Rolling Hills Rehab Ctr

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 19 sampled Residents (R2) and 1 of 1 supplemental Residents (R58) reviewed for change of condition. R58 was diagnosed with Covid 19 on [DATE] and then pneumonia on [DATE]. On [DATE], R58 had noted oxygen saturation levels in the low 80s, complained of shortness of breath (SOB), labored breathing and was also noted to be more fatigued than the day prior and disoriented at times. There is no evidence comprehensive assessment or R58's physician being updated of R58s condition changes and R58 expired [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 49 residents who reside in the facility. Surveyor observed [NAME] U not allow thermometer to air dry before probing food. Surveyor observed [NAME] U reheat mashed potatoes in the microwave and then serve them without getting the internal temperature to 165 degrees F (Fahrenheit). Surveyor observed the facility's mixer to have food particles on the undercarriage. Surveyor observed [NAME] BB remove gloves, use a marker to label a plastic bag and then go back to working with food without washing his hands. Evidenced by:Example 1Facility policy, titled Food Handling, reviewed 5/7/26, includes: [...]

Inspectors wroteBased on record review and interview, the facility did not maintain a quality assessment and assurance committee consisting of the required members to identify issues through the committee. This deficient practice has the potential to affect all 49 residents currently in the facility. The IPC (Infection Prevention and Control nurse) did not attend Quality Assurance Performance Improvement (QAPI) meetings on 2 out of 4 quarterly meetings. This is evidenced by:The facility's policy Quality Assurance/Assessment and Performance Improvement Plan, undated, includes: The Quality Assessment and Assurance (QAA) Committee consist of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the infection control and prevention officer. [...]

Inspectors wroteBased on interview and record review, the facility failed to have a system in place to ensure advance directive paperwork was on file for 1 of 19 sampled residents (R7) reviewed for advance directives. R7's chart did not contain a copy of her advance directive paperwork specifying her designated power of attorney. This is evidenced by:The facility's policy, titled Heath Care Power of Attorney, Advanced Directives and POST (Physician Orders for Scope of Treatment) Form Use, revised 5/8/26, states, in part: Policy: Rolling Hills Rehab Center recognizes the desires of a resident who is capable of making his/her own health care decisions supersedes the effect of an advance directive at all times. Advanced Directives can be a Health Care Power of Attorney (HCPOA) form, a POST Form, or a Living Will form. Procedure: 1. [...]

Inspectors wroteBased on interview and record review, the facility did not notify and consult with a resident's physician when there was a change in condition. This occurred for 1 of 19 Residents (R25) reviewed for notification of change in condition. R25 had unwitnessed falls on 1/2/26 and 3/26/26 with no notification to the medical provider. Evidenced by: Facility Policy Subject: Falls Assessment Procedure: 3. CONSULT WITH Physician if head injury or injury caused a significant change in status. R25 was admitted to the facility on the 10/29/24. Her diagnoses include: Hallucinations(a false sensory experience that feels readl, even though it is created by the mind), Generalized anxiety disorder(chronic uncontrollable and excessive worrying about everyday things that feels impossible to turn off). [...]

