Rolling Hills Care Center

Inspectors wroteBased on observation, staff interviews and review of facility documents, the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards for food service safety when:1. Leftover previously cooked rice was not monitored for cooling;2. One sanitation solution in a red bucket was not the appropriate concentration when the Food Service Worker (FSW 2) sanitized the food preparation counter; and3. The can opener was dirty with a thick black substance on the blade. This had the potential for the growth of microorganisms which can lead to food borne illness for the 31 residents admitted to the facility1. During an observation, in the kitchen, in the reach-in refrigerator, on 5/19/26 at approximately 10:38 a.m., there was a container of cooked rice dated 5/18/26 with a use by date of 5/21/26 that was 43 degrees Fahrenheit (F). [...]

Inspectors wroteBased on interview and record review, the facility failed to promote and implement an antibiotic (ATB) stewardship and surveillance program (ATBS-designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) for the use of antibiotics when the Infection Preventionist (IP) did not ensure the antibiotic surveillance log (chronological record used to continuous monitor antibiotic use) was complete and accurate to identify, track, and monitor resident antibiotic use. This failure had the potential to result in the administration of unnecessary and inappropriate antibiotic use, as well as inaccurate monitoring of antibiotic use which could lead to antibiotic-resistant organisms and inaccurate data monitoring and reporting. During a concurrent interview and record review on 5/21/26 at 3:45 p.m. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an environment free of accident hazards when: 1. Oxygen safety precautions were not implemented for one of thirty two residents (Resident 36) when oxygen equipment was present in Resident 36's room and oxygen-in-use signage was not posted outside the room. This failure had the potential to expose the residents, staff, visitors and emergency responders to accident hazards, including fire or injury, due to unrecognized oxygen use and exposure to ignition sources. 2. One of seven slings (specialized fabric support used with a patient lift to safely transfer individuals with limited mobility between beds, wheelchairs, and commodes) were found with frayed edges and torn corners in the clean linen closet ready for use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to post actual direct care staffing hours worked for public review for 30 of 30 residents in the facility, as required, by posting projected DHPPD (Direct Hours Per Patient Day) staffing information instead of actual hours worked for the prior day. This failure had the potential to prevent residents' family members and visitors from having accurate information regarding the actual nursing staffing levels providing care in the facility. During an observation on 5/19/26 at 9:34 a.m. the facilities publicly posted staffing document titled Rolling Hills Care Center Tuesday, May 19th, 2026 was reviewed. The posting reflected a projected census of 30, projected staff hours of 127 and projected Nurse Hours Per Patient Day (NHPPD) of 4.23. [...]

Inspectors wroteBased on observation, staff interview and review of facility documents, the facility failed to ensure menus were followed for the lunch meal on 5/19/26 when the facility served: 1) A #12 scoop (1/3 cup) of cauliflower instead of #8 (1/2 cup) of peas for five residents (Residents 4, 26, 35, 37 and 20);2) One resident on a soft and bite sized diet (Resident 25) received 1/3 cup instead of 1/2 cup of cauliflower; and3) Four residents on a renal diet (Resident 35, 37, 20 and 28) 1/2 cup instead of 1/3 cup of oven browned potatoes. This failure has the potential to result in residents not meeting the micronutrients (referred to as vitamins and minerals, are vital to healthy development, growth, disease prevention, and well-being) in the physician prescribed therapeutic diets which could compromise nutritional and medical status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 15) was informed in advance, by the physician of the risks and benefits of proposed treatment when Resident 15 did not have a signed physician informed consent (a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or intervention) prior to the administration of venlafaxine HCL (an antidepressant prescription medication used to relieve symptoms of depression such as feelings of sadness or loss of interest in activities). This failure resulted in Resident 15 receiving medication without being informed of the risks, benefits, or alternatives, limiting the resident's ability to make informed decisions about their care. During a concurrent interview and record review on 5/21/26 at 4:11 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for three of five sampled residents (Residents' 20, 21, and 35) when: 1. Resident 20 and 35 did not have a care plan for Enhanced Barrier Precaution (EBP-refer to an infection control intervention designed to reduce transmission of multi-resistant drug organisms that employ targeted gown and gloves use during high contact resident care activities) secondary to having dialysis access port. This failure placed Resident 20 and Resident 35 at risk of cross-contamination (unintentional transfer of harmful bacteria, virus, or allergens from one surface, object, or food to another) and not meeting their needs and care. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Resident 20 and Resident 35) when Resident 20 and Resident 35 did not have an order for Enhance Barrier Precautions (EBP-refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities) upon admission to the facility due to presence of hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) catheters. This deficient practice placed Resident 20 and resident 35 at risk of cross contamination which could lead to more serious health conditions. During a concurrent observation and interview on 5/20/26 at 11:10 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon a Medication Regimen Review (MMR) irregularity for one of seven sampled residents (Resident 24) when the facility's Consultant Pharmacist recommended Resident 24's calcium (a mineral needed for bones, teeth, muscles, and nerves) administration time be changed to 10:00 a.m. or later due to medication interaction with levothyroxine (medication that replaces the natural thyroid hormone the body is missing and must be taken on an empty stomach), scheduled for 6:00 a.m. Resident 24's calcium administration time was instead changed to 8:00 a.m. without obtaining the required physician documentation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 37) was free from unnecessary drugs when Resident 37's use of anticoagulant medication (refers to class of medication that are used to prevent clot extension and formation) had no monitoring for side effects. This failure resulted in Resident 37 receiving medication and had the potential to experienced side effects of medication without proper monitoring. During a concurrent observation and interview on 5/19/26 at 9:05 a.m. with Resident 37 in the hallway outside of room [ROOM NUMBER]. Resident 37 was observed sitting up in his wheelchair and was assisted by staff, left foot wrapped with gauze dressing (medical cloth patch or gauze made of loosely woven cotton), Resident 37 stated his left small toe was surgically amputated. [...]

