Rolling Green Village Care Center

Based on clinical record review, family interview, staff interviews and policy review, the facility failed to immediately notify and inform a family member (Resident #1) and the resident's physician (Resident #2) of a change in status for 2 of 3 residents reviewed for notification. The facility reported a census of 48 residents.Findings include: 1. The Minimum Data Set (MDS) assessment, dated 3/30/26, documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The resident had diagnoses to include medically complex conditions, heart failure, arthritis and respiratory failure. The Care Plan initiated 3/24/26, included a Focus that indicated Resident #1 required assistance with Activities of Daily Living (ADL's). The goal listed Resident #1 would receive assistance with ADLs as required. The interventions included:a. Encourage participation on ADL's. b. Gait belt with transfers and ambulation. c. Provide sufficient time for completion of ADL tasks.d. Staff will allow resident independence to the best of their ability with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interviews, the facility failed to develop and implement a comprehensive person centered Care Plan for 1 of 14 residents reviewed for Care Plans (Resident #8). The facility reported a census of 47 residents. Findings include: Resident #8's Minimum Data Set (MDS) assessment dated [DATE] indicated they had symptoms of feeling down, depressed or hopeless for several days during the lookback period. The MDS included diagnoses of medically complex conditions and depression. The MDS reflected Resident #8 took an antidepressant during the lookback period. Resident #8's Medical Diagnoses reviewed on 11/14/24 listed diagnoses of major depressive disorder, recurrent, in partial remission. Resident #8's November 2024 Medication Administration Record (MAR) included the following orders: a. Bupropion HCI ER (antidepressant) oral tablet 150 milligrams (mg) related to Major Depressive Disorder b. Fluoxetine HCI (antidepressant) oral capsule 40 mg, related to Major Depressive Disorder…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and policy review the facility failed to revise a Care Plan for 1 of 15 residents reviewed (Residents #47). The facility reported a census of 47 residents. Findings include: Resident #47's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #47 required set up or clean up assistance with eating. Resident #47's MDS included diagnoses of hypertension (high blood pressure), traumatic brain injury, and dysphagia (difficulty with swallowing). The MDS documented Resident #47 received a mechanically altered diet that required a change in texture of food or liquids. A Physician diet order dated 7/22/24 directed staff to administer a mechanical soft diet with pureed meats with all solids cut into bite size pieces, only soft canned vegetables or fruit, no lettuce or cabbage unless pureed and honey consistency liquids. The Share Negotiated Risk Agreement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident and staff interview, the facility failed to meet professional standards of quality for services provided during medication administration for 1 of 1 resident reviewed (Resident #51). The facility reported a census of 47 residents. Finding include: Resident #51's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, anemia (low iron levels in the blood), atrial fibrillation (abnormal heart rate), hypertension (high blood pressure), renal insufficiency (poor kidney function), diabetes mellitus, hyperlipidemia (elevated type of cholesterol), seizure disorder, respiratory failure and metabolic encephalopathy (brain dysfunction due to problems with the metabolism). The Incident Report - Medication Event dated 11/2/24 at 7:21 PM identified Resident #51 received another resident's (Resident #46) supper and hour of sleep (HS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, facility policy review, resident, and staff interview the facility failed to keep a resident's environment free from accidents and hazards by not storing the resident's smoking materials in a secured location for 1 of 1 resident reviewed for smoking (Resident #30). The facility reported a census of 47 residents. Findings include: Resident #30's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #30 used a wheelchair for mobility. The MDS further documented the resident had diagnoses to include diabetes, arthritis, Parkinson's disease, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis. Resident #30 reported shortness of breath with exertion and while lying flat. The MDS described Resident #30 as a current tobacco use. The Care Plan Focus with a target date of 12/26/24 indicated Resident #30 preferred to smoke. The Goal reflected Resident #30 would follow the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, policy review and staff interview, the physician failed to respond to gradual dose recommendations (GDR) for 1 of 5 residents reviewed (Residents #9). The facility reported a census of 47 residents. Findings included: 1. Resident #9's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS included diagnoses of heart disease, respiratory failure, metabolic encephalopathy (brain dysfunction due to problems with the metabolism) and depression. The MDS documented Resident #9 received an antidepressant medication during the lookback period. The Care Plan Focus with a target date of 11/27/24 indicated Resident #9 used a psychotropic medication in the category of an antidepressant. The Intervention instructed to evaluate for GDR quarterly or as indicated. Resident #9's November 2024 Medication Administration Record (MAR) included the following psychotropic medications: a. Start date 3/25/24:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, resident interview, staff interviews and policy review, the facility failed to ensure residents are free of significant medication errors for 1 of 1 resident reviewed (Resident #51). During the orientation of one Certified Medication Aide (CMA), Staff K, the trainer gave the person in training resident's medications without ensuring they gave the medications to the correct resident. Due to it only being Staff K's second day of training she didn't know the residents and gave Resident #51, Resident #46's supper and hour of sleep medications (HS). The facility reported a census of 47 residents. Findings include: Resident #51's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions, anemia (low iron levels in the blood), atrial fibrillation (abnormal heart rate), hypertension (high blood pressure), renal insufficiency (poor kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to discard expired stock medications to avoid compromising the integrity of the medications. The facility reported a census of 47 residents. Findings include: On 11/13/24 at 2:35 PM observed