Rocky Knoll Health Care

Inspectors wroteBased on interview and record review, the facility did not report injuries of unknown origin to the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents. On 5/22/26, staff observed yellow and purple discoloration on R1's right ankle. An X-ray revealed multiple fractures. The injury of unknown origin was not reported to the SA.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 138 residents residing in the facility. The facility did not consistently follow safe food cooling protocol. The facility did not ensure wash and rinse cycles for the dishwasher met the minimum required temperatures. The facility did not ensure cooked, pureed, and reheated food or food held for service reached a temperature of 165 degrees Fahrenheit (F).

Inspectors wroteBased on staff interview and record review, the facility did not ensure care plans were revised for 2 residents (R) (R9 and R11) of 28 sampled residents. R9 started Hospice care on 11/5/25. R9's care plan did not indicate R9 was on Hospice. R11 returned to the facility on 3/5/26 from a hospitalization where a catheter was inserted. R11's care plan did not indicate R11 had a catheter.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the resident environment was as free of accident hazards as possible for 1 resident (R) (R37) of 4 sampled residents. R37 was admitted to the facility on [DATE] and had a history of falls. R37 fell at the facility on 5/27/26 and 5/30/26. admission and post-fall risk assessments did not accurately reflect R37's status.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 1 resident (R) (R9) of 5 sampled residents. R9 was on enhanced barrier precautions (EBP) related to an indwelling catheter. R9's catheter bag was observed on the floor on multiple occasions. In addition, staff did not wear gowns or gloves during catheter care.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure an allegation of abuse was reported timely to the State Agency (SA) for 1 resident (R) (R1) of 4 sampled residents. This had the potential to affect resident safety in the facility. R2 hit R1 in the dining room on 5/30/25. The allegation of abuse was not reported to the SA in a timely manner.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored, prepared, and served in a sanitary manner. This practice had the potential to affect all 134 residents residing in the facility. Staff did not store or date food in a manner to ensure food safety. Staff did not follow safe food cooling protocols. Staff did not adhere to temperature requirements when testing parts per million (PPM) of the sanitizing solution. Staff did appropriately process clean dishes and did not maintain dishwasher temperature testing strips. Staff did not follow microwave safe heating procedures. Staff did not consistently wear hair restraints in the kitchen and while serving food. Staff did not perform proper hand hygiene prior to applying and removing gloves and while preparing and serving food.

Inspectors wroteBased on observation and resident and staff interview, the facility did not maintain dignity for 7 residents (R) (R29, R5, R45, R50, R18, R34, and R10) of 7 residents who required dining assistance. R29, R5, R45, R50, R18, R34, and R10 required assistance with dining. During the lunch meal on 3/3/25 and the breakfast meal on 3/4/25, staff did not sit down while feeding R29, R5, R45, R50, R18, R34, and R10.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the Ombudsman was notified of emergency room (ER) or hospital transfers for 6 residents (R) (R23, R36, R56, R91, R93 and R99) of 7 residents reviewed for hospitalization. The Long-Term Care Ombudsman was not notified of ER or hospital transfers for R23, R36, R56, R91, R93, and R99. In addition, the facility did not have a process in place to notify the Ombudsman of ER or hospital transfers.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications were labeled and stored appropriately for 2 residents (R) (R43 and R228) of 6 sampled residents. This practice had the potential to affect more than 4 of the 134 residents residing in the facility. On 3/3/25, two bags of unidentified and unsecured medications were observed in R43's room. During observations of medication administration, staff left a tray of medication unattended on top of the medication cart.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 4 residents (R) (R17, R55, R89, and R116) of 4 sampled residents. On 3/4/25, Licensed Practical Nurse (LPN)-C dropped a pill on the floor in the dining room and then administered the medication to R17. During multiple care observations on 3/3/25, staff did not follow enhanced barrier precautions (EBP) for R55. During an observation of care on 3/3/25, Certified Nursing Assistant (CNA)-F removed soiled gloves and did not wash or sanitize hands before touching R89 and objects in R89's environment. During a wound care observation on 3/5/25, staff did not follow EBP precautions for R116.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a physician was notified of a change in condition for 1 resident (R) (R93) of 7 sampled residents. On 1/1/25, R93 had a low blood pressure reading of 84/43 mmHg (millimeters of mercury). R93's physician was not notified.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide privacy during medication administration for 2 residents (R) (R17 and R228) of 5 sampled residents. On 3/4/25, Licensed Practical Nurse (LPN)-C lifted the back of R17's shirt and lowered the back of R17's pants to administer a lidocaine patch in the dining room. On 3/4/25, LPN-C administered insulin to R228 in the hallway.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R13, R36, and R38) of 7 sampled residents met the PASRR (Pre-admission Screening and Resident Review) requirements. R13 was prescribed Abilify (an antipsychotic medication) on 1/5/23. A new PASRR Level II Screen was not completed. R36 had a positive PASRR Level 1 Screen upon admission and remained at the facility beyond the 30 day exemption period. A Level II Screen was not completed until 3/4/25. R38 had a negative PASRR Level I Screen upon admission. A Level II Screen was not completed when R38 received a qualifying diagnosis and was prescribed medication.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the necessary care and services were provided to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R376) of 2 sampled residents. R376 had an unstageable pressure injury on the middle spine. The facility did not assess the wound and implement wound orders according to the facility's policy. In addition, staff did not ensure R376's wound treatment was completed as ordered and R376's care plan did not contain goals or interventions for treatment.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R43) of 1 sampled resident received the necessary care and services for oxygen therapy. R43's oxygen order did not specify the flow rate. On 3/4/25, R43 was observed without oxygen. In addition, R43's plan of care did not indicate R43 used continuous oxygen.