Inspectors wroteBased on interview and record review, the facility failed to fully prevent further potential abuse, neglect, exploitation, or mistreatment of residents while an investigation was in process for 1 of 3 residents (R7) investigated for an incident involving alleged abuse. A staff member involved in a facility reported incident was not directly supervised at all times while working to ensure protection of other residents after the facility became aware of an allegation of abuse made by R7. This is evidenced by: The facility's policy, titled Misconduct Investigation & Reporting, reviewed 2/24/25, states, in part: Policy: Rolling Hills Senior Living prohibits abuse, neglect, exploitation and misappropriation of resident property. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 19 Residents (R25) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing. R25 requested side rails to aid in bed mobility and the facility did not provide the side rails to R25 timely. This is evidenced by:R25 admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive neurodegenerative disorder of the central nervous system), restless leg syndrome (a neurological disorder characterized by an irresistible urge to move the legs), rheumatoid arthritis (a chronic autoimmune disorder where the immune system attacks the joint lining causing inflammation, swelling, and stiffness) and chronic pain. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident who needs respiratory care is provided with such care consistent with professional standards of practice for 1 of 2 residents (R6) reviewed for oxygen. R6 did not have oxygen tubing/nasal cannula changed on a monthly basis. Evidenced by:The facility's Oxygen Therapy policy, dated 1/2026, states, in part: .8. Replace nasal cannula monthly. R6 admitted to the facility on [DATE] and has diagnoses that include: acute and chronic respiratory failure with hypercapnia (a condition when the lungs cannot adequately supply oxygen to the blood or remove carbon dioxide); Cor pulmonale, chronic (the enlargement and failure of the right ventricle of the heart caused by high pressure in the lungs arteries, linked to lung disease); [...]

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one of five sampled residents (Resident (R)2) reviewed for allegations of abuse. The facility failed to notify the State Agency (SA) in a timely manner regarding an alleged incident involving R2.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections that has the ability to affect all 50 residents (R). -Facility staff failed to transport linens in a manner to prevent the spread of infection. -Facility staff did not properly doff personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). -Facility staff demonstrated poor hand hygiene during medication administration. -Facility staff did not prep skin prior to administering a subcutaneous injection of insulin. This is evidenced by: [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents received appropriate treatment and services to maintain range of motion (ROM). This had the potential to affect four residents (R) reviewed for mobility (R25, R26, R30, and R31). -R25 was not provided restorative services at least three times per week as identified in her care plan. -R26's care plan did not identify the frequency and duration of restorative services needed. -R30 was not provided restorative services daily as identified in her care plan. -R31 was not provided restorative services five times per week as identified in her care plan. This is evidenced by: Per Appendix PP of the State Operations Manual (SOM), regulation F688 reads in part . [...]

Inspectors wroteBased on the interview and record review, the facility failed to implement its policies and procedures and did not protect 2 of 3 residents from abuse. (R43, R35). R43 was not protected from verbal abuse when Certified Nursing Assistant (CNA) D threatened R43 by stating CNA D would throw R43 over shoulder and carry out of room if R43 didn't do what CNA D wanted R43 to do. R36 was not protected from physical abuse when R35 grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist.

Inspectors wroteBased on interview and record review, the facility did not report 2 of 3 (R43, R36) potential misconduct incidents to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident. *CNA D threatened R43 by stating CNA D would throw R43 over shoulder and carry out of room if R43 didn't do what CNA D wanted R43 to do. *R35 grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist.

Inspectors wroteBased upon interview, policy review and record review, the facility did not ensure allegations of verbal and physical abuse were thoroughly investigated or prevent further potential abuse from occurring while the investigation was in progress for residents (R) (R43, R36) and other undocumented residents, which has the potential to affect all 19 residents on the Birchwood unit. Facility did not protect R43 when allowing Certified Nursing Assistant (CNA) D to continue to work with R43 when accused of verbal abuse. Facility allowed CNA D to continue to work with R43 during complaints of rough cares was being investigated. This is evidenced by: Facility policy titled Misconduct Investigation and Reporting, last revised 08/20/24, stated in part, .-2. [...]

