Rolling Hills Care Center

Based on record review and interview, the facility failed to ensure medication was administered according to physician orders for 1 (#1) of 3 sampled residents reviewed for medication administration. The administrator identified 55 residents resided in the facility. A quarterly assessment for Resident #1, dated 03/27/26, showed the resident was severely cognitively impaired for daily decision making with a brief interview for mental status score of 0. An admission record for Resident #1, dated 04/18/26, showed the resident had diagnoses which included Alzheimer's disease, dementia, hypertension, and depression. A physician order for Resident #1, dated 05/14/26, read in part, Risperdal oral tablet 1mg. Give one tablet by mouth two times a day. A physician order for Resident #1, dated 05/14/26, read in part, metoprolol succinate extended-release oral tablet 24-hour 50 mg. Give one tablet by mouth one time a day. On 06/02/26 at 11:13 a.m., CMA #2 stated they did not crush medications for Resident #1 because they did not have an order to crush the medications. On 06/02/26 at 11:17 a.m.,…

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, record review, and interview, the facility failed to ensure 1 (treatment cart #1) of 3 treatment carts observed were locked.The DON reported 50 residents resided in the facility.On 12/02/25 at 10:57 a.m., treatment cart #1 was observed to be South of the nurse's station, unlocked and unattended. On 12/02/25 at 10:58 a.m., LPN #1 was observed sitting on the North side of the nurse's station with their back to treatment cart #1. The cart was observed to be unlocked and unattended. On 12/02/25 at 3:03 p.m., treatment cart #1 was observed to be unlocked and unattended on the South side of the nurse's station. On 12/02/25 at 3:04 p.m., LPN #2 was observed to walk out the of the storage closet on Hall A, toward treatment cart #1 located on the South side of the nurse's station. Treatment cart #1 was observed to be unlocked and unattended. On 12/02/25 at 3:06 p.m., RN #1 was observed to stand in room A1 on Hall A. Treatment cart #1 was observed to be unlocked and unattended. On 12/08/25 at 12:51 p.m., treatment cart #1 was observed to be unlocked and unattended…

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 record review and interview, the facility failed to ensure assessments were accurate for 1 (#26) of 2 sampled residents reviewed for indwelling urinary catheters.LPN #1 identified four residents had indwelling urinary catheters.Findings: Based on record review and interview, the facility failed to ensure assessments were accurate for 1 (#26) of 2 sampled residents who were reviewed for indwelling urinary catheters. LPN #1 identified four residents who had indwelling urinary catheters. Findings: On 12/03/25 at 9:38 a.m., Resident #26 was observed in their room. An indwelling urinary catheter bag was observed to hang from their chair. On 12/09/25 at 11:30 a.m., LPN #1 and CNA #1 were observed to provide care to the resident's suprapubic catheter. A policy titled, MDS Assessment Coordinator, dated November 2019, read in part, Each individual who completes a portion of the assessment [MDS] must certify the accuracy of that portion of the assessment by: a. Dating and signing the assessment [MDS]; and b. Identifying each section completed. A physician order, dated 08/02/25,…

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 record review and interview, the facility failed to close out trust accounts and convey funds within 30 days for three (#115, #116, and #18) of three residents reviewed for open trust accounts and had been discharged from the facility over 30 days. The Business Office Director identified five residents who no longer resided in the facilty and trust accounts were not closed out within 30 days. Findings: 1. Resident #115 discharge summary documented the resident had been discharged from the facility on 10/11/23. Resident #115 trust account ledgers, dated 05/07/23, documented the resident had an open trust account balance of $$3,577.07. 2. Resident #116 discharge summary documented the resident had been discharged from the facility on 08/02/23. Resident #116 trust account ledgers, dated 05/07/23, documented the resident had an open trust account balance of $2,617.85. 3. Resident #118 discharge summary documented the resident had been discharged from the facility on 07/14/23. Resident #118 trust account ledgers, dated 05/07/23, documented the resident had an open trust account…

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 record review and interview, the facility failed to ensure residents who received medicaid and had money in the trust account were notified of balances within $200 of the social security resource limit of $2,000 for three (#9, #13 and #45) of three sampled residents reviewed for trust account balances. The business office manager identified 33 residents who had a payer source as medicaid and had money in the resident trust account. Findings: An undated Accounting of Resident Funds policy, read in part, .a representative of the business office informs the resident if the balance in personal funds account reached $200 less than the .resource limit . 1. Resident #9 trust account ledger, documented they had a current balance of $2,063.56 on 05/07/24. The admission summary documented Resident #9 had a payer source of medicaid. 2. Resident #13 trust account ledger,documented they had a current balance of $2,650.20 on 05/07/24. The admission summary documented Resident #13 had a payer source of medicaid. 3. Resident #45 trust account ledger, dated 05/07/24, had a current balance…