Inspectors wroteBased on staff interview and record review, the facility did not implement their antibiotic stewardship program and monitor antibiotic use for 1 resident (R) (R115) of 3 sampled residents. R115 was prescribed a prophylactic antibiotic. R115's medical record did not indicate the prophylactic antibiotic was routinely assessed. In addition, the facility's infection surveillance log for antibiotic use contained inaccurate documentation for continued appropriate use of an antibiotic for R115.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of sexual abuse was reported to the State Agency (SA) for 2 residents (R) (R2 and R5) of 3 sampled residents. On 4/21/24, R5 approached R2 in the lobby. R5 kissed R2 on the mouth and R2 touched R5's breast. The allegation of sexual abuse was not reported to the SA.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate an allegation of sexual abuse for 2 residents (R2 and R5) of 3 sampled residents. On 4/21/24, R5 approached R2 in the lobby. R5 kissed R2 on the mouth and R2 touched R5's breast. The facility did not thoroughly investigate the allegation of sexual abuse. The facility's investigation did not include interviews with R5 and R2, interviews with other resident interviews, and interviews with staff who were working at the time of the incident.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure care plan interventions were followed which resulted in a resident-to-resident interaction between 2 residents (R) (R2 and R5) of 11 sampled residents. On 4/21/24, R5 approached R2 and kissed R2 on the mouth. R2 then touched R5's breast. The incident occurred while R2 self-propelled R2's wheelchair back from the dining room. R2's care plan contained an intervention to escort R2 to and from R2's room and keep R2 separate from female residents. The intervention was not consistently followed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner which had the potential to affect all 113 residents residing in the facility. Procedures for reheating food in a microwave were not followed. Initial cook temperatures were not consistently documented. Four boxes of Italian Wedding Soup were stored on the floor of the walk-in freezer. The edge of the mixer contained dried debris and the mixer was not covered.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable temperature for 7 Residents (R) (R9, R1, R57, R72, R83, R13, and R130) of 26 sampled residents. R9, R1, R57, R72, R83, R13, and R130 indicated hot food is not always served hot. During the lunch meal on 2/12/24 and 2/13/24, food was not served at a palatable temperature.

Inspectors wroteBased on staff and power of attorney (POA) interview, and record review, the facility did not notify a POA of a medication change for 1 Resident (R) (R89) of 26 sampled residents. R89's metformin (a medication used to treat diabetes) was discontinued on 1/23/24. R89's POA was not notified or informed of the risks versus benefits prior to discontinuation of the medication.

Inspectors wroteBased on staff interview and record review, the facility did not ensure written notification of financial liability via an Advanced Beneficiary Notice (ABN) was provided for 1 Resident (R) (R69) of 2 residents who remained in the facility when their Medicare Part A benefits ended. The facility did not provide an ABN to R69's Health Care Agent when R69's Medicare Part A benefits ended on 1/7/24 and R69 remained in the facility.

Inspectors wroteBased on staff interview and record review, the facility did not ensure Minimum Data Set (MDS) assessments (a screening and assessment tool that forms the foundation of a comprehensive assessment and is used to guide care planning and monitoring) accurately reflected a resident's status for 1 Resident (R) (R97) of 26 sampled residents. R97's MDS assessment, dated 10/18/23, indicated R97's Brief Interview for Mental Status (BIMS) assessment (used to assess cognitive status in the elderly) and Patient Health Questionnaire (PHQ-2-9) interview (used to assess depression) were not completed. In addition, R97's MDS assessment, dated 1/17/24, indicated R97's BIMS assessment was not completed, but a partial staff assessment was completed. R97's PHQ-2-9 indicated R97 was rarely/never understood. A staff assessment indicated R97 was severely impaired and rarely/never made decisions; [...]

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure 2 Residents (R) (R57 and R83) of 2 residents reviewed for nutrition received the necessary care and services to prevent or monitor weight loss. R57 had an order for weekly weights which were not consistently completed. In addition, R57 did not consistently receive R57's nutritional supplement. R83 had an order for bi-weekly weights which were not consistently completed.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccinations were reviewed, offered, or administered for 2 Residents (R) (R8 and R12) of 5 residents reviewed for vaccines. The facility did not review R8's vaccination history or offer R8 the PCV20 (Prevnar 20®) vaccine. The facility did not review R12's vaccination history or offer R12 the Prevnar 20® vaccine.