Rolling Hills Rehab and Care Ctr

Inspectors wroteBased on observation, interview, review of facility temperature logs, and facility policies, the facility failed to safely store drugs at proper temperatures to preserve their integrity. Further, the facility failed to proper ensure controlled medications were stored in a separately locked, permanently affixed compartment. This affected four residents (Resident #13, 19, 25, and 42), and had the potential to affect all residents of the facility due to stock medications.

Inspectors wroteBased on review of facility infection control logbook, review facility policy, and interview with the facility infection preventionist, the facility failed to maintain standardized surveillance of its antibiotic stewardship program. This had the potential to affect 52 residents residing in the facility. The facility census was 52. Findings Include: Review of the infection control logbook from January 2026 to July 2026 revealed a monthly log sheet containing a list of residents with infections, type of infection, type of organism if available, treatment ordered and completed, and available laboratory data. Further review of the logbook revealed blank copies of the McGeer's infection surveillance tool in the back of the logbook. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of medical records, review of facility policies, and interviews with facility staff, the facility failed to provide a comprehensive immunization program to ensure residents are offered and received immunizations timely. This affected four (Residents #9, #10, #20, and #26) of five residents reviewed for immunizations. The facility census was 52. Findings Include;1. Review of Resident #9 medical record revealed admission to facility on 11/05/19 for diagnoses including toxic encephalopathy (water on the brain), major depressive disorder, anemia (low blood count), dementia (confusion and forgetfulness), anxiety disorder, heart disease and high blood pressure. [...]

Inspectors wroteBased on medical record review, policy review, and interview, the facility failed to notify a resident's representative of severe weight loss. This affected one (Resident #50) of three residents whose responsible parties were interviewed.

Inspectors wroteBased on medical record review and interview, the facility failed to timely complete a significant change assessment for a resident who exhibited a severe weight loss and developed pressure ulcers since their prior assessment. This affected one (Resident #50) of 17 residents whose minimum data set (MDS) assessments and clinical records were reviewed for significant changes in condition.

Inspectors wroteBased on medical record review, observation and interviews with residents, and interviews with staff, the facility failed to provide activities of interest for Resident #26 and Resident #50. This affected two (Residents #26 and #50) of two residents reviewed for activities. The facility census was 52. Findings Include: 1. Review of the medical record for Resident #26 revealed admission to the facility on [DATE] for diagnoses including lung disease, diabetes, depression, anxiety, atrial fibrillation (irregular heartbeat), schizoaffective disorder (paranoid personality tendences), and poor circulation in legs. [...]

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure residents who smoked did so at scheduled times and in designated smoking areas. This affected one (Resident #13) of two residents screened for smoking. The facility identified 14 residents who smoked.

Inspectors wroteBased on observation, interview and review of drug information the facility failed to observe residents administer their respiratory inhalers and failed to ensure residents rinsed their mouth after using a steroidal inhaler. This affected one resident (Resident #10) of three residents reviewed for medication administration.

Inspectors wroteBased on review of medical records, observations and interviews the facility failed to provide comprehensive dementia care to deter resident wandering into other resident rooms. This affected two residents (Resident #8 and #22) of two residents reviewed for abuse. The facility census was 52.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure pharmacy provided medications as ordered and the discrepancy was identified prior to medication administration. This affected one resident (Resident #10) of three reviewed for medication administration. The facility census was 52.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure infection control guidelines were implemented prior to the administration of an injection. This affected one resident (Resident #10) of three observed for medication administration. The facility census was 52.

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staffing information was posted. This had the potential to affect all 51 residents.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEYBased on medical record review, interview, and Self-Reported Incident (SRI) review, the facility failed to ensure Resident #200 was free from staff to resident physical abuse when Registered Nurse (RN) #100 inappropriately treated the resident by attempting to spray holy water on the resident. This affected one resident (#200) out of one three residents reviewed for abuse. The facility census was 58. Findings Include:Review of the medical record for the Resident #200 revealed an admission date of 11/12/25 and a discharge date of 03/01/26. Diagnoses included hemiplegia, hemiparesis, aphasia following cerebral infarction, major depressive disorder, anxiety disorder, and a need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, review of hospital notes, review of consents, and medical record review, the facility failed to implement appropriate interventions and supervision to ensure Resident #2 did not leave the facility without supervision and engage in unsafe behaviors. This affected one resident (#2) out of three residents reviewed for safety interventions. The facility's census was 58. [...]

