Rolling Hills Healthcare And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility investigation documentation, and staff interview, it was determined that the facility failed to ensure resident privacy for one of four residents reviewed (Resident 3).Findings include: Clinical record review for Resident 3 revealed a quarterly MDS assessment dated [DATE], that assessed Resident 3 as having a memory problem and that he had severe cognitive impairment (never or rarely made decisions). Review of an incident investigation dated September 5, 2025, revealed that Employee 3 (nurse aide) reported to the Director of Nursing that Employee 5 (nurse aide) sent an electronic private message with a picture attachment of Resident 3. Resident 3's face was obscured by a filtering program; however, Employee 3 was able to identify that it was a facility resident. Statements obtained by the facility during the investigation determined that Employee 5 sent the same photo to Employee 4 (nurse aide). The facility substantiated that Employee 5 took and disseminated a…

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 and staff interview, it was determined that the facility failed to provide treatment and services for an indwelling urinary catheter as ordered by the physician for one of one resident reviewed for urinary catheter concerns (Resident 1).Findings include: Clinical record review for Resident 1 revealed physician orders to maintain a coude foley catheter (flexible tubing inserted into the bladder to drain urine; a coude catheter is equipped with a bent tip to allow passage beyond obstructions such as the prostate gland) for obstructive uropathy (blockage in the urinary system that hinders urine flow; commonly an enlarged prostate) as follows: 24 French (scale where one French unit corresponds to approximately 0.33 millimeters in diameter) coude foley with 10 cc (cubic centimeters, one cc equals one milliliter) balloon changed monthly every 30 days and as needed for blockage or obstruction. This may only be changed by the registered nurse (dated May 31, 2025, to August 29, 2025). 24 French coude foley with 30 cc balloon changed monthly every 30 days and…

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, clinical record review, and staff and resident interview, it was determined that the facility failed to provide professional dental services for two of two residents reviewed for dental concerns (Residents 27 and 46). Findings include: Observation of Resident 27 on July 30, 2025, at 10:32 AM revealed she was edentulous (without natural teeth). Interview with Resident 27 on the date and time of the observation revealed that she once had a full denture for her upper and lower jaws; however, Resident 27 alleged that staff took her lower denture, and she did not know when or where they took them. Review of Resident Evaluation documentation dated June 1, 2024, at 4:00 AM for a quarterly review revealed that she was mentally oriented to person and place; however, was noted to have current and a history of behaviors. Staff assessed Resident 27 as having a full upper denture plate and a full lower denture plate. and Resident 27 preferred her dentures only removed at night. An annual MDS assessment…

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, clinical record review, and staff interview, it was determined that the facility failed to provide a dependent resident assistance with nail hygiene for one of three residents reviewed for activities of daily living concerns (Resident 46). Findings include: Observation of Resident 46 on July 30, 2025, at 11:47 AM revealed his fingernails were long (extending beyond the tips of his fingers) with darkened material under them. Clinical record review for Resident 46 revealed that the facility developed a plan of care to address Resident 46's risk for alteration in skin integrity related to poor self-care and history of picking at skin (initiated October 4, 2024). A plan of care initiated by the facility on October 4, 2024, noted Resident 46's self-care deficit regarding activities of daily living that listed interventions that included staff assist with daily hygiene, grooming, dressing, oral care, and eating as needed. Resident 46 required the extensive assistance with staff for hygiene and grooming. Review of quarterly MDS assessments (Minimum Data Set, an…

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, observation, and staff interview, it was determined that the facility failed to ensure the highest practicable care regarding a pacemaker for one of 18 residents reviewed (Resident 44). Findings include: Clinical record review for Resident 44 revealed that the facility admitted him on April 4, 2023. Diagnoses listed for Resident 44 upon his admission to the facility included the presence of a cardiac pacemaker (surgically inserted medical device with wires attached to the heart for the purpose of administering electrical impulses to regulate the heart rate). Review of Resident 44's clinical record revealed a current care plan for cardiac disease related to coronary artery disease (a condition where the arteries supplying blood to the heart narrow due to plaque buildup restricting blood flow), congestive heart failure (the heart does not pump blood well enough causing fluid to accumulate), hypertension (high blood pressure), and a pacemaker. The listed interventions included instructions to perform pacemaker checks; however, there was no intervention…

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, clinical record review, and staff interview, it was determined that the facility failed to assess a resident's bed system for potential accident hazards for one of 18 residents reviewed (Resident 15). Findings include: The FDA (The United States Food and Drug Administration) Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, is guidance that identifies key parts of the body at risk for entrapment, describes potential entrapment areas or zones, and recommends maximum and minimum dimensional limits of gaps or openings in hospital bed systems. Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system discussed in this guidance are the head, neck, and chest. To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. The FDA is using a head breadth dimension of 120 mm (4.75 inches) as the basis for its dimensional limit recommendations. To reduce the risk of neck…

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 and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist reported any irregularities to the attending physician (and the facility's medical director if applicable) and the Director of Nursing on a separate, written report; and that the attending physician documented a review and actions taken to address the identified irregularity in the resident's medical record for one of five residents reviewed for medication regime concerns (Resident 27).Findings include: Interview with the Nursing Home Administrator, Director of Nursing, and Employee 1 (registered nurse/director of clinical operations) on July 30, 2025, at 1:45 PM revealed that the facility's contracted consulting pharmacist reviews each resident's medication regime monthly and, unless listed on the document entitled, Listing of Residents Reviewed with No Recommendations, a resident has a separate report of the identified potential medication irregularity on which the attending physician documents a review and response. The interview indicated that…

