walker and stand
by assist of staff.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 3 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #5's signed physician orders for the month of April 2024 revealed orders including fall
floor mat to right side of the bed dated 01/21/24, bed in the lowest position dated 01/21/24, and bed against
the wall dated 01/21/24.
Review of Resident #5's assessments revealed admission fall risk assessment dated [DATE] Resident #5
was assessed as a high fall risk. Further fall risk assessments dated 01/10/24, 01/15/24, 01/16/24,
01/21/24, 04/07/24 continued to rate Resident #5 as a high fall risk.
Review of Resident #5's progress note dated 01/10/24 at 8:09 P.M. authored by LPN #409 revealed
Resident #5 was observed laying in bed with a large hematoma located to the back of her head. There was
a laceration observed in the center of the hematoma with moderate amount of bleeding observed. Resident
#5 was sent to the hospital emergency room for evaluation and treatment.
Review of Resident #5's progress note dated 01/16/24 at 1:00 P.M. authored by LPN #442 revealed
Resident #5 was observed face down on the floor of the bathroom. Resident #5 was attempting to use the
bathroom independently. Resident #5 was observed with a laceration to the forehead and a skin tear
located to the left hand. Resident #5 was sent to the hospital emergency room for evaluation and treatment.
Review of Resident #5's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
Section J Health Conditions - J1800 Any Falls Since Admission/Entry or Reentry or Prior Assessment
(OBRA or Scheduled PPS) was marked as No. Section J1900 Number of Falls Since Admission/Entry or
Reentry or Prior Assessment (OBRA or Scheduled PPS) B - Number of falls since admission or Prior
assessment - Injury was marked as No.
An observation on 04/11/24 at 9:51 A.M. revealed Resident #5 laying in a low bed against the wall with a
blue fall mat located to the right side of the bed. Resident #5 was resting quietly watching television.
An interview on 04/11/24 at 12:15 P.M. with MDS Registered Nurse (RN) #540 confirmed Resident #5 had
two falls on 01/06/24 and 01/10/24 with injury since admission to the facility on [DATE] and the admission
MDS dated [DATE] was not completed accurately to reflect the two falls and the injury incurred.
2. A record review of Resident #5's medical record revealed Resident #5 was admitted to the facility on
[DATE] with the diagnoses including high blood pressure, Chronic Obstructive Pulmonary Disease (COPD),
history of falls with multiple fractures of the lumbar vertebrae, thoracic vertebrae, and skull. Resident #5
required assistance from staff, was cognitively intact and ambulated with a front wheeled walker and stand
by assist of staff.
Review of Resident #5's admission assessment revealed there were no completed assessments for
enabler or restraint used by Resident #5.
Review of Resident #5's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed
Section P - Restraints and Alarms P0100 Physical Restraints E. Trunk Restraints was marked as used less
than daily.
An observation on 04/10/24 at 3:50 P.M. revealed Resident #5 was sitting independently on the edge of the
bed eating a snack. There was a front wheeled walker located across the room from the bed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 4 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
There was no wheelchair present in the room.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/11/24 at 10:00 A.M. with State Tested Nursing Assistant (STNA) #471 revealed Resident #5
ambulated with a front wheeled walker and stand by assist from staff. Resident #5 does not use a
wheelchair or had any type of restraint or enabler for positioning in bed.
Residents Affected - Few
Interview on 04/11/24 at 12:15 P.M. with MDS RN #540 confirmed Resident #5 does not use a trunk
restraint and the admission MDS dated [DATE] was marked as a trunk restraint being used less than daily
by Resident #5.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 5 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, and interview the facility failed to ensure a skin assessment upon admission was timely
obtained for the accurate initial assessment of skin impairment for Resident #11. This affected one resident
(Resident #11) out of four residents reviewed for pressure ulcers. The facility census was 110.
Residents Affected - Few
Findings Include:
A record review for Resident #11 revealed Resident #11 was admitted to the facility on [DATE] with
diagnoses including chronic kidney disease, heart failure, peripheral vascular disease (PVD), and
Alzheimer's disease. Resident #11 had intact cognition and requires assistance from staff for personal
hygiene cares, dressing, and transfers.
Review of Resident #11's baseline care plan dated 02/02/24 revealed interventions including use of
pressure reducing mattress, pressure reducing cushion in wheelchair, encourage use of appropriate
footwear while out of bed, and assess/monitor skin for impairments.