Inspectors wroteBased on observation, interview, review of hospital paperwork, review of Substance Use Disorder Program consent, review of the facility investigation, and record review, the facility failed to ensure residents received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for substances abuse. This affected one resident (#2) out of three residents reviewed for safety interventions. The facility's census was 58. Findings Include: [...]

Inspectors wroteBased on observation, interview, record review, review of the Facility Assessment, and review of the facility's admission agreement, the facility failed to provide sufficient nursing staff was available to ensure resident safety and effectively care for residents. This had the potential to affect all residents residing in the facility. The facility census was 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the services of a Registered Nurse (RN) were provided for at least eight consecutive hours a day, seven days a week. Additionally, the facility failed to ensure a full time Director of Nursing (DON) was employed and actively working within the facility. This had the potential to affect all residents residing in the facility. The facility census was 65.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure medications were administered per physician orders. This affected one resident (Resident #73) of five residents reviewed for medication administration. The census was 65. Finding Include: Record review revealed Resident #73 admitted to the facility on [DATE] with diagnoses including abscess of the spleen, chronic viral hepatitis C, and peritoneal abscess. Review of Resident #73's physician orders revealed an order for Cubicin Intravenous (IV) solution reconstituted 500 milligrams (mg) (Daptomycin), give 350 mg IV one time a day at 9:30 A.M. for abdominal abscess until 03/24/26. Further review revealed the resident had a peripherally inserted central catheter (PICC)/ midline (left arm) with orders to monitor for leaking and/ or signs and symptoms of infection every shift. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received appropriate supervision and intervention to prevent leaving the facility unsupervised. This affected one resident (Resident #55) of two residents reviewed for accidents. The census was 65.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure Resident #49 was served food in mechanically altered form to meet her needs. This affected one resident (#49) of three residents reviewed for appropriate diets. The facility identified 13 residents who were identified by the facility to require a mechanically altered diet. The facility census was 65.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Assessment addressed what resources are necessary to care for its residents completely during both day to day operations (including nights and weekends) and emergencies. This had the potential to affect all residents residing in the facility. The facility census was 65.

Inspectors wroteBased on interview and observation, the facility failed to maintain a clean, safe, comfortable and sanitary environment. This had the potential to affect all 51 residents residing in the facility. The facility census was 51. Findings Include: Initial tour on 09/16/25 from 1:35 P.M. to 1:44 P.M., revealed the South Unit shower room had a sewer odor that lingered into the beginning of the 100 and 200 hallway and nurse's station. The carpet behind the nurse's station was stained and dirty. Wallpaper in the corner by the vending machine was pulled away from the wall and mold spots were noted behind the wallpaper on the wall. The carpet floor tiles in the vending room were pulling up off the ground, some were not cut properly to fit the edge of the room, and all the carpet tiles were moved under the snack vending machine. [...]

Inspectors wroteBased on record review, facility policy review, Self-Reported Incident (SRI) review, and interviews, the facility failed to provide documented evidence of a thorough investigation and report allegations of sexual abuse to the State survey agency. This affected two residents (Resident #19 and Resident #45) of three residents reviewed for abuse. The facility census was 51. Findings Include:1. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, vascular dementia, alcohol use, flaccid bladder, hydronephrosis, major depressive disorder, hypertension, and anxiety. Record review of Resident #19's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #19 had severe cognitive impairment and could independently walk at least 150 feet. [...]

Inspectors wroteBased on medical record review, hospital record review, review of data found at www.kidneyfoundation.org, policy review and interviews, the facility failed to prevent an incident of neglect when Resident #51 did not receive hemodialysis treatments as ordered due to a lack of facility provided transportation. This resulted in Immediate Jeopardy and actual harm with risk of death beginning on 07/21/25 when Resident #51, who was dependent on hemodialysis due to end stage renal disease, was not transported to a scheduled dialysis treatment. The resident subsequently missed hemodialysis on 07/23/25 again due to a lack of facility provided/arranged transportation. As a result, Resident #51 developed symptoms of fluid volume overload, shortness of breath, fatigue and weakness. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure operations were conducted in a manner that supported and encouraged the highest level of resident care, as staff were prohibited from speaking freely with state agency personnel, which hindered their ability to advocate for residents without fear of retaliation. The facility administration also failed to ensure contracted staff were not asked to alter legal documents contained within resident medical records. This affected one resident (#7) and had the potential to affect all 52 residents residing in the facility.