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 and staff interview, it was determined that the facility failed to ensure that medical records were readily accessible to individuals performing health oversight activities for one of 18 residents reviewed (Resident 27). Findings include: The state survey agency entered the facility on July 29, 2025, at 9:00 AM and provided the Nursing Home Administrator the federal Entrance Conference Worksheet, which included the form entitled, Electronic Health Record (EHR) Information. Instructions on the form direct the provider to, Provide specific instructions on where and how surveyors can access the following information in the EHR (or in the hard if using split EHR and hard copy system) for the initial pool record review process. Surveyors require the same access staff members have to residents' EHRs in a read-only format. Clinical record review for Resident 27 revealed that the surveyor was unable to view three months of nurse aide documentation of the completion of tasks necessary for Resident 27's care (e.g., bathing, toileting assistance, bowel…

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 and staff interview, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a transfer to the hospital for three of three residents reviewed (Residents 13, 37, and 46). Findings include: Review of Resident 13's clinical record revealed that the facility transferred him to the hospital on August 8, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 13's transfer to the hospital. Review of Resident 37's clinical record revealed that the facility transferred him to the hospital on June 20, 2023, and again on September 17, 2023. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of Resident 37's transfers to the hospital. Review of Resident 46's clinical record revealed that the facility transferred the resident to the hospital on August 31, 2023, at 7:50 AM. There was no documented evidence that the facility notified the Office of the State Long-Term Care Ombudsman of…

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 interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 4, 42, and 49). Findings include: Clinical record review for Resident 4 revealed the facility admitted her on September 9, 2021, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of a significant change Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 21, 2023, indicated that the facility assessed Resident 4 as having the diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed. A review of Resident 4's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address 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, observation, and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for one of 14 residents reviewed (Resident 39) Findings include: Clinical record review for Resident 39 revealed a diagnoses list that included a history of muscle weakness. Resident 39's current care plan noted the resident was at risk for falls due to weakness. An intervention included having the call bell in reach. Observation of Resident 39 on October 11, 2023, at 11:28 AM revealed the resident was in bed. The resident's call bell was observed draped over a recliner that was positioned next to the bed. The call bell was four feet from the resident and not easily accessible. Observation of Resident 39 on October 13, 2023, at 10:44 AM revealed the resident was in bed. The resident's call bell was observed coiled up on the right arm of the recliner that was positioned next to the bed and not easily accessible. Interview with Employee 4, licensed practical nurse, on October 13, 2023, at 10:44 AM…

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 review of select facility policies and procedures, review of clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of one resident reviewed (Resident 3). Findings include: The policy entitled Abuse Policy, last reviewed on August 29, 2023, indicates that the facility describes an injury of unknow origin as an injury that was not observed by any person, cannot be explained by the resident, and a suspicious location not generally vulnerable to trauma. The policy does not specify how the facility will specifically rule out abuse when an injury of unknown origin occurs. Review of Resident 3's clinical record revealed a nursing care plan indicating that she needs the help of two staff members to use a mechanical lift to transfer her out of bed. Resident 3 is not self-ambulatory. A nursing note dated October 6, 2023, at 6:30 PM indicated that staff noted a bruise to the top of Resident 3's left foot measuring 5 cm (centimeters) by 4 cm. The note further described the bruise as green and blue…

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 interview, it was determined that the facility failed to provide the highest practicable care regarding the care of a pacemaker for one of one resident reviewed with a pacemaker (Resident 12). Findings include: Clinical record review revealed Resident 12 was admitted to the facility on [DATE]. Clinical record review of Resident 12's diagnoses list included a left bundle branch block (a disease that impacts or disrupts the electrical impulse that causes the heart to beat). Clinical record review for Resident 12 revealed hospital documentation that noted the resident had a pacemaker implanted in October 2018. A current care plan for Resident 12 indicated the resident had cardiac disease related to the left bundle branch block and an intervention included, pacemaker checks as ordered. A review of the current physician orders for Resident 12 revealed no current orders related to pacemaker checks; however, an order dated October 28, 2018, noted cardiology consult as needed. A…

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, review of facility investigation, and staff interview, it was determined that the facility failed to thoroughly investigate an accident regarding an elopement and implement interventions to prevent recurrence for one of one resident reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed nursing documentation dated September 21, 2023, at 4:56 PM indicating that nursing staff called Resident 51's representative to discuss Resident 51's elopement. Nursing documentation dated September 21, 2023, at 5:08 PM indicated that Employee 5, cook, received a text message from a neighbor indicating that an older lady was standing in front of her house. v Employee 5 drove to the neighbor's house and found Resident 51 in front of the neighbor's garage. Employee 5 brought Resident 51 back to the facility in her personal vehicle at approximately 4:25 PM with no apparent injuries. Review of the facility's investigation into Resident 51's elopement revealed that according to witness statements, Resident 51 was last seen at the nursing…

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.