the medication room across from the nurses' station with Staff B, Licensed Practical Nurse (LPN). The room contained the following expired items: a. 1 unopened bottle of Rubbing Alcohol 70%, 16 fluid ounces with an expiration date of March 2024. b. 1 unopened box of Assure Prism Blood Glucose Monitoring System with an expiration date of 8/25/24 c. 2 unopened bottles of Geri Dryl (similar to Benadryl) Allergy Relief with an expiration date of September 2024. In an interview on 11/13/24 at 3:10 PM, the Assistant Director of Nursing (ADON) stated she didn't know if they had a facility policy related the prevention of expired stock medications in the medication storage area but she would implement one if they didn't. She stated she expected the staff to discard all expired medications, so the staff didn't use or give them to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, menu review, observations, staff interviews, and policy review the facility failed to provide residents food in a form to meet the needs of 2 of 6 residents (Resident #51 and #50). The facility reported a census of 47 residents. Findings include: A Physician diet order dated 10/24/24 for Resident #51 directed staff to administer a mechanical soft, ground meat diet. A Physician diet order dated 11/6/24 for Resident #50 directed staff to administer a mechanical soft texture diet. A facility menu titled Week 3 Wednesday documented the noon meal for a mechanical soft diet included a ground steak sandwich with grilled onion, potato salad with no raw vegetables, cooked broccoli cuts and maraschino cherry cake. On 11/13/24 at 11:20 AM, prior to the start of the noon meal service, observed the steam table didn't contain ground steak meat. The observation of the steak meat revealed various sizes of cut up meat. On 11/13/24 observations during the noon meal service revealed Staff A, Cook, prepared a steak sandwich with cut up meat for Resident #51. They served…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility document review, and staff interviews the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 5 of 31 days reviewed (September 23rd through October 23rd). The facility reported a census of 37 residents. Findings include: Review of a facility provided document titled Nurse Dept (9/23/2023-10/23/2023) revealed the facility had no RN coverage on 9/24/23, 10/7/23, 10/21/23, and 10/22/23. The document further revealed that the facility only had 4.5 hours of RN coverage on 10/8/23. During an interview on 10/26/23 at 11:21 AM with the Administrator revealed that there was no RN coverage for 8 hours on 9/24/23, 10/7/23, 10/13/23, 10/21/23, and 10/22/23. The Administrator revealed there was RN coverage from 3:30 PM-8 PM only on 10/8/23. The Administrator further revealed her expectation is for RN coverage for 8 hours a day. During a follow up interview 10/26/23 at 1:40 PM with the Administrator revealed the facility does not have a policy for staffing RN's 8 hours a day, but that it's a regulation.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation and staff interviews, the facility failed to supervise administration of medication according to accepted standards of clinical practice for 2 of 6 residents reviewed for medication administration (Residents #15 and #188). The facility reported a census of 37 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] documented Resident #15 had a Brief Interview for Mental Status (BIMS) of 5 out of 15 indicating severely impaired cognition. The MDS further documented the resident had diagnoses to include non-Alzheimer's dementia. The Care Plan with a target date 12/14/23 documented Resident #15 had impaired cognition such as impaired short term/long term memory, being easily confused, disorientation to person, situation and needing assist with decisions. The Care Plan had a goal the resident would accept redirection when confused. Review of Resident #15's October 2023 Medication Administration Record (MAR) revealed the following order: a. Miralax Oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice as the facility failed to obtain a physician's order for a continuous positive airway pressure (CPAP) and failed to ensure proper cleaning and storage of the CPAP machine, tubing, and mask for 1 of 3 residents (Resident #15) reviewed. Facility reported a census of 37 residents. Findings include: A Minimum Data Set (MDS) dated [DATE] for Resident #15, included diagnoses of Non-Alzheimer's Dementia and Obstructive Sleep Apnea. A Brief Interview for Mental Status (BIMS) score of 5 out of 15 indicated severe cognitive impairment for decision making. Observation and interview on 10/24/23 at 2:48 PM, a CPAP, mask and tubing were sitting on Resident #15's end stand. The resident stated he wears the CPAP at night as the CPAP helps him sleep better, the staff have to help him put the CPAP on, and he denied that the staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility policy review the facility failed to store food in accordance with professional standards for 37 of 37 residents. The facility reported a census of 37 residents. Findings include: On 10/23/2023 from 11:00 AM through 11:20 AM a continuous observation during the initial kitchen tour revealed: a. A 4 pound bag of Fajita Blend vegetables opened with approximately half of the vegetables gone with no open date in the double door freezer in the kitchen. b. A 4 pound bag of Country Blend vegetables opened with approximately half of the vegetables gone with no open date in the double door freezer in the kitchen. During an interview on 10/23/2023 at 11:10 AM with the Dietary Manager revealed her expectation is for opened items to have a date on the bags to show when they were opened. During an interview on 10/23/2023 at 12:43 PM with the Administrator revealed that her expectation is for items to be dated when opened in the kitchen. Review of a facility provided policy titled Frozen Food Storage, documented: Frozen leftovers will be labeled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, facility policy review and skills checklist review, the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents when providing cares and treatments. (Resident #4 and #31). The facility reported a census of 37 residents. Findings include: 1. Resident #4's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. The MDS indicated Resident #4 required an indwelling catheter. The MDS included diagnoses of obstructive uropathy, diabetes mellitus, anxiety disorder and depression. During an observation of catheter care and emptying of the catheter bag on 10/24/23 at 2:00 PM, Staff A, Certified Nursing Assistant (CNA) completed hand hygiene and donned appropriate personal protective equipment (PPE) for Enhanced Barrier Precautions prior to entering the resident's room. Resident #4 stood in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.