Inspectors wroteBased on interview and observation, the facility failed to maintain a clean, safe, comfortable and sanitary environment. This had the potential to affect all 52 residents residing in the facility.

Inspectors wroteBased on observation, and interviews the facility failed to provide an effective pest management program. This had the potential to affect all 52 residents residing in the facility.

Inspectors wroteBased on interview, record review and resident agreement review the facility failed to ensure residents were transported to medical appointments. This affected one resident (Resident #17) of four residents reviewed.

Inspectors wroteBased on record review, facility policy review, facility investigation review and interviews the facility failed to thoroughly investigate and report allegations of sexual abuse to the state survey agency. This affected two residents (Resident #7 and #54) of three residents reviewed for abuse. The facility census was 52. Findings Include:1. Record review revealed Resident #7 admitted to the facility on [DATE] with diagnoses of vascular dementia, alcohol use, flaccid bladder, hydronephrosis, major depressive disorder, hypertension, metabolic encephalopathy, and anxiety. Record review of Resident #7 quarterly Minimum Data Set(MDS) dated [DATE] revealed Resident #7 had severe cognitive impairment, exhibited behaviors and could independently walk at least 150 feet. [...]

Inspectors wroteBased on record review, interview and policy review the facility failed to maintain accurate care plans. This affected one (Resident #51) of nine residents reviewed. The census was 52.

Inspectors wroteBased on observation and interview, the facility failed to ensure office spaces were clean and sanitary. This had the potential to affect all residents residing in the facility. The census was 55.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure resident representatives were notified when there was a change in the residents' treatments/ medications as required. This affected three of three residents reviewed for changes in condition.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for residents at risk and with a history of falls as per their plan of care. This affected two (Resident #45 and #51) of three residents reviewed for falls.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to implement preoperative orders prior to a scheduled surgical procedure resulting in the procedure being rescheduled. This affected one resident (Resident #18) of five reviewed for physician orders.

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain a clean and comfortable environment for the residents residing in the facility. This affected one resident (Resident #6) of five residents interviewed on the 100 and 200 units who utilized the community shower. The facility census was 63.

Inspectors wroteBased on record review, review of Quality Assurance Performance Improvement (QAPI) sign-in sheets, staff interview, and policy review, the facility failed to ensure the governing body was engaged and involved in the oversight of the functions of the facility in regards to the QAPI program. This affected all 50 residents in the facility. The facility census was 50.

Inspectors wroteBased on interview, record review, and review of the facility arbitration agreement, the facility failed to ensure residents or their representative were educated regarding their right to communicate with local, state, or federal officials before signing an arbitration agreement or within thirty days of signing the agreement. This affected all residents residing in the facility. The facility census was 50.

Inspectors wroteBased on interview, record review, and review of the facility arbitration agreement, the facility failed to ensure their arbitration agreement allowed for a mutually agreeable arbitrator and venue. This had the potential to affect all residents residing in the facility. The facility was census was 50.

Inspectors wroteBased on interview, review of survey history, review of approved plans of corrections, and policy review, the facility failed to establish a Quality Assurance and Performance Improvement (QAPI) program that thoroughly evaluated identified areas in need of improvement, and monitored and evaluated the effectiveness of corrective action making revisions to systems and practices as needed to ensure ongoing compliance. This affected all 50 residents residing in the facility.

Inspectors wroteBased on review of Quality Assurance and Performance Improvement (QAPI) attendance logs, staff interview, and policy review, the facility failed to hold quarterly meetings composed of staff who understood the characteristics and complexities of the care and services delivered by each unit, and/or department including the director of nursing (DON), Medical Director, Infection Preventionist (IP), and at least three other staff, one of whom was the facility's administrator, owner, board member, or other individual in a leadership role who had knowledge of facility systems and the authority to change those systems. This affected all 50 residents residing in the facility.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to ensure privacy was maintained during the administration of an injectable medication and transdermal patch. This affected one resident (#160) out of four residents observed for medication administration. The facility census was 50.

