Rolling Hills Health and Rehab

Inspectors wroteBased on observation and interviews, the facility failed to follow sanitary dietary standards related to food storage, unclean floors, and monitoring of dishwasher temps.

Inspectors wroteBased on observation, record review, and interview, the facility failed to offer and provide or obtain informed declination for the influenza and pneumococcal vaccination for Resident (R) 1, R5, R49, and R62 or their representative.

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain an informed declination for the COVID-19 vaccination was provided for Resident (R)1, R5, R49, and R62 or their representative.

Inspectors wroteBased on interviews and record review, the facility failed to provide the correct Center for Medicare and Medicaid (CMS) Form 10055, Advanced Beneficiary Notice (ABN), for two residents, Resident (R)34 and R55.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of an antipsychotic (class of medications used to treat mental disorder characterized by a gross impairment in reality testing) for Resident (R) 62.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide Resident (R) 5, or their representative with a copy of the bed hold policy, written notification of transfer, and failed to notify the ombudsman when she was transferred to the hospital. The facility failed to ensure the Notice of Transfer to Hospital form included the required rights to appeal and the ombudsman information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective person-centered interventions to prevent falls for two residents. Resident (R)38, who had three falls with staff, and R1, whose fall interventions were not implemented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to collaborate care and services provided by the facility with the care and services provided by hospice for Resident (R)11.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement adequate infection control practices related to sanitary storage of respiratory supplies and hand hygiene during wound care for Resident (R) 4.

Inspectors wroteBased on record review and interview, the facility failed to submit complete and accurate staffing information through the Payroll Based Journal (PBJ) as required.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure a safe environment free from accident hazards for Resident (R) 6 when staff did not use the right type of slide board for R6, who had a previous staff-assisted fall using a slide board. The facility further failed to address the risk after a staff-assisted fall. The facility failed to ensure a safe environment free from accident hazards for R10, who had large openings in the side rails presenting a risk for entrapment. Additionally, the facility failed to ensure a safe environment for R47 who had medications stored on her bookshelf, and for R52 who did not wear a smoke apron as per her plan of care while smoking. [...]

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to revise the care plan for one resident, Resident (R)40, whose hydrochlorothiazide (HCTZ-a diuretic) was discontinued. This placed the resident at risk for inappropriate care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents with one reviewed for dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood). Based on observation, record review, and interview, the facility failed to ensure ongoing communication with the dialysis provider regarding dialysis treatments and monitoring for Resident (R)54. This placed the resident at risk for complications and health decline.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents, with one reviewed for side rails. Based on observation, record review, and interview, the facility failed to obtain written informed consent which included potential risks versus benefits from the resident and/or representative for the use of side rails for Resident (R)10. This placed her at risk for accident or injury due to uninformed choices regarding side rail use.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Certified Nurse Aide (CNA) staff possessed adequate competency and skill for the use of a slide board for one resident, Resident (R) 6, who was lowered to the ground during a slide board transfer. This placed the resident at risk for injury.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist identified and reported the lack of an appropriate indication, or the required physician documentation, for Resident (R) 37's use of an antipsychotic (medications used to treat any major mental disorder characterized by gross impairment in reality)and irregularities with R38's blood pressure and pulse monitoring. This placed the resident at risk for unnecessary medications and related side effects.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to notify the physician when Resident (R) 38's blood pressure and pulse were outside the physician-ordered parameters. This placed the residents at risk for ineffective medication regimens and unnecessary medication side effects.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents, with five reviewed for unnecessary medications. Based on observations, interviews, and record review, the facility failed to ensure an appropriate indication, or a documented physician rationale which included the unsuccessful attempts for nonpharmacological symptom management and risk versus benefits for the continued use of Resident (R)37's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment testing) medication. This placed R37 at risk for unintended effects related to psychotropic (alters mood or thought) medications.

Inspectors wroteThe facility had a census of 63 residents, with 19 residents included in the sample. Based on observation, record review, and interview, the facility failed to prevent significant medication errors for one resident, Resident (R) 105, who did not receive medications that were ordered to treat high blood pressure. This placed R105 at risk for adverse complications due to high blood pressure.

Inspectors wroteThe facility had a census of 64 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to correctly prepare a pureed diet for two residents that retained both nutritive value and palatability. This placed the affected residents at risk for impaired nutrition or decreased quality of life.

Inspectors wroteThe facility reported a census of 69 residents with 13 selected for review. Based on observation, interview, and record review, the facility failed to maintain comfortable and safe temperature levels of 71 degrees Fahrenheit (F) or greater for ten residents, Resident (R)2, R5, R6, R7, R8, R9, R10, R11, R12, R13 when a facility furnace quit working mid-morning on 01/12/24. The furnace supplied heat to one of four wings, covering six resident rooms, with ten residents affected. Following the breakdown, a repairman came to the facility that afternoon and determined the part needed to repair the furnace required ordering. The facility placed portable infrared space heaters in the resident rooms until 01/16/24 at 02:04 PM, at which time the Fire Marshall instructed the facility to remove the space heaters. [...]

Inspectors wroteThe facility reported a census of 69 residents, with thirteen sampled, and three reviewed for significant medication errors. Based on observation, record review, and interview, the facility failed to prevent a significant medication error for Resident (R)1 when facility staff prepared and wrongly administered R4's medications, which included high risk medications, to R1 on 12/18/23. Certified Medication Aide (CMA) R prepared R4's medications, then asked R1 if she was ready for her medication and R1 nodded yes, so CMA R administered R4's medications to R1. CMA R thought R1 resembled the picture in the Medication Administration Record (MAR) for R4. Shortly after administration of the medications, CMA R heard Administrative Nurse E speak to R1 and realized she administered R4's medications to R1. [...]

Inspectors wroteThe facility reported a census of 63 residents with 16 residents sampled, including one resident reviewed for admission, transfer, and discharge. Based on observation, interview and record review, the facility failed to notify in writing one Resident (R)116 and their representative of the intention to involuntarily discharge the resident from the facility, 30 days before the date of discharge.

Inspectors wroteThe facility reported a census of 63 residents with 16 residents sampled, including six residents reviewed for Activities of Daily Living (ADL). Based on observation, interview, and record review the facility failed to complete appropriate personal hygiene for one dependent Resident (R)11, regarding long, jagged, dirty fingernails and failed to complete appropriate oral care for dependent resident R117.

Inspectors wroteThe facility reported a census of 63 residents, with two residents reviewed for the care of a gastrostomy tube (G-tube) (a tube that is placed directly into the stomach through an abdominal wall incision for the administration of food, fluids, and medications, also called a PEG tube, percutaneous endoscopic tube.). Based on observations, interviews, and record review, the facility failed to provide appropriate and sufficient services, treatment, and care based upon current standards of practice to ensure that Resident (R) 13 received proper treatment and services to prevent infection of the stoma (surgically created opening of an internal organ on the surface of the body) where the G-tube inserted through the skin.

Inspectors wroteThe facility reported a census of 63 residents with 16 residents sampled, including three residents reviewed for respiratory. Based on observation, interview and record review, the facility failed to provide appropriate respiratory care for one Resident (R)117, of the three sampled, regarding oxygen tubing to prevent respiratory infections.