Rockland Ridge Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Rockland Ridge Nursing & Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 4, 2026

  Based on medical record review, staff interview, physician assistant interview, review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, and facility policy review, the facility failed to identify potential risks for skin breakdown and implement preventative measures and failed to timely identify the resident's pressure injury until it reached an advanced stage. This resulted in Actual Harm on 03/11/26 when the facility found an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) on Resident #32's mid back caused by mechanical lift pad straps bunched up behind the resident's back while seated in the wheelchair. This affected one (Resident #32) of four residents reviewed for wound care. […]

• No harm, potential for more than minimal, widespreadF812Jun 8, 2023

  Based on observation, interview, and facility record review the facility failed to ensure refrigerators had thermometers in them to confirm the internal temperature, failed to ensure refrigerator and freezer temperatures were monitored, failed to ensure all food was temperature checked prior to being served, and failed to ensure food preparation equipment was air dried. This had the potential to affect all 68 residents receiving meals from the kitchen. Findings included: 1. Observations on 06/05/23 between 8:10 A.M. and 8:25 A.M. of facility refrigerators revealed no thermometers in the walk-in refrigerator, cook's reach in refrigerator or service refrigerator. […]

• No harm, potential for more than minimal, patternF805Jun 8, 2023

  Based on observation, interview and facility form review, the facility failed to ensure puree was at an appropriate texture for consumption. This had the potential to affect all five residents (Resident #1, #10, #24, #35, and #209) who received a pureed diet. The facility census was 68. Findings included: Observation of the puree process on 06/06/23 at 10:50 A.M. of Dietary Cook (DC) #101 preparing the puree. DC #101 placed the glazed rainbow carrots in the Robot Coupe food processor. The carrots were purred, and he believed the mixture was too thin and therefore, added one tablespoon of thickener. After pureeing for a couple of minutes, DC #101 tasted the carrot puree and reported it was the correct consistency and ready to be served. […]

• No harm, potential for more than minimal, patternF880Mar 28, 2022

  Based on record review, observation, staff interview, review of CDC guidelines, and policy review, the facility failed to ensure staff properly donned and doffed appropriate personal protective equipment (PPE) when entering a resident's room in transmission based precautions (TBP's) as part of a 14 day quarantine following a recent admission. The facility also failed to ensure staff properly disinfected their eye protection when leaving the isolation room. This affected one resident (Resident #41) of 59 residents residing in the facility. Findings include: A review of Resident #41's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #41's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF558Nov 17, 2025

  Based on record review, observation, and interview, the facility failed to ensure call lights were maintained in a resident's reach. This affected one resident (#78) of 24 residents reviewed for observations during the initial pool. The facility's census was 66. Findings Include:Review of the medical record revealed Resident #78 was admitted to the facility on [DATE]. Diagnoses included left knee replacement, osteoarthritis of the left knee, diabetes, left foot drop, lumbar sacral plexus disorder, hypertension, anxiety disorder, varicose veins of the lower extremities, radiculopathy, sacrococcygeal disorders, hip trochanteric bursitis, low back pain, thoracic spine pain, sciatica, Raynaud's syndrome, spinal stenosis, pacemaker, and anemia. […]