Rolling Hills Care Center

Inspectors wroteBased on observations, interviews, record review, and review of pertinent documents on 1/30/25, it was determined that the facility failed to ensure 5 of 5 cognitively impaired residents (Residents #3, #13, #29, #37, and #42) at risk of aspiration (accidental breathing in of fluid or food into the lungs) and who had physician's order (PO) for a pureed textured (blended, mixed, or processed into a smooth and uniform texture) diet received an entrée consistent with the prescribed diet. This deficient practice was identified for 5 of 5 residents reviewed for mechanically altered diet (require change in texture of food or liquids; example pureed food). On 1/30/25 at 12:13 PM, the surveyor observed the lunch meal tray preparation in the kitchen. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to maintain kitchen sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 1/29/25 from 9:28 AM to 11:31 AM, the surveyor, accompanied by the Dietary Aide (DA #1) and the Food Service Director (FSD) toured the kitchen and observed the following: 1. On 1/29/25 at 10:09 AM the surveyor observed a high temperature dish machine running at 136 degrees Fahrenheit (F). The FSD stated that per the manufacture's recommendations the dish machine should wash above 150 degrees and rinse above 180 degrees. DA #1 placed a rack of soiled trays in the dishwasher and when the cycle was complete dipped a test strip onto a wet tray immediately. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a) accurately monitor and document a dressing change for a midline (a thin, flexible tube inserted in a vein in the upper arm to deliver fluids or medications) intravenous catheter and b) ensure that a resident (Resident #4) received care and treatment in accordance with professional standards of clinical practice, the physician's order, and the facility's policy. This deficient practice was identified for 1 of 1 resident (Resident #159) reviewed for infection and 1 of 1 resident (Resident #4) reviewed for hospitalization and was evidenced by the following: [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to maintain a safe and home like environment. This deficient practice was identified on 1 of 3 nursing units [South Unit] reviewed for environmental concerns, and was evidenced by the following: On 1/29/2025 at 9:38 AM, the surveyor toured the South Unit and observed the following: 1.) Inside resident room #S18, on the wall adject to the door was a large area of unfinished plaster surrounding two sides of an electrical outlet, peeling wallpaper behind the resident's bed, and brown stains on the floor tiles between the resident's bed and the wall adjacent to the door. 2.) Outside room #S19 the wallpaper was peeling. 3.) Across the hall from room #S19, the kick plate on the lower half of the door to the room labeled Spa, was detached and warped. [...]

Inspectors wroteBased on interview, record review, and review of facility documents, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of a resident hospitalization. This deficient practice was identified for 1 of 2 residents (Resident #4) reviewed for hospitalization and was evidenced by the following: On 1/29/25 at 10:10 AM, the surveyor observed the resident awake and alert sitting in a wheelchair with a visitor at their bedside. Resident #4 stated they were in the hospital back in October 2024. On 1/29/25 at 11:00 AM, the surveyor reviewed the medical record for Resident #4. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included respiratory syncytial virus (RSV) and enterocolitis (inflammation of the intestines). [...]

Inspectors wroteBased on interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy for 1 of 2 residents (Resident #4) reviewed for hospitalizations. This deficient practice was evidenced by the following: On 1/29/25 at 10:10 AM, the surveyor observed the resident awake and alert sitting in a wheelchair with a visitor at their bedside. Resident #4 stated they were in the hospital back in October 2024. On 1/29/25 at 11:00 AM, the surveyor reviewed the medical record for Resident #4. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included respiratory syncytial virus (RSV) and enterocolitis (inflammation of the intestines). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to obtain a re-weight according to the facility's policy for a resident with a history of significant weight loss. This deficient practice was identified for 1 of 3 residents (Resident #19) reviewed for nutrition and evidenced by the following: On 1/30/25 at 1:01 PM, the surveyor observed Resident #19 in his/her room being served lunch. The resident received double portions of ground spaghetti and meatballs with sauce, vegetables, and bread. The resident stated he/she enjoyed the food. At 1:43 PM, the surveyor observed Resident #19 had consumed approximately 50% of his/her lunch meal. The surveyor reviewed the medical record for Resident #19. [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to maintain proper infection control practices to ensure a.) staff performed appropriate hand hygiene while donning (putting on) and doffing (removing) gloves for 1 of 1 staff member observed, and b.) enhanced barrier precautions (EBP) was initiated for 1 of 1 resident (Resident #24). This deficient practice was evidenced by the following: 1.) On 1/29/2025 at 10:06 AM, during the initial tour of the South Unit, the surveyor observed the Environmental Services staff member (EVS #1) exit resident room S24 doffed gloves, disposed them in the garbage and donned another pair of gloves without performing hand hygiene, EVS #1 then entered resident room S25. [...]