Inspectors wroteBased on self-reported incident review, medical record review, resident interview, staff interview, and policy review, the facility failed to ensure allegations of abuse were reported to the state agency in a timely manner. This affected one (Resident #30) of three residents (Resident #14, Resident #30, and Resident #53) reviewed for abuse. The facility census was 50.

Inspectors wroteBased on self-reported incident review, medical record review, resident interview, staff interview, and policy review, the facility failed to investigate an allegation of misappropriation of resident property. This affected one (Resident #30) of three residents (Resident #14, Resident #30, and Resident #53) reviewed for abuse. The facility census was 50.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents and/or the resident representatives were provided with transfer notices after the residents were transferred to the hospital. This affected two residents (#45 and #55) of three residents reviewed for hospitalization and discharge. The facility census was 50 residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure residents and/or resident representatives were provided with bed hold notices following hospital transfers. This affected two residents (#45 and #55) of two residents reviewed for hospitalizations. The facility census was 50 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure psychiatric progress notes were obtained from the provider, failed to ensure a new diagnosis of schizoaffective disorder was identified and added to the medical record and care plan, and failed to accurately transcribe changes to psychiatric medications. This affected one resident (#37) out of one resident reviewed for mood and behavior. The facility census was 50.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to obtain a physician ordered urinalysis (UA) and culture and sensitivity (C&S) for Resident #38, delaying antibiotic treatment. This affected one resident (#38) out of two residents reviewed for urinary tract infections (UTI). The facility census was 50. Findings Include: Review of the medical record for Resident #38 revealed an admission date of 08/19/2024. Diagnoses included unspecified dementia, end stage renal disease, and muscle wasting and atrophy. Review of Resident #38's annual minimum data set (MDS) 3.0 assessment with a reference date of 10/16/24 revealed the resident had a severe cognitive impairment. Review of Resident #38's nursing progress note dated 10/24/2024 at 2:31 P.M. revealed the resident had complaints of pain upon urination and the resident complained of abdominal pain. [...]

Inspectors wroteBased on record review, staff interview, observation, and facility policy, the facility failed to ensure weights were obtained per the residents individual needs and as ordered for Resident #16, #25, and #158; Additionally, the facility failed to ensure nutritional supplements were received for Resident #16. This affected three residents (#16, #25, and #158) out of four residents reviewed for nutrition. The facility census was 50.

Inspectors wroteBased on record review, observation, staff and resident interviews, and facility policy, the facility failed to ensure the mask of a resident's nebulizer (a device which turns liquid medicine into a fine mist that can be inhaled) was properly stored after use. This affected two residents (#25 and #47) out of three residents reviewed for respiratory care. The facility identified eight residents (#2, #5, #19, #25, #30, #47, #159, and #161) as utilizing nebulizers. The facility census was 50.

Inspectors wroteBased on record review, interview, observation, and policy review, the facility failed to ensure Resident #21 was provided pain gel medications as ordered for tooth pain. This affected one resident (#21) out of three residents (Resident #21, Resident #43, and Resident #51) reviewed for pain. The facility census was 50.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a pharmacy recommendation for laboratory monitoring was addressed by the physician. This affected one (Resident #43) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, observation, record review, and policy review the facility failed to ensure Resident #21 received timely dental services after experiencing dental pain. This affected one out of two residents (Resident #21 and Resident #8) reviewed for dental services. The facility census was 50.

Inspectors wroteBased on record review, staff interviews, review of the Ohio Dietetics website, and review of the nutritional consulting company's contract with the facility, the facility failed to ensure the nutritional staff member who was completing quarterly reviews was qualified to assess the nutritional status for resident quarterly reviews. This affected one (Resident #25) of three residents who were reviewed for nutrition and had the potential to affect all residents who required a nutritional quarterly review. The facility census was 50.

