Rollingbrook Rehabilitation and Health Care Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level 1 residents with mental illness were provided with an accurate PASSR Level 1 screening for 1 (Resident # 11) of 2 residents reviewed for PASSR screening. Resident #11 did not have an accurate and updated PASRR Level 1 screening reflecting a diagnosis of mental illness. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #10) of 4 residents observed for medication administration. LVN A failed to keep Resident #10 in a safe and sanitary environment by attempting to administer insulin to him with the incorrect insulin pen. This failure could place residents at risk of adverse reactions and exposure and/or possible transmission of communicable diseases and infections. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and 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 for 1 (Resident #100) of 1 resident reviewed for infection control. LVN A failed to follow EBP prior to administering medications to Resident #100 through a gastrostomy tube (also called a g-tube). This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for Food and Nutrition Services. The facility failed to label, and date left over food items in walk in refrigerator\freezer. This failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on interview, and record review the facility failed to ensure a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS was completed within 14 calendar days after admission, excluding readmissions in which there was no significant change in the resident's physical or mental condition reviewed for assessments . The facility failed to ensure Resident #35's admission MDS Assessment was completed within 14 days of admission. This failure could place residents at-risk of not having their assessments completed timely, which could result in denial of services and or payment for services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 3 residents reviewed for quality of care in that: The facility failed to ensure oxygen was administered to CR #1 when her oxygen saturation went down to 81% on [DATE]. The facility failed to assess CR #1's vital signs during change in condition on [DATE]. The facility failed to ensure CR #1 was sent to the hospital promptly, approximately more than an hour delay, when CR #1 had change in condition on [DATE] resulting in delayed care/intervention. A private ambulance was used instead of 911 which contributed to delayed care, and the family requested CR #1 to be sent to the hospital. CR #1 continued to deteriorate and expired at the hospital on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (CR#1) reviewed for drug administration. 1. The facility failed to obtain vital signs for CR #1 on [DATE] . 2. The facility failed ensure CR #1's Midodrine medication (medication prescribed to increase blood pressure for residents with persistent low blood pressure) was not withheld. CR #1 continued to deteriorate and expired at the hospital on [DATE]. 3. The facility failed to ensure CR #1 received pain medication when she was in pain on [DATE]. CR #1 continued to deteriorate and expired at the hospital on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 7 of 10 Residents (Resident #32, Resident #52, Resident #53, Resident #75, Resident #85, Resident #78, Resident #292) reviewed for pharmacy services. The facility failed to ensure controlled drug medications were stored correctly. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program to the maximum extent practicable for 1 of 7 residents (Resident #24) reviewed for PASARR. -The facility failed to update the PASARR Level 1 forms for Resident #24 after a diagnoses of mental illness This failure could place residents requiring PASARR services at risk of not having their special needs assessed and met by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an accurate comprehensive person- centered care plan for 1 of the 5 (Resident #414) residents reviewed for care plans. The facility failed to provide a fall mat to Resident #414 which was documented as an intervention in the resident's care plan. This failure could place resident at risk for unmet care needs and decreased quality of care.