Rockdale Estates & Rehabilitation

Based on interview and record review, the facility failed to ensure that a designated DON was providing coverage on a full time basis for one out of one facility. The facility failed to ensure they had a DON on duty for a total of 12 days from 04/04/2025 to 04/14/2025. This failure could place residents at risk of missing assessments, interventions and care. Findings include: On 04/14/2025 at 10:30 AM an interview with the Executive Director revealed the facility does not have an active Director of Nursing employed at the facility. The ED stated that the facility has ensured a Registered Nurse is onsite at all times. The ED also reported that a Corporate Nurse was on site once a month to help with DON coverage. The ED stated that the facility uses telehealth and is available for support at all times. The ED reported the last time the DON was on site was 04/03/2025. On 04/14/2025 at 2:30 PM record review indicated that the DON was last in the facility providing DON coverage on 04/03/2025. RR indicated that for the week dated 03/30/2025 to 04/05/2025, the DON provided DON coverage for…

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, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #52) of 5 residents reviewed for care plans. The facility failed to ensure Resident #52's comprehensive care plan included her ADL status, incontinence, risk for falls, risk for pressure ulcers, nutritional status, code status, medical diagnoses, and therapies received. This failure could place residents at risk for not receiving necessary care and services or having important care needs identified and met. Findings included : Review of Resident #52's face sheet, dated 04/15/25, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (dementia that damages the brain), unspecified protein-calorie malnutrition, hypertension (high blood pressure), abnormalities of gait…

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 interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #50 & #171) of 6 residents reviewed for quality of care. The facility failed to document weekly skin assessments for Residents #50 & #171 according to physician orders. This failure could place residents at risk of not receiving necessary medical care, and hospitalization. Findings included: Review of Resident #50's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified dementia (progressive loss of mental abilities like memory, thinking, and reasoning, so severe that it interferes with daily life), unspecified severe protein calorie malnutrition (a condition characterized by a significant deficiency in both protein and energy intake, leading to a range of physical symptoms), muscle…

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, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (100/200 nurse cart) reviewed for medication storage. The facility failed to ensure an expired insulin pen was removed from the medication cart. This failure could place residents at risk of not receiving the intended therapeutic effect of the insulin. Findings included: An observation of the 100/200 nurse cart on 05/15/25 at 2:09 PM revealed an insulin pen with an open date of 03/04/25. During interview on 04/15/25 at 2:11 PM, LVN B stated he was not sure when insulin pens expired after being opened, but he would get the answer. LVN B returned and stated the insulin was good for 28 days so, the pen opened on 03/04/25 should have been removed from the cart. He stated if expired medications were administered, the resident may not have received the desired effect. During an interview 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 observations, interviews, and record reviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (Resident #66) of five residents reviewed for unnecessary medications. The facility failed to indicate an adequate diagnosis for Quetiapine (an atypical antipsychotic medication used to treat schizophrenia and bipolar disorder) for Resident #66. This failure could place residents on psychoactive medications, without an adequate diagnosis, at risk for taking unnecessary medications. Findings included: Review of Resident #66's undated face sheet reflected an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Alzheimer's disease (dementia that damages the brain) - unspecified (primary diagnosis), dementia in other diseases classified elsewhere - severe - without behavioral disturbances - psychotic disturbance - mood disturbance and anxiety, essential hypertension (high blood pressure), difficulty walking, other lack of coordination, 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.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services in that: Dietary staff failed to effectively label items in the refrigerator and freezer. These failures could place residents at risk for food contamination and foodborne illness. The findings include: During the initial tour of the kitchen on 04/14/2025 beginning at 9:11 am the following was observed: The refrigerator contained what appeared to be green bell peppers, tomatoes, and bananas in a clear plastic bin with no label. The freezer contained what appeared to be cheese sticks in a clear plastic bag with no label. Interview with the Dietary Manager on 04/16/2025 at 11:05 am, the DM stated all items in the refrigerators and freezers should be sealed, labeled, and dated. The DM confirmed that the items not labeled were green bell peppers, tomatoes, bananas, and cheese sticks. The DM stated all items have been thrown away due to them not being 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 observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of four residents (Resident #2 and Resident #52) reviewed for infection control. The facility failed to ensure LVN A wore a gown on 04/15/25 when she provided wound care to Resident #2, who was on EBP. The facility failed to ensure CNA D performed hand hygiene when changing gloves on 04/15/25 when she provided incontinent care for Resident #52. These failures could place residents at risk of cross contamination or infection. Findings included: Review of Resident #2's face sheet, dated 04/15/25, reflected an [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included other chronic osteomyelitis right ankle and foot (infection of the bone), peripheral…

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, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. A. The facility failed to ensure Dietary Manager wore a hair net when standing by clean plates in the kitchen. B. The facility failed to maintain sanitary all 3 ovens and the only fryer in the kitchen. C. The facility failed to ensure the Dietary Manager properly used proper hand sanitation during food preparation. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illness, and decreased quality of life. Findings included: A. Observation on 03/05/21 at 9:05 AM, Dietary Manager exited the dining room and entered the dishwashing room area without wearing a hair net. She stood by clean plates and cups in the dishwashing room. The Dietary Manager continued to walk in the kitchen and stood by the sink where she donned her hair net. Observation on 03/05/2024 at 9:07 AM revealed there were hair nets…

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, interview and record review the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 15 residents (Residents #69, #1, and #59) reviewed for ADLs. The facility failed to ensure Residents #69, #1, and #59 were provided nail care, personal hygiene as documented in their plan of care and MDS. This failure could place residents at risk of scratches, infection, and poor self-esteem. Findings included: 1. Record review of Resident #69's Face Sheet reflected he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of unspecified Dementia (a group of thinking and social symptoms that interfere with daily functioning, impairment of at least two brain functions, such as memory loss and judgment), unspecified severity, with mood disturbance and age-related physical debility (general weakness). Record review of Resident # 69's Quarterly MDS assessment dated…

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, interview, and record review, the facility failed to provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 3 of 5 residents (Resident #43, Resident #46 and Resident #59) reviewed for quality of life. The facility failed to ensure one-on- one activities for Residents #43, Resident #46 and Resident #59 was provided according to the one-on-one activity schedule. This failure could place residents at risk for a decline in social, mental, psychosocial well-being, and a diminished quality of life. Findings included: 1. Record review of Resident #43's face sheet, dated 03/06/2024, reflected Resident #43 was a [AGE] year-old female who was admitted…

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, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was turned or repositioned for 12 hours the night of 11/21/23 to the morning of 11/22/23. This failure placed residents at risk of developing avoidable pressure ulcers, pain, and infection. Findings included: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of multiple sclerosis (a disease that affects central nervous system making it difficult for the brain to send signals to rest of the body), paraplegia (paralysis of the legs and lower body), muscle weakness, need for assistance with personal care, joint contracture (condition in which a joint becomes very stuff and has limited movement), dementia, muscle wasting and atrophy, lack…

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, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 4 residents (Residents #43, #41, #31, and #58) reviewed for incontinence care and usage of wrist blood pressure monitor, as indicated by: a) CNA A while providing incontinent care for Resident # 43, did not sanitize the bedside table used for incontinent care and did not discard the food on that table before leaving the room. CNA A also contaminated the clean wet wipes by pulling out them directly from the whole packet with gloves soiled with feces. b) CNA B did not clean and disinfect the wrist blood pressure monitor while using it on Resident # 41, Resident #31 and Resident # 58. This failure could place the residents at the facility at risk of transmission of disease and infection. Findings included: Review of Resident #43's face sheet, dated 01/05/23, reflected Resident #43 initially admitted to…

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.