A review of Resident #11's admission assessment dated [DATE] revealed Resident #11 refused staff to
perform a head-to-toe skin assessment to assess any skin impairments acquired prior to admission.
Review of Resident #11's progress notes dated 02/2/24 to 02/11/24 revealed no further documentation of
attempts by staff to complete the admission head to toe skin assessment for Resident #11.
Review of Resident #11's weekly skin assessment dated [DATE] revealed abrasions located to bilateral
lower legs. No further skin impairments were documented.
A review of Resident #11's shower/skin observation sheets dated 02/02/24 to 04/02/24 revealed no new
skin areas were observed or noted by staff during Resident #11's showers and or bed baths.
An interview on 04/12/24 at 10:22 A.M. with facility wound nurse LPN #419 confirmed Resident #11 did not
have an admission skin assessment completed by staff upon admission and there were no further attempts
to complete a skin assessment due to Resident #11's initial refusal on admission to the facility. LPN #419
stated, The nurses should have attempted to complete the skin assessment within 8 hours of admission. If
the resident refused, the nurse should have asked another nurse to attempt to complete the assessment.
Review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries dated 07/01/17 revealed, Assess
the resident on admission (within eight hours) for exiting pressure ulcer/injury risk factors. Repeat the risk
assessment weekly and upon any changes in condition.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 6 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record revealed Resident #109 was admitted to the facility on [DATE] with diagnoses including
dementia with behavioral disturbance, prostate cancer, shared psychotic disorder, anxiety, and depression.
Review of the physician orders for Resident #109 revealed an order for Zyprexa (an antipsychotic
medication) 7.5 milligrams (mg) for mood at bedtime every day.
Review of the pharmacist recommendations revealed on 12/21/23 the pharmacist requested an appropriate
diagnosis for the use of the antipsychotic medication, Zyprexa, for Resident #109. The pharmacist provided
appropriate diagnoses of Schizophrenia, Schizoaffective disorder, delusional disorder, mania, bipolar
disorder, depression with psychotic features, refractory major depression, schizophreniform disorder,
psychosis, atypical psychosis, or brief psychotic disorder, delirium with manic/psychotic symptoms.
On 01/12/24 the psychiatric NP signed the pharmacist recommendation but did not provide an appropriate
diagnosis for the use of Zyprexa for Resident #109.
Interview with the Regional Director of Clinical Services on 04/11/24 at 1:30 P.M. confirmed the NP did not
select an appropriate diagnosis provided by the pharmacist after signing the pharmacist's recommendation.
Review of policy Medication Regimen Reviews, revised April 2007 did not indicate a time frame for
responses to pharmacy recommendations by the physician.
Based on record review, interview, and review of policy and procedure, the facility failed to ensure
pharmacy recommendations were timely addressed for Resident #90 and #109. This affected two residents
(#90 and #109) of five residents reviewed for unnecessary medications. The facility census was 110.
Findings include:
1. Review of the medical record for Resident #90 revealed an admission date of 06/24/21. Diagnoses
included Alzheimer's disease, dementia with behavioral disturbance, and post-traumatic stress disorder
(PTSD).
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #90 had
impaired cognition.
Review of the pharmacy recommendation for Resident #90 dated 10/31/23 was for Divalproex
(anticonvulsant) 250 milligrams (mg) twice a day. The pharmacy recommendation documented questioning
if a gradual dose reduction (GDR) could be attempted at this time to verify this resident was on the lowest
possible dose? If no, please indicate response below. There was a list of five different response to select
from, but no response was checked. On the bottom of the form, revealed the nurse practitioner checked the
box that read disagree, no change indicated, current benefit outweighs potential risk. The Nurse Practitioner
(NP) signed and dated the pharmacy recommendation on 12/06/23.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 7 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Interview on 04/12/24 at 8:24 A.M. with Regional Director of Clinical Services (RDCS) #538 stated they
would like to see the pharmacy recommendations addressed within 30 days and verified response was not
selected and it was not addressed by the NP until 12/06/23.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 8 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to assess and monitor the use of a necessary
antipsychotic medication. This affected one resident (Resident #10) out of five residents reviewed for
unnecessary medications. The facility census was 110.