Inspectors wroteBased on interview and review of facility documents, the facility failed to ensure there was a full time qualified Dietary Manager (DM) met state requirements, California Health and Safety Code (CA HSC) 1265.4(b) when the Registered Dietitian (RD) was not employed full-time. This failure resulted in puree food not in the proper form, puree foods not being prepared by methods that conserve nutritive value and flavor, menus not being followed and food stored not being monitored for cool down procedures for the 31 residents admitted to the facility. (Cross Reference F803, 804, 805, 812). During a review of the California Health and Safety Code (CA HSC) 1265.4 (a), If the facility employs a RD less than full-time, they shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. [...]

Inspectors wroteBased on observation, interview and review of facility documents, the facility failed to ensure puree foods were prepared by methods that conserve nutritive value and flavor when [NAME] 1 made puree roasted potatoes and cauliflower were prepared with water for two residents (Residents 4 and 26) that were on a physician's prescribed puree diet. This can result in residents receiving improper nutrients from the food which can result in a decrease in meeting the nutrient needs which can further compromise their medical status. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:21 a.m, [NAME] 1 scooped two #8 (1/2 cup) scoop portions into blender then added, #24 scoop (1-1/3 ounces) butter, and five ounces of hot water from hot water dispenser spicket then blended. [...]

Inspectors wroteBased on observation, staff interviews and review of facility documents, the facility failed to ensure puree food was in the proper form for two sampled residents (Residents 4 and 26) on their lunch meal tray on 5/19/26. This failure has the potential to result in choking (when the airway is obstructed by food, drink, or foreign objects) for Residents 4 and 26 who were on the physician prescribed therapeutic diet. During an observation in the kitchen and concurrent interview with [NAME] 1 on 5/19/26 at 10:21 a.m, [NAME] 1 scooped two #8 (1/2 cup) scoop portions into blender then added, #24 scoop (1-1/3 ounces) butter, and five ounces of hot water from hot water dispenser spicket then blended. The measuring cup contained 8 ounces of hot water then after hot water was poured into blender there were three ounces of hot water left. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and confidential medical records in accordance with accepted professional standards and practices for one of five sampled residents (Resident 15) when Resident 15's electronic health record (EHR) contained annual History and Physicals (H&P - A comprehensive assessment of a person's medical history), that belonged to five different residents (Residents 6, 17, 24, 40, and 41). These failures resulted in the compromised accuracy of Resident 15's medical records and violated the confidentiality of Protected Health Information (PHI - any health-related information that identifies a specific person) for Residents 6, 17, 24, 40, and 41.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sterile water bottles used for oxygen humidification were labeled with the open date for one of 32 residents (Resident 35) observed receiving oxygen therapy. This failure had the potential to result in the use of contaminated respiratory equipment and increased the risk of infection.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively when DC 1 thawed frozen meat without running cold water. This failure had the potential to result in unsafe food being served, consumed, and could have cause food borne illness (contamination of food and occur at any stage of the food production, delivery and consumption chain) to 29 residents who were served food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food service safety when: 1 One opened box of pancake batter mix was not labeled with an open on date. 2. Residents snacks were not labeled with prepared on date an in refrigerator for residents to eat. 3. A hornet and wasp pesticide (bug spray) bottle was found below kitchen sink cabinet. 4. Six bags of muffins in the freezer were not labeled with the received-on date. 5. Resident refrigerator contained unlabeled foods with no received on date, resident name and content. 6. Uncooked frozen meat were found inside the resident refrigerator. [...]