Inspectors wroteBased on record review, policy review, review of a respiratory care journal, personnel file review and interview, the facility failed to ensure only competent staff provided tracheostomy care/insertion to residents. This affected one (Resident #58) of two residents reviewed for tracheostomy care.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to ensure infection control practices were maintained to prevent the spread of COVID-19 and failed to ensure enhanced barrier precaution were maintained during resident care. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on medical record review and interview the facility failed to ensure an admission skin assessment was completed timely and post trauma skin alteration treatments were administered as ordered. This affected one resident (#20) of three records reviewed for skin alterations.

Inspectors wroteBased on closed record review, review of email correspondence and interview the facility failed to ensure all requirements were met in issuing a discharge notice to Resident #51. This affected one resident (#51) of three residents reviewed for discharge.

Inspectors wroteBased on medical record review, policy review and interview the facility failed to ensure Resident #51 was permitted to return to the facility following a hospitalization. This affected one resident (#51) of three residents reviewed for hospitalization. The facility census was 50.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, interview, record review, facility investigation review and policy review the facility failed to ensure residents were free from staff physical abuse. This affected two residents (#38 and #56) of three residents reviewed for abuse. The facility census was 57.

Inspectors wroteBased on record review, self- reported incident (SRI) review, interview, and policy review the facility failed to ensure a resident was free from verbal and physical abuse from a family member. This affected one resident (#22) of three residents reviewed. The facility census was 48.

Inspectors wroteBased on record review, self- reported incident (SRI) review, interview, and policy review revealed the facility failed to thoroughly investigate an allegation of resident abuse. This affected one resident (#22) of three residents reviewed. The facility census was 48.

Inspectors wroteBased on record review, observation, review of the guidance provided in the website for the National Library of Medicine, and interview, the facility failed to check a gastrostomy tube placement prior to administering a tube feed in order to prevent complications. This affected one resident (#62) of three residents reviewed for weight loss. The facility census was 48.

Inspectors wroteBased on observation, interview and review of facility policies, the facility did not prepare and serve food under sanitary conditions. This had the potential to affect all 45 Residents in the facility who received meals from the kitchen, as the facility identified no residents who did not receive meals from the kitchen. The facility census was 45.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to develop care plans for all Residents. This affected four Residents (#3, #4, #34, and #41) of 15 Residents reviewed for care plans. The facility census was 45.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure residents who were cognitively independent were included in care conferences. This affected one Resident (#6) of 15 residents reviewed for care planning. The facility census was 45.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to ensure code status was consistent between the paper chart and electronic health record (EHR) for Resident #6. This affected one Resident (#6) of 16 Residents reviewed for advanced directive. The facility census was 45.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure preadmission screening for individuals with mental disorders were accurate. This affected three (Resident #3, Resident #41 and Resident #43) of four residents review for preadmission screening. The facility census was 45.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure care plans were revised after new fall interventions were implemented and when psychotropic medications were discontinued. This affected two (Residents #3 and #26) of 15 residents reviewed for care plans. The facility census was 45.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with loose stools was assessed and care provided. This affected one Resident (#36) of one Resident reviewed for general concerns. The facility census was 45.

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to follow physician's orders for tube feeding infusing times and solution type. This affected one (Resident #25) of one residents reviewed for tube feeding. The facility identified one resident utilizing tube feedings.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to maintain a medication error rate of less than five percent. Three errors occurred within 25 opportunities for error resulting in a medication error rate of 12%. This affected one Resident (#33) out of six residents observed for medication administration. The facility census was 45.

Inspectors wroteBased on observation, staff interview, and review of the facility policy and procedure, the facility failed to ensure the medication cart was kept locked against unauthorized access. This had the potential to affect one Resident (Resident #41) identified by the facility as cognitively impaired and independently mobile out of 20 residents residing on the 300 and 400 unit hall way where the unlocked medication cart was kept. The facility census was 45.

Inspectors wroteBased on observation, interview and facility policy review the facility failed to ensure food did not lose nutritional value during the puree process. This had the potential to affect one Resident (#25) who was the only resident ordered a pureed diet. The facility census was 45.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to ensure assistive devices were provided during meals. This affected one Resident (#13) of one Resident reviewed for nutrition. The census was 45.

Inspectors wroteBased on record review, interview and policy review the facility failed to follow antibiotic stewardship guidelines. This affected one Resident (#34) of five Residents reviewed for unnecessary medications. The facility census was 45.