Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr · Cleveland, OH · 44135 · 2162513300
120 certified beds For profit - Limited Liability company Chain: Garden Healthcare Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $68,068 in fines in the last 24 months.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
3 immediate-jeopardy citations in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
3 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
$68,068 in federal fines in the last 24 months
3 fines — CMS fines are reserved for verified, serious non-compliance.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 1 of 5 Staffing: 1 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.27 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.33 | 0.55–0.75 |
| Weekend hours / resident-day | 2.87 | ≈ weekday level |
| Nursing turnover / year | 57% | median 45% |
| Fines (3-yr window) | 3 · $68,068 |
Inspection citations (43 in the current record)
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Potential for harm · E January 14, 2026 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 16, 2026 · Quality of Life and Care
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Potential for harm · D January 14, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 16, 2026 · Quality of Life and Care
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Potential for harm · E January 14, 2026 · found via complaint
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.
Corrected January 16, 2026 · Pharmacy Service
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Potential for harm · D January 14, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected January 16, 2026 · Resident Assessment and Care Planning
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Potential for harm · F January 14, 2026 · found via complaint
Provide and implement an infection prevention and control program.
Corrected January 16, 2026 · Infection Control
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Potential for harm · E January 14, 2026 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected January 16, 2026 · Environmental
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Immediate jeopardy · J December 4, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected November 18, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 4, 2024 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected December 11, 2024 · Quality of Life and Care
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Immediate jeopardy · J October 23, 2024 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected December 4, 2024 · Quality of Life and Care
-
Immediate jeopardy · J July 22, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 23, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D July 22, 2024 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 23, 2024 · Resident Rights
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Potential for harm · D April 12, 2024
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected May 10, 2024 · Resident Rights
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Potential for harm · D April 12, 2024
Assess the resident when there is a significant change in condition
Corrected May 10, 2024 · Resident Assessment and Care Planning
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Potential for harm · D April 12, 2024
Ensure each resident receives an accurate assessment.
Corrected May 10, 2024 · Resident Assessment and Care Planning
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Potential for harm · D April 12, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected May 10, 2024 · Quality of Life and Care
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Potential for harm · D April 12, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected May 10, 2024 · Pharmacy Service
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Potential for harm · D April 12, 2024
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.
Corrected May 10, 2024 · Pharmacy Service
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Potential for harm · D April 12, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected May 10, 2024 · Pharmacy Service
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Potential for harm · F April 12, 2024
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.
Corrected May 10, 2024 · Pharmacy Service
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Potential for harm · F April 12, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected May 10, 2024 · Nutrition and Dietary
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Potential for harm · D April 12, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected May 10, 2024 · Resident Assessment and Care Planning
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Potential for harm · F December 15, 2023 · found via complaint
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected December 18, 2023 · Environmental
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Actual harm · G June 14, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 11, 2023 · Quality of Life and Care
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Actual harm · G June 14, 2023 · found via complaint
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected July 11, 2023 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 14, 2023
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected July 11, 2023 · Resident Rights
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 23, 2024 | Fine | $17,068 |
| October 23, 2024 | Fine | $17,414 |
| October 23, 2024 | Payment Denial | 25 days |
| July 22, 2024 | Fine | $33,586 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 365392 · certified since July 1, 1979. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.