Rolling Hills Health Center

Inspectors wroteThe facility identified a census of 44 residents. Based on observation, record review, and interviews, the facility failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. This placed all residents who resided in the facility at risk of a lack of assessment and inappropriate care.

Inspectors wroteThe facility identified a census of 44 residents with one kitchen and dining room. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to food storage and equipment cleaning. This deficient practice placed the residents at risk of food-borne illnesses and food safety concerns.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 2's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) bag was properly hung. The facility failed to ensure R34 and R54's nasal cannula (NC- a hollow tube medical device that provides supplemental oxygen therapy to people who have lower oxygen levels) were properly stored when not in use. This placed R2, R34, and R54 residents at risk of infection development and possible respiratory and/or urinary complications.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide a safe environment when cleaning chemicals and Sani-wipes (a disposable disinfecting wipe) were not securely stored out of the residents' reach. The facility failed to ensure interventions were put in place after Resident (R) 27 had a fall. This placed the residents at risk for avoidable falls and avoidable injury.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 27's care plan was revised with new interventions after having falls. This placed R27 at risk for delayed care and possible injuries.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 12 residents, with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 2's pressure-reducing interventions were implemented correctly when R2's low air-loss mattress (a specialized adjustable air mattress that reduces pressure applied to the body) was not set within her current weight range. This deficient practice placed R2 at risk for complications related to skin breakdown and pressure ulcers.

Inspectors wroteThe facility reported a census of 44 residents. The sample included 12 residents, with two reviewed for urinary catheter care. Based on record review, interviews, and observations, the facility failed to maintain Resident (R) 2's indwelling urinary catheter in a safe and sanitary manner. This deficient practice placed R2 at risk for complications related to urinary tract infections.

Inspectors wroteThe facility identified a census of 44 residents. The sample included 12 residents, with one resident reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R) 3's post-traumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R3 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility had a census of 95 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ). This placed the residents at risk for impaired care due to unidentified staffing issues.

Inspectors wroteThe facility documented a census of 41 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure an environment free from accident hazards for Resident (R) 1, who required staff assistance and a mechanical lift for safe transfers. As a result, R1 sustained a humerus (upper arm bone) fracture. This deficient practice also placed R1 at risk for pain and impaired independence.

Inspectors wroteThe facility identified a census of 47 residents. Based on record review and interview, the facility failed to provide a Registered Nurse (RN) for at least eight consecutive hours, seven days a week. This placed all residents in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 47 residents. The sample included 14 residents and five Certified Nurse Aides (CNA) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 47 residents. The facility failed to provide the services of a full-time certified dietary manager for the 47 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility identified a census of 47 residents. The facility had one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to ensure proper transportation of food items from the kitchen to the kitchenette. The facility also failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened, and the food items were not placed in a sealed container/storage bag with the proper labeling and date. This placed all residents who ate food from the facility at risk for food-borne illness.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interviews, the facility failed to ensure a dignified dining experience for the residents who chose to eat in their rooms when the facility provided plastic silverware with the room trays. This deficient practice placed residents at risk for an undignified and unenjoyable dining experience.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the residents were provided a safe, clean, comfortable, and homelike environment. This placed the residents at risk for decreased psychosocial well-being and impaired safety and comfort for the affected residents.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents. The facility identified two influenza (highly contagious viral infection) positive residents. Based on record review, observations, and interviews, the facility failed to ensure infection prevention standards were followed related to disinfecting shared equipment, urinary catheter care, laundry services, and wound treatment practices. This deficient practice placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 47. The sample included 14 residents with 14 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)30's Care Plan to reflect his needs related to the type of wheelchair needed. The facility failed to revise R32's Care Plan to ensure the interventions listed matched the resident's current needs and goals. The facility failed to ensure R25's Care Plan was revised to address antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication use. This deficient practice placed R30, R32, and R25 at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to provide the necessary assistive care and services to Resident (R) 29. This deficient practice placed the resident at risk for poor hygiene, decreased self-esteem, and impaired dignity.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure a compression glove was provided for Resident (R) 29's left hand. This deficient practice placed R29 at risk for increased left-hand edema, pain, and skin related difficulties.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing measures were placed on Resident (R) 10's bilateral lower extremities and failed to ensure staff implemented appropriate infection control practices during wound care. This deficient practice placed these residents at risk of development of pressure ulcers, wound worsening, and complications related to infections.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with three residents sampled for position and mobility. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 26's carrot (conical-shaped item used to treat contractures [abnormal permanent fixation of a joint or muscle]) was applied as directed, to prevent an avoidable reduction of range of motion (ROM) and/or mobility of his left hand. This deficient practice left R26 at risk for further decline and decreased ROM or mobility.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with three reviewed for accidents/falls. Based on record review, interviews, and observations, the facility failed to ensure Resident (R) 41's non-slip floor strips remained in place next to her bed per her care plan. The facility further failed to ensure R10 had her call light within reach. This deficient practice placed the residents at risk for preventable falls and injuries.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with three residents reviewed for urinary catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid). Based on record review, observations, and interviews, the facility failed to provide catheter care that met the standards of practice when staff failed to securely anchor Resident (R) 2's suprapubic (inserted through the abdomen into the bladder) catheter tubing to his abdomen. This placed R2 at risk for catheter dislodgement and potential injury.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure R4 was provided physician-ordered supplemental shakes and/or failed to monitor intake for the supplement. This placed R4 at risk of additional weight loss and related complications.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R)23's PRN (given as needed) Ativan (antianxiety medication that calms and relaxes people with excessive anxiety, nervousness, or tension) medication lacked a 14 day stop date or specified duration with rationale. This deficient practice placed the resident at risk for ineffective treatment and unnecessary side effects.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to provide a 14-day stop date or intended duration of therapy, and rationale for extended use related to Resident (R)23's PRN (given as needed) Ativan (antianxiety medication that calms and relaxes people with excessive anxiety, nervousness, or tension) medication. This deficient practice placed the resident at risk for ineffective treatment and unnecessary side effects.