Inspectors wroteBased on record review and interview, the facility did not transmit the Minimum Data Set (MDS) assessments within 14 days of completion for 3 residents (R) (R40, R47, and R31) out of 12 sampled residents. R40 had a Quarterly (Q) MDS assessment completed on 10/02/24 and a Quarterly MDS assessment completed on 12/31/25. Both assessments had not been transmitted as of end of survey, 02/20/25. R47 had a Prospective Payment System (PPS) discharge assessment completed 11/08/24 and a Quarterly MDS completed 12/23/24. MDS assessments had not been transmitted. R31 had a Quarterly MDS assessment completed on 10/02/24 and another Quarterly MDS completed on 12/31/24 which were not submitted by the facility. This is evidenced by: The requirements for the RAI are found at 42 CFR 483.20 and are applicable to all residents in Medicare and/or Medicaid certified long-term care facilities. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 15 residents (R13, R35) reviewed. R13 was left unattended while connected to mechanical lift equipment. R35 did not have increased supervision to prevent resident to resident altercations after incidents on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. This is evidenced by: Example 1 The Food and Drug Administration (FDA) Safety Information guidance provided in Kwikpoints Patient Lifts Safety Guide, states in part: Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure a medication error rate of 5% or less. During the medication administration task, Surveyors observed 4 errors out of 35 medication opportunities, resulting in an error rate of 11.4%. This affected 2 out of 4 residents (R) observed for medication administration sample. (R11 and R39) R11 received two insulin injections by using injectable pens that were not primed before administration. R39's insulin was not primed prior to administration of insulin.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure drugs and biologics were stored in accordance with current accepted professional practice. This had the potential to affect 2 out of 2 residents (R) for proper labeling. (R29 and R39) This is evidenced by: According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication. According to the American Diabetes Association, insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 and 86 degrees F for up to 28 days and continue to work. After 28 days the insulin should be discarded. On 3/29/21, R29 was admitted to the facility with a diagnosis including type 2 diabetes mellitus. [...]

Inspectors wroteBased on record review and interview, the facility did not conduct a thorough investigation of a resident-to-resident altercation by interviewing all residents who were in area at time of incident, did not provide follow up supervision for 48 hours per facility report to protect other residents, and did not provide staff education following an incident for 1 of 4 residents (R1). This is evidenced by: The facility policy, entitled Misconduct Investigation & Reporting last reviewed on 08/23/11 and states in part under section 14 of policy: All resident witnesses/victims should be interviewed as part of the investigation. Nursing or Social Services will assess the resident(s) and make official entries in client charts indicating any behavioral, emotional or changes from their baseline and recommend follow-up or longer if deemed necessary. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure adequate supervision to reduce risk of wandering/elopement for 1 of 3 residents (R) reviewed (R1). R1 left the facility without staff's knowledge and was not added to the facility's Wanderer's List for increased supervision after incident per facility policy. This is evidenced by: The facility's policy titled, Wanders-Identification, Observation, and Possible Search For, with most recent revision dated 08/2022 stated in part that required follow up following a wandering/elopement event nursing staff must include resident on Wanderer's List. R1 was admitted to the facility on [DATE] with pertinent diagnoses of hemiplegia (impaired body function) on right side due to cerebral infarction (blood clot in brain) and aphasia (impaired speech). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure food was prepared and served in accordance with professional standards for food service safety. Staff touched ready to eat foods with potentially contaminated gloves and did not wash hands between glove changes during two meal service observations on Pine View unit. This affected 10 of 16 residents (R) on the Pine View unit. (R15, R9, R4, R149, R30, R2, R36, R31, R12, and R13). This affected 11 of 17 residents on the Birchwood unit. (R39, R40, R10, R26, R44, R41, R18, R25, R8, R38, R17). This affected 8 residents on [NAME] Lane (R34, R24, R7, R19, R46, R6, R21, and R3).

Inspectors wroteBased on observation and interview, the facility did not ensure each resident is treated with dignity in a manner and in an environment that promotes enhancement of his or her quality of life. This occurred for two of three residents (R) being assisted with eating during lunch on the Pine View unit. (R14 and R20)

Inspectors wroteBased on observation and interview, the facility did not ensure the privacy and confidentiality of resident medical records. This occurred for 2 of 10 residents (R) during medication administration. (R31 and R13)

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Staff observed not performing hand hygiene with glove changes during cares. This affected 2 of 5 residents (R) observed for cares. (R13 and R8) Staff observed touching medications with bare hands during medication administration. This affected 2 of 10 residents observed for medication administration. (R150 and R38)