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 record review and interview, the facility failed to ensure summaries of the admission care plan was provided to residents for three (#35, #51 and #114) of three newly admitted residents reviewed for base line care plans. The facility form 802 matrix identified four residents who had been admitted to the facility in the past 30 days. Findings: 1. Resident #35 admission summary documented they were admitted to the facility on [DATE]. Resident #35 base line care plan was completed on 02/22/24. There was no documentation on the base line care plan or in the clinical record to indicate Resident #35 received a summary of their care plan. 2. Resident #51 admission summary documented they were admitted to the facility on [DATE]. Resident #51 base line care plan was completed on 02/21/24 There was no documentation on the base line care plan or in the clinical record to indicate Resident #51 received a summary of their care plan. 3. Resident #114 admission summary documented they were admitted to the facility on…

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 record review and interview, the facility failed to document on a preadmission screening and resident review a mental health illness for one (#51) of one resident reviewed for the need of a level two screening. The director of nursing identified seven residents who had an active diagnosis of bipolar disorder. Findings: Resident #51 was admitted to the facility on [DATE] with an active diagnosis of bipolar disorder, a mental health illness. The admission base line care plan, dated 02/22/24, documented Resident #51 received an antidepressant medication to treat bipolar disorder. An admission assessment, dated 02/28/24, documented the resident had an active diagnosis of bipolar disorder. A level one preadmission screening and resident review, dated 02/27/24, documented the resident had a diagnosis of bipolar. The assessment question two under level was checked as no to indicate Resident #51 did not have a mental health illness. On 05/09/24 at 8:50 a.m., the assistant director of nursing stated Resident #51…

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 interview, the facility failed to provide a clean and safe environment for two (#1 and #145) of 16 residents who resided on hall E in the facility. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 45 residents resided in the facility. Findings: A Cleaning and Disinfecting of Residents' Rooms policy, revision date August 2013, documented .The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms . Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . 1. Resident #1 had diagnoses which included dementia and anxiety disorder. A Care Plan, dated 04/19/18, documented the resident was at risk for incontinence. A Quarterly MDS Assessment, dated 01/07/23, documented the resident had severe cognitive impairment and required extensive assistance with toileting. The assessment documented the resident was always incontinent. 2. Resident #145 had diagnoses dementia and anxiety disorder. A Care Plan, dated 03/11/23,…

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 record review, observation, and interview, the facility failed to obtain and follow the physician's order for Tubigrip stockings for one (#29) of one sampled resident reviewed for Tubigrip stockings. The Resident Census and Conditions of Residents report, dated 03/27/23, identified 45 residents who resided in the facility. Findings: A policy, Telephone Orders, dated February 2014, read in parts, .Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/LVN, pharmacist, physician, etc.) .The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information . A Quarterly MDS Assessment, dated 02/10/23, documented the resident was cognitively intact and required extensive two person assist with bed mobility, transfers, and dressing. A Plan of Care, dated 02/11/23, read in parts, .Infection: I have an infection of the bone Osteomyelitis (left knee), I will remain free from discomfort, complications, or s/s related to my infection through the review date, administer medications…

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 record review, observation, and interview, the facility failed to provide a privacy curtain for one (#145) of 12 sampled residents who required a privacy curtain. The Resident Census and Conditions of Residents report, dated 03/29/23, documented 45 residents resided in the facility. Findings: Resident #145 had diagnoses of dementia and anxiety disorder. A Care Plan, dated 03/11/23, documented the resident was at risk for incontinence. An admission MDS Assessment, dated 03/18/23, documented the resident had severe cognitive impairment and required supervision with toileting. On 03/27/23 at 1:05 p.m., resident #145's room was observed to have only one privacy curtain for two residents who resided in the room. On 03/28/23 at 10:55 a.m., CNA #1 reported two curtains were to be hung in a room with two residents to provide privacy. The CNA observed resident #145's room and stated there should have been two privacy curtains in the room. The CNA stated she had not noticed the missing curtain and had not reported it to maintenance. On 03/28/23 at 11:02 a.m., LPN #1 reported there…

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 record review, observation, and interview, the facility failed to maintain the kitchen with professional standards to ensure a clean, sanitary environment. The Resident Census and Conditions of Residents report, dated 03/27/23, identified 44 residents who received nutrition from the facility's kitchen and one resident received enteral nutrition. Findings: A Cooks Cleaning List, dated 3/20/23 through 03/26/23, documented cleaning was to be performed on Monday, Tuesday, Wednesday, and Thursday. This list did not include cleaning for air conditioning vents or the dishwasher area. On 03/28/23 at 11:13 a.m., a kitchen tour was conducted. A six-foot area of wet towels was observed on the floor along the wall behind the dishwashing machine. Dietary aide #1 was asked about the towels underneath the dishwasher. The aide removed several wet towels with black spots on them that were on the floor tucked in behind the dishwasher. The area behind the dish machine was approximately a six- foot area along the back of the wall with a black scum-like substance extending up the wall tiles…

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.