Rolling Green Village Care Center

Inspectors wroteBased on clinical record review, written staff statement, staff interviews and policy review, the facility failed to provide adequate nursing supervision related to a fall and failed to ensure appropriate steps were taken after a fall to ensure resident safety for 1 of 3 residents reviewed for falls (Resident #2). The facility corrected the noncompliance prior to the start of the survey on 3/13/26 by completing the following:3/13/26: The facility started educating their employees on falls.3/13/26: The facility started educating their employees on the fall occurrence policy. 3/13/26: The facility started educating their employees on abuse prevention.3/13/26: The facility began using the audit tool on new falls to ensure the staff followed the occurrence policy and understood the fall policy. The facility reported a census of 48 residents.

Inspectors wroteBased on clinical record review, family interview, staff interviews and policy review, the facility failed to immediately notify and inform a family member (Resident #1) and the resident's physician (Resident #2) of a change in status for 2 of 3 residents reviewed for notification. The facility reported a census of 48 residents.

Inspectors wroteBased on observation, interviews, record reviews and policy the facility failed to assess and treat a pressure ulcer for 2 of 2 residents observed with pressure ulcers (Residents #9 and #50). Resident #50 documentation indicated the facility found their pressure wound on 11/1/24. Interviews determined hospice found the pressure wound before that date. The facility, hospice staff, and Resident #50's family had a meeting before the facility documented the pressure ulcer. At the meeting, hospice reported the got an order for heel protectors for Resident #50. Resident #50's clinical record lacked documentation of the order. When the facility reported the concern to the physician, the directed to monitor the wound. Resident #50 reported she didn't like the boots because they made her feet hot. [...]

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to develop and implement a comprehensive person centered Care Plan for 1 of 14 residents reviewed for Care Plans (Resident #8). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, staff interviews, and policy review the facility failed to revise a Care Plan for 1 of 15 residents reviewed (Residents #47). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, resident and staff interview, the facility failed to meet professional standards of quality for services provided during medication administration for 1 of 1 resident reviewed (Resident #51). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, record review, facility policy review, resident, and staff interview the facility failed to keep a resident's environment free from accidents and hazards by not storing the resident's smoking materials in a secured location for 1 of 1 resident reviewed for smoking (Resident #30). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview, the physician failed to respond to gradual dose recommendations (GDR) for 1 of 5 residents reviewed (Residents #9). The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interviews and policy review, the facility failed to ensure residents are free of significant medication errors for 1 of 1 resident reviewed (Resident #51). During the orientation of one Certified Medication Aide (CMA), Staff K, the trainer gave the person in training resident's medications without ensuring they gave the medications to the correct resident. Due to it only being Staff K's second day of training she didn't know the residents and gave Resident #51, Resident #46's supper and hour of sleep medications (HS). The facility reported a census of 47 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to discard expired stock medications to avoid compromising the integrity of the medications. The facility reported a census of 47 residents.

Inspectors wroteBased on clinical record review, menu review, observations, staff interviews, and policy review the facility failed to provide residents food in a form to meet the needs of 2 of 6 residents (Resident #51 and #50). The facility reported a census of 47 residents.

Inspectors wroteBased on facility document review, and staff interviews the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 5 of 31 days reviewed (September 23rd through October 23rd). The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, observation and staff interviews, the facility failed to supervise administration of medication according to accepted standards of clinical practice for 2 of 6 residents reviewed for medication administration (Residents #15 and #188). The facility reported a census of 37 residents.

Inspectors wroteBased on observation, record review, and staff interview the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice as the facility failed to obtain a physician's order for a continuous positive airway pressure (CPAP) and failed to ensure proper cleaning and storage of the CPAP machine, tubing, and mask for 1 of 3 residents (Resident #15) reviewed. Facility reported a census of 37 residents.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to store food in accordance with professional standards for 37 of 37 residents. The facility reported a census of 37 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, facility policy review and skills checklist review, the facility failed to maintain proper infection control practices to prevent cross contamination and potential infection of residents when providing cares and treatments. (Resident #4 and #31). The facility reported a census of 37 residents.