Inspectors wroteBased on observation and interview during the survey period of 11/19/24 to 11/25/24, the facility failed to provide the minimum of at least 80 square feet (sq. ft- unit of measurement) per resident in multiple resident bedrooms, and at least 100 sq. ft in single residents rooms for 11 of 20 rooms (Rooms 1, 5, 6, 8, 9, 10, 11, 12, 18, 19, and 20), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 5, 6, 8, 9, 10, 11, 12, 18, 19, and 20 to not have reasonable privacy or adequate space.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the environment free from insects in accordance with the facility's policy and procedure (P&P) Pest Control Program when ants were observed in the kitchen floor and cabinet. This failure led to insects being observed in the kitchen facility and had the potential to cross contaminate food being prepared in the kitchen for 29 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for three of 16 residents (Residents 3, 9 and 23) when: 1. Resident 9's care plan was not developed to address the use and storage of Resident 9's Incentive Spirometer (IS - a hand-held device that helps people take slow deep breaths to improve lung functioning). This failure put Resident 9 at risk of infection and harm due to improper storage and use of the IS. 2. Resident 23's care plan was not developed to address the use and care of a nebulizer (a device that changes medication from a liquid to a mist so it can be inhaled into the lungs). This failure put Resident 23 at risk of infection and harm due to improper storage and use of Resident 23's nebulizer. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for three of 16 sampled residents (Resident 23 and Resident 3) when: 1. Resident 23's oxygen flow rate was set to 3L (liters-a unit of measurement) instead of the ordered 2L. This failure had the potential to result in shortness of breath and respiratory distress (difficulty breathing) for Resident 23. 2. The Attending Physician (AP) was not notified of Resident 3's refusal of lidocaine (medication is used on the skin for pain) patch. This failure resulted in Resident 3 not receiving ordered pain medication. 3. Resident 3's physician order (a set of instructions written by a doctor for clinicians to follow when caring for a resident) for pain medication was not followed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored and labeled in accordance with currently accepted professional standards and practice when: 1. One of one bottle of folic acid (a mineral) did not have a readable expiration date on the bottle, and one of 161 pill packets (a packet that contains a set number of medication pills of the same brand in individual pop-out wrapping) was expired. These failures had the potential for residents to receive expired medications resulting in medication ineffectiveness (not producing any significant or desired effect). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to be established and maintained an infection control program to provide safe, sanitary, and comfortable environment to help prevent infections for two of 12 sampled residents (Resident 30 and Resident 23) when: 1. Resident 30's continuous positive airway pressure (CPAP- is a machine that uses mild air pressure to keep breathing airways open while you sleep) mask was observed not stored in a bag and on the ground. 2. Resident 23's oxygen tubing (a tube that delivers oxygen to people who have low oxygen levels) was observed wrapped around Resident 23's bed rail, not stored in a bag, and Resident 23's nebulizer (a device that changes medication from a liquid to a mist so it can be inhaled into the lungs) was observed on the ground, not covered in a bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable and homelike environment for two of 16 sampled Residents (Resident 9, Resident 23), when Resident 9 and Resident 23 were unable to access and use their personal belongings and medical equipment to the extent possible as needed. This failure resulted in Resident 9 and Resident 23 not having a safe homelike environment.

