Rockdale Estates & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for seven (September 2025, October 2025, December 2025, February 2026, March 2026, April 2026, and May 2026) of eight meetings reviewed for QAPI.The facility did not ensure the Medical Director, or a designee attended quarterly QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, for one of seven residents (Resident #28) reviewed for abuse. The facility failed to ensure Resident #28 was free from verbal abuse by CNA C when, as reflected on video dated 05/19/2026, CNA C told Resident #28, I am going to f*** you up. This failure could place residents at risk for psychosocial harm and diminished quality of life.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with a mental illness was completed correctly and were provided with a PASRR Level II assessment for one (Resident #19) of 5 residents reviewed for PASRR assessments. The facility failed to ensure the accuracy of the PASRR Level l for Resident #19. The PASRR Level 1 did not indicate a diagnosis of mental illness, although the diagnoses (major depressive disorder, single episode, unspecified ( experience major depressive episode with no history of previous depressive episodes - sadness, loss of interest in daily activities) and post-traumatic stress disorder(a mental health condition that some people develop after they experience a terrifying event) diagnosis were present upon Resident #19 admission date on 04/14/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #11) reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #11 to address hisrepeated behavior of pulling on his catheter, putting the catheter tubing in his mouth, or disconnecting the catheter tubing from the catheter bag. This failure could place residents at risk of not receiving care and services to meet individualized, behavioral, medical and nursing needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for two of five residents (Residents #79 and #19 ) reviewed for dietary services. The facility failed to ensure the staff served hot meals to the residents, on 06/03/2026. This failure could place residents who received meals from the food cart at risk for diminished or altered nutritional status and potential weight loss.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations interview, and record review, the facility failed to provide adequate supervision and to prevent accidents for one resident (Resident #1) of five reviewed for accidents and hazards in that: The facility failed to supervise Resident #1 when she was found walking in the hallway without her walker, resulting in a fall with injuries on 3/13/2024. This failure placed residents at risk of accidents or falls resulting in injuries, pain and hospitalization.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.