Rockdale Healthcare Center

Inspectors wroteBased on observations, record review,staff interviews and a review of the facility policy title Accident and Incident Prevention, Reporting, and Response and Care Plan-Comprehensive, the facility failed to ensure that appropriate care plan interventions were developed and implemented to meet the needs of two of three residents care plan reviewed. Specifically, the facility failed to develop post fall interventions for one Resident (R1) following three separate falls. In addition, the facility failed to implement and establish care plan interventions for Activities of Daily Living (ADL) for R3. Review of the policy titled Accident and Incident Prevention, Reporting, and Response, dated 05/2026. Purpose: [...]

Inspectors wroteBased on observation, interviews, record review, including a review of the Certified Medication Aide job description, the facility failed to ensure that professional standards of practice were maintained with one of three sampled Resident (R) (R2) during a scheduled medication pass. Specifically, the Certified Medication Aide (CMA) DD failed to maintain direct visual observation during the medication administration process, resulting in the resident being discovered holding a white pill that was actively dissolving in their hand.

Inspectors wroteBased on observations, resident, family and staff interviews, record review and a review of the facility's policy titled Accommodation Of Needs the facility failed to provide activities of daily living (ADL) for one resident (R) (R3) out of three dependent on staff for care.

Inspectors wroteBased on record review, interviews, and the facility policy titled Accident and Incident Prevention, Reporting, and Response, the facility failed to ensure that an environment free from accident hazards was maintained, and failed to provide adequate supervision and sufficient individualized interventions to prevent accidents for one Resident (R) (R1) who was identified as a high risk for falls and a history of recurrent falls. Specifically, the facility failed to develop and implement effective post-fall safety interventions following three separate falls sustained by R1 resulting in a major injury including a lumbar two (L2) compression fracture and a left distal femur fracture.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Advance Directives, the facility failed to ensure the Advance Directive status was consistently documented in the clinical record for one of 45 sampled residents (R) (R71). This deficient practice had the potential to place R71 at risk of not receiving life-sustaining treatment in accordance with the resident's wishes.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure the residents were allowed to receive mail/packages without staff opening and obtaining copies of the documents without the resident's/resident's representative's permission for one of 14 Residents (R) (R3) interviewed about receiving mail unopened.

Inspectors wroteBased on record review, staff interview and review of the facility's policy titled, Discharging/Transferring the Resident, the facility failed to notify the resident's responsible party on the day the resident was discharged and transported out of the facility for one of three Residents (R) (R7) reviewed for discharge out of a total sample of 20.

Inspectors wroteBased on record review, interview, and review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, the facility failed to ensure the resident's right to be free from verbal/mental abuse for one of eight Residents (R) (R) (R11) reviewed for abuse out of a total sample of 20.

Inspectors wroteBased on interview, record review, and facility's policy titled, Prevention of Resident Abuse, Neglect, Misappropriation or Misappropriation of Property, the facility failed to report an allegation of verbal/mental abuse to the State Survey Agency within two hours after the allegation was made for one of eight Residents (R) (R11) reviewed for abuse out of a total sample of 20.

Inspectors wroteBased on record review, staff interviews, review of the facility's policy titled, Prevention of Resident Abuse, Neglect, Mistreatment, or Misappropriation of Property, the facility failed to ensure allegations of abuse were thoroughly investigated for two of eight Residents (R) (R1 and R14) reviewed for a total sample of 20.

Inspectors wroteBased on interview, record review, and review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, the facility failed to ensure residents were not inappropriately transferred or discharged against the resident's/residents' representatives wishes for two of three Residents (R) (R7 and R4) reviewed for discharge out of a total sample of 20.

Inspectors wroteBased on interview, record review, and review of the facility's policy and procedure titled, Documentation of Transfers/Discharges, the facility failed to notify the resident and the resident's representative of the reasons for a discharge/transfer, failed to notify the Office of State Long-Term Care Ombudsman of the discharge/transfer, and failed to record the reasons for the transfer/discharge in the resident's medical record for two of three Resident (R) (R7 and R4) reviewed for discharge out of a total sample of 20.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure notifications of discontinuation of Medicare Part A benefits were issued in a timely manner for three of three residents (R) (R36, R81, and R605) reviewed for beneficiary notification. This failure had the potential to result in a lack of understanding of appeal rights and/or the termination of the current level of care against the resident's/representative's wishes.

Inspectors wroteBased on observation, staff interviews, and review of the facility's policy titled, Food Service Director, the facility failed to maintain sanitary practices in the kitchen in regard to food handling and hair coverings. The deficient practice had the potential to affect 101 of 103 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on observations, staff and interviews, record review, and review of the facility's policies titled Activities of Daily Living (ADLs)/Maintain Abilities, and Care of Fingernails, the facility failed to ensure that Activities of Daily Living (ADL) was provided for two of three residents (R) R72 and R83 reviewed for ADL.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled Self-Administration of Medication, the facility failed to adequately assess one of 50 sampled residents (R) (R24) for self-administration of medication. This failure placed R24 at risk for inappropriate and unsafe medication use. Findings Include: A review of the facility policy titled Self-Administration of Medication, dated 4/2022, revealed the Policy was, The purpose of this procedure is to establish uniform guidelines concerning the self-administration of drugs. The General Guidelines section included 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. [...]