Inspectors wroteThe facility identified a census of 47 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to ensure the medication error rate did not exceed five percent (%) when staff failed to ensure Resident (R)23's Keppra (a medication used to treat violent involuntary series of contractions of a group of muscles- seizures) was administered as ordered. The facility failed to ensure the insulin (a hormone that lowers the level of glucose in the blood) pen was appropriately primed before insulin administration to R32 and R6. This resulted in a medication error rate of 8.82%.

Inspectors wroteThe facility identified a census of 41 residents. Based on observations, record reviews, and interviews, the facility failed to maintain an effective quality assessment and assurance (QAA) program to identify and develop corrective actions plans and monitor them to correct identified quality deficiencies prior to survey. This deficient practice placed the resident's at risk for ineffective care. Findings Included: - The facility failed to maintain dignified care practices for Residents (R)3, R19, R20 and R25. (Refer to F550) The facility failed to ensure bathing and personal hygiene was provided for R21 and R8 who required assistance from staff to complete the care. [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with 12 reviewed for resident rights. Based on observation, record review, and interviews, the facility failed to maintain dignified care practices for Resident (R)3, R19, R20, and R25. This deficient practice placed the residents at risk unnecessary embarrassment and decreased psychosocial well-being. Findings Included: - On 07/11/22 at 09:45 AM staff transported R20 through the main television area uncovered and wearing only a loosely draped hospital gown in the facility's shower seat. On 07/11/22 at 09:10 AM staff transported R25 to his room after taking a shower. The door to the room failed to latch upon being closed and R25 was observed from the hallway sitting in the shower chair, wearing only an incontinence brief. [...]

Inspectors wroteThe facility identified a census of 43 residents. Based on observation and interview, the facility failed to maintain a clean, safe, homelike environment when it failed to ensure unused medical equipment was stored out of resident's way and in a manner which did not impede the residents' use of personal and common space. The facility further failed to ensure the facility carpet was clean and free of stains in the residents' communal area. This deficient practice placed the residents at risk for impaired comfort and decreased homelike environment. Findings Included: - On 07/11/22 at 07:15 AM an initial walkthrough was conducted in the facility. [...]

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide weekend activities. This deficient practice placed the residents in the facility at risk for boredom and decreased socialization. Findings Included: - On 07/14/2022 at 10:41 AM during an interview with Resident (R)13 , she verbalized that the facility never offered activities on the weekends. She reported that while she did enjoy going to some of the activities throughout the week the facility never did anything on the weekends for the residents. She stated that she would like to attend Bingo or some other event if they provided it. A review of the April, May, June, and July activity calendar for 2022 revealed that activities had been scheduled for Monday thru Friday but not offered on the weekends (Saturday and Sunday). [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to ensure a system to promote an accurate reconciliation of controlled drugs at the end of daily work shifts and maintain the staff count sheets for the controlled drugs. This placed residents at risk for misappropriation of medications by staff.

Inspectors wroteThe facility identified a census of 41 residents and one facility kitchen. Based on observation, record review, and interviews, the facility failed to maintain sanitary dining services related to equipment cleaning, and safe food temperatures and storage during service. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: - On 07/11/22 at 07:15 AM an initial walk-through of the kitchen was completed. An inspection of the dish washing area revealed the floor drain had trash and debris visible and obstructing some of the drain holes. An inspection of the ice machine revealed food and trash items under the unit. A bug was observed crawling under the ice machine. An inspection of the dry good storage area revealed an undated, opened bag of noodles. [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with 12 residents reviewed for care plan. Based on observation, record review, and interviews, the facility failed to revise the care plan to include resident-centered fall interventions for R21. This placed her at risk of future falls and uncommunicated care needs.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with five residents reviewed for bathing. Based on observation, record review, and interviews, the facility failed to ensure bathing and personal hygiene was provided for Resident (R) 21 and R8 who required assistance from staff to complete the care. This deficient practice placed R21 and R8 at risk for potential skin breakdown and/or complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with four residents reviewed for quality of care. Based on observation, record review, and interviews, the facility failed to implement a physician order for daily weights to monitor for congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) for Resident (R) 9 and failed to follow up and/or implement a physician order for hospice services for R8. This deficient practice placed these residents at risk of delayed treatment and untreated illness.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with two reviewed for the prevention of pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin). Based on observation, record review, and interviews, the facility failed to implement interventions to prevent pressure injuries for Residents (R)39 and R21. This deficient practice placed the residents at increased risk for skin breakdown. Findings Included: [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with eight reviewed for falls. Based on observation, record review, and interviews, the facility failed to implement fall interventions per the plan of care for Residents (R) 39 and failed to develop and implement resident-centered fall interventions appropriate for R21 to prevent falls. This deficient practice placed the residents at risk for falls and injuries. Findings Included: [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with one resident reviewed for dementia care (progressive mental disorder characterized by failing memory, confusion). Based on observations, record reviews, and interviews, the facility failed to provide dementia care and services to support Resident (R)3's highest practicable level of well-being. This deficient practice placed R3 at risk for decreased quality of life and impaired well-being due related to dementia. Findings Included: [...]

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to perform physician ordered weekly heart rate monitoring related to medication use. These deficient practices placed R8 at risk for side effects of unnecessary medications or complications.