Findings Include:
Observation on 04/10/24 at 10:15 A.M. revealed Resident #10 resting quietly in bed. Further observations
on 04/11/24 at 2:25 P.M. and on 04/12/24 at 11:25 A.M. revealed Resident #10 resting quietly in bed with
no behaviors observed.
A review of Resident #10's medical record revealed Resident #10 was admitted to the facility on [DATE]
with the following diagnoses including Chronic Obstructive Pulmonary Disease (COPD), heart failure, high
blood pressure, and Alzheimer's Disease. Resident #10 had impaired cognition and was dependent on staff
for all personal hygiene cares, transfers and dressing.
Review of Resident #10's signed physician orders dated 04/01/24 revealed an order dated 12/25/23 for the
use of antipsychotic medication Zyprexa 2.5 milligrams (MG) to be given daily for behaviors.
Review of Resident #10's Pharmacy Recommendations dated 09/10/23 revealed recommendation for the
physician to address the diagnoses for the use of Zyprexa for behaviors. Response was marked as other please see Doctor's Orders/Progress Notes.
Review of Resident #10's progress notes dated 09/10/24 to 10/01/24 revealed there was no documentation
or entries to reflect the physician addressing or changing the diagnoses for the continued use of Zyprexa.
Review of Resident #10's behavioral documentation dated 02/01/24 to 04/11/24 revealed Resident #10 did
not exhibit any behaviors which were documented by staff.
An interview on 04/12/24 at 12:01 P.M. with the Director of Nursing (DON) confirmed Resident #10's
diagnosis for the use of Zyprexa was for behaviors, and Resident #10 was not exhibiting any behaviors in
the last 90 days. The DON stated, The diagnosis of behaviors is not an appropriate diagnosis for the use of
the antipsychotic medication Zyprexa. The resident has had no behaviors like she had on admission.
Review of the facility's policy titled, Medication regimen Reviews dated 04/01/07 revealed, The primary
purpose of this review is to help the facility maintain each resident's highest practicable level of functioning
by helping them utilize medications appropriately and prevent or minimize adverse consequences related to
medication therapy to the extent possible.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 9 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to maintain a medication
administration error rate of less than 5%. The facility had 37 opportunities for medication error with two
medication errors occurring resulting in a medication error rate of 5.41%. This affected one resident
(Resident #46) out of four residents observed for medication administration. The facility census was 110.
Residents Affected - Few
Findings Include:
Medication administration observation on 04/11/24 at 7:25 A.M. revealed Licensed Practical Nurse (LPN)
#476 preparing morning medication for Resident #46. LPN #476 placed the tablets into a medication pouch
to be crushed and poured into a medication cup. LPN #476 took a soft gel capsule of Omega 3 Fish Oil and
placed it in a separate pouch to crush and pour the liquid into the medication cup. The soft gel was crushed
with a small amount of the liquid being poured into the medication cup. LPN #476 then took a soft gel
capsule of B Vitamin Complex and placed it in a separate pouch to crush and pour the liquid into the
medication cup. The soft gel was crushed with the liquid staying in the pouch. LPN #476 attempted to
squeeze the liquid into the medication cup, this attempt was not successful, and the liquid medication
remained in the pouch. LPN #476 mixed the crushed medications with applesauce and administered the
medication to Resident #46.
Review of Resident #46's physician signed medication orders dated 04/01/24 revealed Resident #46
received the following medications during morning medication administration, Calcium Acetate 667
milligrams (mg), Abilify 20 mg, Aspirin 81 mg, Duloxetine 80 mg, Isosorbide Mononitrate 30 mg,
Levetiracetam 250 mg, B-Complex Vitamin, Carvedilol 3.125 mg, Eliquis 5 mg, Omega 3 Fish Oil 1,000 mg,
Ranolazine 1000 mg, and Topiramate 200 mg. Resident #46 required medications to be crushed for ease in
swallowing.
Review of the manufacturing guidelines for Omega 3 Fish Oil revealed the soft gel capsules should not be
crushed or split for the removal of the liquid may lead to incorrect dosage.
Review of the manufacturing guidelines for the B Vitamin Complex revealed the soft gel capsule form of the
medication should not be pierced, split, or crushed due to the removal of the medication may lead to
incorrect dosage.
Interview with LPN #476 confirmed the soft gel capsules of Omega 3 Fish Oil, and the B Vitamin Complex
should not have been crushed, and a different form of the medication should have been used so that it
could have been crushed and administered correctly.