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to maintain a safe and sanitary food storage room. This deficient practice was identified in 1 of 1 emergency food storage rooms and was evidenced as follows: On 1/31/2025 at 10:00 AM, the surveyor and the Regional Food Service Director (RFSD) toured the emergency food storage room in the basement. The surveyor heard intermittent liquid dripping and observed a brown puddle of liquid on the floor. In the nearby vicinity, an open box containing serving utensils and two (2) boxes of coffee cup lids and were located on the lower shelf. The boxes appeared to be disfigured and discolored containing brown splatter marks. At the same time, the surveyor observed an opening in the ceiling near the window. Two brown long drip lines were noted on the wall. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to handle potentially hazardous foods and maintain sanitation in a safe consistent manner. This deficient practice was evidenced by the following: On 11/15/23 at 10:56 AM, the surveyor accompanied by the Food Service Director (FSD), observed the following in the kitchen: 1. Upon entry to the kitchen, nine (9) stacks of dessert tray cups were observed with scattered white substances. The FSD informed the surveyor that the white substances were dust. The FSD stated that two (2) out of nine (9) stacks were empty. He further stated that they were considered clean but would not be used as of that time, the facility was using disposables for dessert because of the short staff lately for a month or so now. 2. In the metal dish racks, there were clean pans and pots. [...]

Inspectors wroteBased on observation, interviews, and review of facility provided documents, it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply in accordance with the facility's emergency disaster plan. This failure had the potential to affect all 62 residents who currently live in the facility. This deficient practice was evidenced by the following: On 11/16/23 at 12:45 PM, the surveyor observed the emergency water storage area in the presence of the Food Service Director (FSD), Licensed Nursing Home Administrator (LNHA), and the Director of Nursing (DON). The resident census on the day of observation was 62 (based on the Matrix [used to identify pertinent care categories for: [...]

Inspectors wroteComplaint # NJ00166500 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a) document an incident report and perform an investigation for a facility acquired pressure ulcer (PU) for two (2) of two (2) residents reviewed for pressure ulcer/injury (Resident #3 and #214) according to standards of clinical practice and facility's policy and procedure, b) accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for one (1) of two (2) residents reviewed for PU (Resident #214), and c) evaluate and complete an assessment of a skin opening opening immediately upon identification, initiate wound care protocol, and consistently implement timely interventions in adherence with the facility wound management policy that included obtain a physician's orders and [...]

Inspectors wroteComplaint # NJ00166500 Based on observations, interview, record review, and review of other pertinent facility documents, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft by failing to ensure resident's personal belongings were labeled and inventoried for one (1) of five (5) residents sampled for closed records (Resident #214). This deficient practice was evidenced by the following: The surveyor reviewed the medical records of Resident #214. Resident #214's closed record included the following Progress Note: Resident #214 was discharged at 6:00 PM today with the resident's representative (RR) but was unable to find resident's clothes that he/she came with Writer and RR searched resident's room and also laundry area but couldn't [could not] find any clothing, not really clear it [if] clothes were labeled . [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to develop a comprehensive care plan (CP) to address smoking and psychotropic medication (any drug capable of affecting the mind, emotions, and behavior) use for one (1) of sixteen (16) sampled residents (Resident #24). This deficient practice was evidenced by the following: On 11/16/23 at 11:18 AM, the surveyor interviewed Resident #24 who stated that he/she smoked cigarettes. The surveyor reviewed Resident #24's medical record. Resident #24's admission Record (an admission summary) indicated that the resident was admitted to the facility with medical diagnoses that included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain the necessary respiratory care and services for a resident who was receiving continuous oxygen for one (1) of two (2) residents (Resident #38) reviewed for oxygen use. This deficient practice was evidenced by the following: On 11/15/23 at 10:51 AM and 11/17/23 at 9:13 AM, the surveyor observed Resident #38 out of bed in a wheelchair reading a book. The resident had a nasal cannula (N/C; a device that delivers extra oxygen through a tube and into nose) tubing that was labeled with a date, and respirations were not labored. The tubing was attached to an oxygen (O2) concentrator (take air from surroundings, extract oxygen and filter it into purified O2 to breathe) with the O2 liters set at 4.5 LPM (liters per minute). The surveyor reviewed the medical records for Resident #38. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility provided documents, it was determined that the facility failed to a.) maintain a system of record keeping of DEA (Drug Enforcement Administration) Form-222 (a federal narcotic requisition form), that ensured drug records were in order, and controlled dangerous substance (narcotics medications), with high potential for abuse were tracked with detail and b.) develop procedures that enabled prompt identification of loss or potential diversion of controlled substance. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation conducted on 11/17/23 and 11/20/23, the surveyor observed four (4) nurses administer medications to six (6) residents. There were 27 opportunities, and two errors were observed which resulted in a medication error rate of 7.41%. This deficient practice was identified for two (2) of six (6) residents (Resident #47 and #55), that was administered by one (1) of four (4) nurses. This deficient practice was evidenced by the following: 1. On 11/17/23 at 8:33 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare medications for Resident #47. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that the Infection Preventionist (IP) had completed specialized training in infection prevention and control per Centers for Medicare & Medicaid Services (CMS) guidance prior to assuming the IP role for one (1) of one (1) employee reviewed for IP. This deficient practice was evidenced by the following: A review of CMS QSO-19-10-NH Memo, dated 3/11/19, included but was not limited to the following: Background: Effective November 28, 2019, the final requirement includes specialized training in infection prevention and control for the individual(s) responsible for the facility's IPCP (infection prevention and control program). Specialized Training for Infection Prevention and Control: In order to receive . [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) verification that recently hired non-certified Nursing Aides (NA) were currently enrolled and actively taking classes in a New Jersey state-approved Certified Nursing Aide (CNA) Training Program, b.) validate completion of Module 1 in their CNA Training Program prior to allocating an independent resident assignment, and c.) there was a delineated policy and/or program in place for the hiring, staffing, and assignments of non-certified NAs for one (1) of one (1) non-certified NA's. This deficient practice was evidenced by the following: Reference: State of New Jersey Department of Health memo dated April 21, 2023 sent to Nursing Homes included the following: Facilities are advised as follows: I. TNAs (Temporary Nursing Assistant) A. [...]