Inspectors wroteBased on observations, staff interviews, record review, review of the facility policy titled Environmental Services, and review of the manufacturer recommendations titled Monthly Maintenance Front Filters, the facility failed to maintain a clean, homelike environment by not ensuring that packaged terminal air conditioner (PTAC) filters were free of debris in 2 of 42 resident rooms. This failure had the potential to compromise the hygiene and safety of the room environments, increasing the risk of infection and negatively impacting the health and well-being of the residents residing in the rooms. The census was 103 residents. Findings Include: [...]

Inspectors wroteBased on observations, interviews, record review, and review of facility's policy titled Resident Assessment, the facility failed to ensure that all high-risk medications were coded on the admission assessment for one of 50 sampled residents (R) R309. This deficient practice had the potential to cause resident not to receive person centered care.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Care Plan -Comprehensive, the facility failed to develop a comprehensive person-centered care plan that addressed all high-risk medications for two of 50 sampled residents (R) (R309 and R83). This failure had the potential for residents to not receive treatment and/or care according to their needs.

Inspectors wroteBased on observations, resident, resident family and staff interviews, record review, and review of the facility's policies titled, Medication Administration and Activities of Daily Living (ADLs)/Maintain Abilities, the facility failed to give ordered medications that were readily available for one of 50 sampled residents (R) (R553) and failed to implement resident-directed care and treatment consistent with the resident's orders as directed by podiatrist and professional standards of practice for one of 50 sampled R (R50). The deficient practices had the potential to cause R553 to be at risk for medical complications, unmet needs, and a diminished quality of life and cause pain and possible open skin which can lead to infection for R50.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled Administration of Drugs, the facility failed to administer oxygen to one of five residents (R) (R28) who received oxygen and failed to secure the oxygen canister. The deficient practice had the potential to place R28 at risk of respiratory complications.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled, Psychopharmacologic Drugs, the facility failed to add a 14-day stop for as-needed (PRN) psychotropic medication for one of five residents (R) (R10) reviewed for unnecessary psychotropic medication. The deficient practice had the potential to affect the resident's highest practicable mental, physical, and psychosocial well-being. The facility census was 103 residents.

Inspectors wroteBased on record review, interviews, and review of the policy titled Care Plan Policy, the facility failed to update and revise the comprehensive person-centered care plan related to unwitnessed falls for one resident (R) (R#306). The sample size was 35 residents.

Inspectors wroteBased on record review, interviews, and review of facility policies, the facility failed to ensure proper assessment and followup for one resident (R) (R#306) post fall on 1/20/2023. Specifically, facility failed to complete a fall assessment after an unwitnessed fall, failed to complete neuro-checks on 1/20/2023, and failed to provide Radiology services in a timely manner. Actual harm was identified on 1/23/2023 when resident was transferred to the hospital with continued pain. Computerized tomography (CT) of the head indicated chronic right posterior parietal lobe subdural hematoma. The sample size was 35 residents.

Inspectors wroteBased on record review, staff and family interview, and review of the policy titled Pain Management - Acute and Chronic, the facility failed to manage pain for one resident (R) (R#306) after a fall. Actual harm occurred on 1/20/2023 when R#306 had an unwitnessed fall, hitting his head, with complaints of pain in bilateral hips and back. Resident was transferred to hospital on 1/23/2023 with continued pain. Computerized tomography (CT) of the head without contrast indicated chronic right posterior parietal lobe subdural hematoma. The sample size was 35 Residents.

Inspectors wroteBased on observations, staff interviews, and review of the policies titled Use and Storage of Food and Beverage Brought in for Residents, Food Procurement and Dishwashing Procedures, the facility failed to label and date opened food items in the walk-in cooler, the walk-in freezer, and the dry storage pantry; failed to discard food items by the discard date; and failed to maintain sanitary conditions by not stacking wet drinking cups. This deficient practice had the potential to affect all 89 residents receiving an oral diet.

Inspectors wroteBased on observation, family and staff interviews, and review of the facility policies titled Cleaning and Disinfection of Environmental Surfaces and Cleaning and Disinfecting Resident's Rooms, the facility failed to maintain a clean and comfortable homelike environment in eight resident rooms (449, 454, 455, 457,458, 460, 461, and 463) on one of two halls, including black scuff marks on walls and dirty and dusty air vents in the bathrooms.

Inspectors wroteBased on observations, record review, resident representative and staff interviews, and review of the policy titled Urinary Catheter Care, Anchoring and Changing, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of seven residents (R) (R#100) who had an indwelling urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life.

Inspectors wroteBased on record review, staff interview, and review of the policy titled Laboratory, Radiology and Other Diagnostic Services, the facility failed to provide radiology services in a timely manner for one resident (R) (R#306). The sample size was 35 residents.