Review of the facility's policy titled, Administering Medications revised in December 2012 revealed,
Medications shall be administered in a safe and timely manner, and as prescribed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 10 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based
observation, interview, and facility policy review the facility failed to keep medication in a secured
environment, and failed to discard expired tuberculin solution. This had the potential to affect all 110
residents in the facility. The facility census was 110.
Findings Include:
1. Observation on [DATE] at 11:15 A.M. revealed the second-floor medication room door was ajar and not
latched completely allowing the door to be pushed open without the use of the door handle. The door
handle was part of a code locking system with the number 7 button stuck enabling the door to be unlocked.
Observation on [DATE] at 11:20 A.M. revealed the third-floor medication room door was closed but not
locked. By turning the door handle it opened the door without having to enter the code to unlock the door.
Observation on [DATE] at 3:26 P.M. revealed State Tested Nursing Assistant (STNA) #418 opening the door
of the third-floor medication room and entering without having a nurse as an escort into the medication
room. STNA #418 then exited the medication with several boxes of gloves to be used in the resident's
rooms.
Interview on [DATE] at 3:24 P.M. with Licensed Practical Nurse (LPN) #534 revealed the second-floor
medication room door has not been able to be locked in several days due to the number 7 on the code box
being stuck.
Interview on [DATE] at 3:30 P.M. with STNA #418 revealed the third-floor medication room was also where
the resident supplies were stored, and the door had not been locked for several days. The STNAs could go
into the medication room to get the supplies needed to take care of the residents.
Interview on [DATE] at 4:00 P.M. with the Director of Nursing (DON) confirmed the medication rooms on the
second and third floors were unlocked, and the staff were able to enter and exit without using a code to
unlock the doors.
Review of the facility policy titled, Storage of Medications dated 04/12 revealed, Only persons authorized to
prepare and administer medications shall have access to the medication room, including any keys.
2. Observation on [DATE] at 10:48 A.M. in the first floor medication refrigerator revealed two partially used
vials of Apisol Tuberculin (TB) solution with out opened dates on either the vials or the manufacturer boxes.
Interview on [DATE] at 10:55 A.M. with Licensed Practical Nurse (LPN) #475 confirmed the two partially
used TB solution vials without an opened date on the vials or the boxes. LPN #475 stated, Those vials and
boxes should have an opened date on them.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 11 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Observation on [DATE] at 11:05 AM in the third floor medication room refrigerator revealed one partially
used vial of Aplisol TB solution without an opened date on the vial or the manufacturer's box.
Interview on [DATE] at 11:10 A.M. with the Assistant Director of Nursing (ADON) confirmed the one partially
used vial of Aplisol TB solution without an opened dated on the vial or the box. The ADON stated, The vials
and the boxes should have an opened date and not be used passed 30 days from the opened date.
Review of the Aplisol TB solution manufacturer guidelines revealed, Vials in use more than 30 days should
be discarded due to possible oxidation and degradation which may affect potency.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 12 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and policy review, the facility failed to ensure foods were labeled, dated
and not retained when expired. This had the potential to affect 106 residents receiving food from the
facility's kitchen as four residents (Residents #19, #41, #74 and #103) were ordered nothing-by-mouth
(NPO). The facility census was 110.
Findings include:
Observation of the facility's nourishment refrigerators on 04/09/24 starting at 9:51 A.M. with Food Service
Director (FSD) #440 revealed the following:
•
In the first floor resident refrigerator, there were two expired yogurts dated 03/23/24, two expired yogurts
dated 03/26/24 and a half-gallon of milk dated 04/04/24.
•
In the second floor resident refrigerator, there was an unidentified pink substance on the inside base of the
refrigerator and there was frozen popsicle material on the inside base of the freezer.
•
In the third floor resident refrigerator, there were two containers labeled with Resident #85's room number
on it but no date.
Interviews with FSD #440 verified the above findings at the time of observation. FSD #440 indicated she or
another dietary staff would check the refrigerators every Friday for expired food. FSD #440 stated
housekeeping staff helped with this process but ultimately nursing staff were supposed to take expired food
out of the refrigerators. FSD #440 stated these refrigerators were also cleaned weekly. FSD #440 confirmed
there was no documentation regarding staff going through these refrigerators for expired food.