Inspectors wroteBased on interview and record review the facility failed to ensure one of eight sampled residents (Resident 31) had a post-discharge plan of care (narrative document for communicating clinical information about what happened to the resident in the facility) when Resident 31 left AMA (Against Medical Advice- term used in healthcare when a patient leaves the hospital before their doctor recommends discharge). This failure resulted Resident 31's not having a post-discharge plan of care (document that summarizes a patient's health conditions, treatments, and other information) and had the potential to not adjust to new living environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor resident rights when: A hot shower request for three of nine sampled residents (Resident 1, 2 and 6), was not an option, and the alternative was a cold shower or no shower. This failure resulted in Resident 1, 2 and 6 individual preferences or choice being devalued (reduce or underestimate the worth of importance of) and not being treated with honor or respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the environment remained free from accident hazards for one of three residents (Resident 1) when Certified Nurse Assistant 2 placed a hot cup of soup at Resident 1 bedside table without first ensuring the temperature of the soup would not burn. CNA 1 was aware of Resident 1's physical limit to reach safely and left the hot cup of soup on the bedside table. These failures resulted in Resident 1 reaching for the hot cup of soup in an unsafe manner, spilling the hot soup on his chest and stomach and suffering burns to the skin that required wound care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 30 of 30 sampled residents when: 1. The cabinet storing clean pots and pans had dust and food crumbs, and a drawer that stored clean utensils had food crumbs. 2. The side wall of the stove was caked with black grime and grease, and the floor behind the stove had a build-up of black grime and crumbs. The upstairs dining room food serving area had a dirty wall with a yellow drip stain and wadded paper observed behind the steam table. Food particles and dirt were observed next to the steam table along the space between the wall and floor where there was no baseboard in place. 3. The floor under the dishwasher was not smooth and easily cleanable. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for three of eight sampled residents (Resident 12, Resident 13 and Resident 20) when: 1. Resident 12's Physician Orders for Life Sustaining Treatment (POLST-a written portable medical order form with instructions for emergency medical care that travels with a resident ) was not completely documented with Resident 12's information. 2. Resident 13 and Resident 20's POLST did not have the second page completed. These failures resulted in Resident 12, Resident 13, and Resident 20's medical information to not be readily accessible and portable in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a system to oversee grievances in accordance with their policy and procedure (P&P) for one of twelve sampled residents (Resident 15) when the facility's Social Services Director (SSD) failed to document, track, and investigate the grievance reported by Resident 15. This failure had the potential to result in Resident 15 not being able to exercise her rights and lack of appropriate action to resolve her grievances.

Inspectors wroteBased on observations, interviews and record review the facility failed to meet standards of quality for one of seven sampled residents (Resident 26) when Resident 26's morning medications (sertraline-antidepressant and lamotrigine-anticonvulsive) were in a medication cup on Resident 26's bedside table. This failure had the potential to result in Resident 26 not taking her medications and other residents in the facility at risk for taking the unprescribed medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from unnecessary medications for one of four sampled Residents (Resident 25) when Resident 25 was administered oxycodone HCl (a narcotic used to treat severe pain that can result in physical dependence) for treatment of a healed wound. This failure placed Resident 25 at risk for receiving pain medication unnecessarily which could lead to medication dependence. During an interview on 1/9/24 at 11:42 a.m. with Resident 25, Resident 25 stated he was experiencing pain in both shoulders that was progressing down both arms. Resident 25 stated the pain increased when lifting both arms and pain medication was not effective. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to store and secure medications in a locked compartment for five of five sampled medications when discontinued medications albuterol sulfate inhalation aerosol (medication for breathing), ipratropium and albuterol (nebulizer solution, used to open the airways in lung diseases where spasm may cause breathing problems), and two boxes of loperamide hydrochloride and simethicone tablets (antidiarrheal and anti-gas tablets) and guaifenesin (helps clear mucus) were stored in an unlocked drawer in the nurse's station. This failure had the potential for residents and staff to have access to the medications.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain and provide one of one resident (Resident 12) beds in safe operating condition when Resident 12's head of the bed and foot of the bed would not raise up or lower. This failure resulted in Resident 12 being uncomfortable while in her bed. During a concurrent observation and interview on 1/9/24 at 9:17 a.m. with Resident 12, Resident 12's bed would not raise or lower at the head of the bed (HOB) or the foot of the bed (FOB). Resident 12 stated, the bed had not functioned for six months, and she had made staff aware of the issue. Resident 12 stated when she wanted to sit upright, the staff would position pillows behind her back in bed, causing discomfort. Resident 12 stated she would have to sit up in her wheelchair during her meals or sit up at the edge of the bed having to adjust frequently. [...]

Inspectors wroteBased on observation and interview during the survey period of 1/9/24 to 1/12/24, the facility failed to provide the minimum of at least 80 square feet (sq. ft- unit of measurement) per resident in multiple resident bedrooms, and at least 100 sq. ft in single residents rooms for 16 of 20 rooms (Rooms 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 14, 16, 18, 19, 20), when the amount of usable living space was not adequate for residents. This failure had the potential for residents in Rooms 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 14, 16, 18, 19, and 20 to not have reasonable privacy or adequate space.