Inspectors wroteComplaint# NJ00154003 Based on interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to: a.) follow a Physician's Order (PO) for a serum Complete Blood Count (CBC; is a blood test that measures many different parts and features) that was ordered on 01/28/22, to be done on 01/31/22 and b.) notify the resident's physician that staff was unable to obtain the serum CBC according to the standards of clinical practice. This deficient practice was identified for one (1) of 16 residents, (Resident #215) reviewed for quality of care. The CBC was drawn on 02/03/23, which was 4 days later which revealed a critical low hemoglobin (hgb; a protein in red blood cells that carries oxygen) of 5.4g/dl (grams per deciliter) [normal range 12-15.5g/dl]. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of facility policies it was determined that the facility failed to provide full visual privacy during medication administration and phlebotomy (use a needle to take blood from a vein) services for 4 of 14 residents (Resident #28, #31, #41 and #302). The deficient practice was evidenced by the following: 1. On 7/19/21 at 8:57 AM, the surveyor observed from the hallway a Phlebotomist in the process of obtaining a blood sample from Resident #31 in room S22-2. The resident's roommate was present in the room. The resident's privacy curtain and door were open. At 9:03 AM, the surveyor observed the Phlebotomist from the hallway obtaining a blood sample from Resident #41 in room N06-2 without pulling the privacy curtain or closing the door. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to consistently implement care plan interventions to: a) provide pressure reduction for a resident at high risk of developing pressure ulcers (Resident #2). The deficient practice was observed for 1 of 17 residents reviewed and evidenced by the following: The surveyor observed Resident #2 on 7/19/21 at 8:23 AM and 11:50 AM, 7/20/21 at 9:32 AM and 11:30 AM, 7/21/21 at 9:00 AM, and 7/22/21 at 10:00 AM. The resident was lying in bed on his/her back without the offloading of pressure to the heels. The surveyor reviewed Resident #2's Electronic Medical Record which revealed the following. The admission Record revealed the resident was receiving palliative care (comfort measures). [...]

Inspectors wroteBased on Observation, interview, and record review, it was determined that the facility failed to follow acceptable standards of practice by not signing for medications in the Electronic Medication Administration (EMAR) for Resident #30 and not signing for treatments in the Electronic Treatment Administration Record (ETAR) Resident #12. The deficient practice was observed for 2 of 14 residents reviewed and evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to administer oxygen in accordance with physician's orders and in a way that would decrease the possibility of transmitting infections. This was found with 2 of 2 residents reviewed for respiratory care, Resident # 32 and Resident # 41. The deficient practice was evidenced by the following: 1. On 7/19/21 at 8:16 AM, the surveyor observed Resident # 32 in bed. The resident was receiving oxygen via a nasal cannula that was attached to an oxygen concentrator and set to deliver oxygen at a rate of 4 liters per minute (lpm). There was an excess of tubing that was looped around several times on the floor. The oxygen concentrator was about six feet from the bed, next to the door. On 7/20/21 at 9:58 AM, the surveyor observed the resident in the wheelchair in the resident's room. [...]

Inspectors wroteBased on observation interview and review of facility records, it was determined that the facility failed to 1) ensure an accurate inventory of controlled medications (narcotic medications) dispensed from the facility's automatic medication dispensing system and 2) sign for the controlled medication after it was removed from inventory. The deficient practice was observed on the automatic medication dispensing system and on the South unit and evidenced by the following: 1. On 7/19/21 at 11:04 AM, the surveyor inspected the automatic medication dispensing system in the presence of the Director of Nursing (DON), for the controlled medication accuracy. The screen showed that there was a discrepancy on 7/1/21 and 7/3/21. [...]