Rocky River Gardens Rehab and Nursing Ctr
4102 Rocky River Dr, Cleveland, OH 44135 · Cuyahoga County · 120 certified beds · avg 94 residents/day · certified since Jul 1, 1979
Part of chain: GARDEN HEALTHCARE GROUP (6 facilities, chain avg rating 2.5★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
⚠ The most recent standard health inspection was more than 2 years ago — conditions may have changed.
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Dec 4, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 18, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Oct 23, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Dec 4, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jul 22, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jul 23, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 14, 2023 · F-0603
The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment.
Why it matters: Forced isolation is emotionally harmful and can hide neglect or abuse from view.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 11, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jun 14, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 11, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (44)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 20, 2026 | D · Potential for harm, one-off | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · from a complaint |
| Jan 14, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 14, 2026 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jan 14, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Jan 14, 2026 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jan 14, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 14, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 4, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 4, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Oct 23, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jul 22, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 22, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Apr 12, 2024 | F · Potential for harm, facility-wide | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 12, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Apr 12, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Dec 15, 2023 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jun 14, 2023 | ▲ G · Actual harm, one-off | The facility did not protect residents from being involuntarily separated — kept apart from other residents, kept out of their own room, or confined to their room. Isolating a resident this way is a form of mistreatment. |
| Jun 14, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 14, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Jun 14, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Dec 5, 2019 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 5, 2019 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Dec 5, 2019 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Dec 5, 2019 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Dec 5, 2019 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Dec 5, 2019 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Dec 5, 2019 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Dec 5, 2019 | D · Potential for harm, one-off | The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them. |
| Dec 5, 2019 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (12 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 9 | 0 | E |
| 2023 | 13 | 2 | G ▲ |
| 2024 | 15 | 3 | J ▲ |
| 2026 | 7 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $68,068, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Oct 23, 2024 | Fine | $17,068 |
| Oct 23, 2024 | Fine | $17,414 |
| Oct 23, 2024 | Payment Denial | 25 days from Nov 16, 2024 |
| Jul 22, 2024 | Fine | $33,586 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Ohio avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.03 | 3.45 | 3.95 | bottom 27% in Ohio; bottom 15% in the U.S. |
| Registered Nurse hours | 0.37 | 0.60 | 0.69 | bottom 15% in Ohio; bottom 18% in the U.S. |
| Weekend total nurse staffing | 2.61 | 3.07 | 3.50 | bottom 19% in Ohio; bottom 13% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.16 | 0.42 | 0.48 | bottom 3% in Ohio; bottom 6% in the U.S. |
| Total nursing staff turnover (%) | 58.7 | 48.7 | 45.8 | bottom 23% in Ohio; bottom 18% in the U.S. |
| RN turnover (%) | 92.9 | 43.9 | 42.9 | bottom 1% in Ohio; bottom 1% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.21, RN 0.39, weekend 2.77. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Braunstein Bears 2016 Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Chickiestrong Real Estate LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Chickiestrong Rocky River LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Eatery Capital LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Eatery Manager LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Eatery Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Feuer, Samuel | Individual | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Garden Care El-Dg Holdings, LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Garden Ohio Operating Holdings LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Garden Ohio Operating Managing Member LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Leshkowitz, Eli | Individual | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Bhimani, Jayantilal | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/30/2016 |
| Bhimani, Jayantilal | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/30/2016 |
| Bhimani, Jayantilal | Individual | ADP of the SNF | NOT APPLICABLE | 12/30/2016 |
| Braunstein Bears 2016 Trust | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2017 |
| Chickiestrong Real Estate LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2017 |
| Chickiestrong Rocky River LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2017 |
| Eatery Capital LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2017 |
| Eatery Manager LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2017 |
| Eatery Trust | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Under what circumstances, if any, would a resident ever be kept in their room or separated from others?"
- "Does your facility have an active resident council, and how does management respond to its concerns?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Can we tour the whole building today, including resident bathrooms and common areas, not just the lobby?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Larchwood Care | 0.0 mi | Cleveland, OH | ★★★★★ | 4/5 | |
| Aristos Nursing and Rehabilitation | 1.1 mi | Cleveland, OH | ★★☆☆☆ | 2/5 | |
| Westpark Healthcare Campus | 1.1 mi | Cleveland, OH | ★★★★★ | 4/5 | |
| O'Neill Healthcare Fairview Park | 1.6 mi | Fairview Park, OH | ★★★★★ | 5/5 | |
| Welsh Home the | 2.6 mi | Rocky River, OH | ★★★★★ | 5/5 | |
| Gardens of North Olmsted | 3.0 mi | North Olmsted, OH | ★★☆☆☆ | 1/5 | |
| O'Neill Healthcare Lakewood | 3.4 mi | Lakewood, OH | ★★★★☆ | 3/5 | |
| North Park Care Center | 3.4 mi | Brook Park, OH | ★★★★★ | 5/5 | |
| O'Neill Healthcare North Olmsted | 3.4 mi | North Olmsted, OH | ★★★★☆ | 3/5 | |
| Crestmont North Nursing Home | 3.5 mi | Lakewood, OH | ★★★★☆ | 3/5 | |
| Enniscourt Nursing Care | 3.5 mi | Lakewood, OH | ★★☆☆☆ | 2/5 | |
| Normandy Manor of Rocky River | 3.8 mi | Rocky River, OH | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 365392.