Review of the facility policy, Food Brought by Family/Visitors, revised February 2014 revealed perishable
foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be
labeled with the residents' name, the item and the use by date. The nursing staff is responsible for
discarding perishable foods on or before the use by date. The nursing and/or food service staff must discard
any foods prepared for the resident that show obvious signs of potential foodborne danger.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 13 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, interview, and review of policy and procedure, the facility failed to ensure accurate
documentation of a resident's weight in the medical record. This affected one resident (#107) of three
residents (#41, #114, and #107) reviewed for nutrition. The facility census was 110.
Findings include:
Review of the medical record for Resident #107 revealed an admission date of 08/23/23. Diagnoses
included chronic kidney disease, diabetes mellitus with diabetic nephropathy, protein-calorie malnutrition,
and dementia with behavioral disturbance.
Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #107 had
impaired cognition, weighed 175 pounds (lbs.), had no significant weight changes, and did not receive a
specialized diet.
Review of the weights and vitals summary for Resident #107 revealed:
•
08/23/23 174.4 lbs. on standup scale
•
10/01/23 172.3 lbs. on standup scale
•
12/15/23 176.2 lbs. while in wheelchair
•
01/17/24 175.2 lbs. on standup scale
•
02/08/24 174.7 lbs. while in wheelchair
•
03/07/24 173.6 lbs. on standup scale
•
03/09/24 173.6 lbs. while in wheelchair
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 14 of 15
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365392
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr
Cleveland, OH 44135
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
03/22/24 175.0 lbs. using a mechanical lift scale
Level of Harm - Minimal harm
or potential for actual harm
•
03/24/24 174.2 lbs. while in wheelchair
Residents Affected - Few
•
03/26/24 127.7 lbs. using Hoyer (mechanical lift scale)
•
04/05/24 126.4 lbs. while in wheelchair
Interview on 04/11/24 at 5:12 P.M. with the Director of Nursing (DON) and Licensed Practical Nurse (LPN)
#436 revealed Resident #107 had always been thin and never a huge guy. LPN #436 stated the weight of
170 lbs. were most likely inaccurate and that the resident ate 50-100 % of his meals. DON stated Resident
#107's son was a physician who visited often and had no concerns.
Interview on 04/12/24 at 11:11 A.M. with the DON and Registered Dietitian (RD) #541 stated Resident
#107 had a large wheelchair that weighed 40.8 lbs. and that the documented weights dated 08/23/23
through 03/24/24 included the wheelchair weights. DON stated the resident was always weighed in his
wheelchair and the documented methods of weighing Resident #107 standing or using the mechanical lift
were also inaccurate. DON stated the resident did not require the use of the mechanical life. DON and RD
#541 stated Resident #107 weight had been consistent with no significant weight changes and had not
appeared with any significant weight changes. RD #541 stated the resident had a recent hospitalization and
had some weight loss but had a gained. RD #541 stated Resident #107 was reweighed today at 131 lbs.
Reviewed policy Charting and Documentation revised July 2017 revealed documentation in the medical
record will be objective (not opinionated or speculative), complete, and accurate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365392
If continuation sheet
Page 15 of 15
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Back to topCitations
31 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0232GeneralS&S Epotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0311GeneralS&S Fpotential for harm
Have an enclosure around a vertical opening shaft.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355GeneralS&S Epotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363GeneralS&S Fpotential for harm
Install corridor and hallway doors that block smoke.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0521GeneralS&S Epotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0781GeneralS&S Fpotential for harm
Have restrictions on the use of portable space heaters.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
- 0161GeneralS&S Fpotential for harm
Use approved construction type or materials.
- 0211GeneralS&S Fpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0225GeneralS&S Epotential for harm
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
- 0753GeneralS&S Epotential for harm
Have restrictions on the use of highly flammable decorations.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F758 - Medication Errors
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.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
FAQ · About this visit
Common questions about this visit
What happened during the April 12, 2024 survey of ROCKY RIVER GARDENS REHAB AND NURSING CTR?
This was a inspection survey of ROCKY RIVER GARDENS REHAB AND NURSING CTR on April 12, 2024. The surveyor cited 31 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ROCKY RIVER GARDENS REHAB AND NURSING CTR on April 12, 2024?
Yes, 31 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have corridors or aisles that are unobstructed and are at least 8 feet in width."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.