Rolette Community Care Center

In the surveyor’s words

From the most serious findings on record at Rolette Community Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 4, 2025

  Based on observation and staff interview, the facility failed to monitor hot water temperatures in resident rooms for 1 of 3 wings (wing 200) with elevated water temperatures. Failure to monitor hot water temperatures in resident rooms may result in resident pain, serious harm, serious impairment, or death. During the on-site recertification survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed on 09/29/25. The IJ was identified when facility water temperatures were taken in resident rooms on the 200 wing. Two of the resident rooms (room [ROOM NUMBER] and 208) registered a temperature of 137 and 133 degrees Fahrenheit (F). This finding placed all resident in immediate jeopardy for hot water burns. * 09/29/25 at 7:48 p.m. […]

• Immediate jeopardy, patternF880Sep 19, 2024

  Based on observation, review of facility policy, review of professional reference, and staff interview, the facility failed to follow standards of infection control for 3 of 12 sampled residents (Resident #1, #3, and #10) and 1 supplemental resident (Resident #14) observed during cares. Failure to follow infection control practices related to enhanced barrier precautions (Resident #1 and #10) and transmission-based precautions (Resident #3 and #14) has the potential to spread infection throughout the facility. During the on-site recertification survey, the team determined an Immediate Jeopardy (IJ) situation existed on 09/09/24 at 1:32 p.m. […]

• Actual harm, isolatedF689Apr 27, 2021

  THIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 07/18/19. Based on information from complainant, record review, review of facility policy, and staff interview, the facility failed to provide necessary supervision/assistance to prevent a fall with major injury for 1 of 1 sampled resident (Resident #2) who required total assistance with bed mobility. Failure to lower the bed to its lowest position resulted in Resident #2's fall with major injury. Findings include: Information provided by the complainants indicated nursing staff failed to provide adequate supervision/assistance resulted in resident fall from bed resulting in fractured neck. Review of the undated facility policy titled Side-Lying Position stated, . […]

• No harm, potential for more than minimal, widespreadF801Sep 19, 2024

  Based on staff interview, the facility failed to ensure 1 of 1 dietary manager (#4) obtained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors. Findings include: During an interview on 09/11/24 at 10:40 a.m., an administrative manager (#2) confirmed the dietary manager (#4) lacked the required training for the position. The facility failed to ensure the dietary manager (#4) completed the education for a certified dietary manager, certified food service manager, or national certification for food service management and safety from a national certifying body.

• No harm, potential for more than minimal, patternF812Dec 4, 2025

  Based on observation, review of professional reference, review of facility policy, review of refrigerator temperature logs, and staff interviews, the facility failed to maintain cold storage areas and kitchen equipment in a sanitary manner for 1 of 1 kitchen. Failure to clean fans, shelving, and bulk bins in areas where food is stored, failure to ensure proper concentration of sanitizer solution, failure to discard outdated foods, failure to monitor refrigerator temperatures daily, and ensure refrigerator temperatures are within acceptable ranges has the potential for contamination of food and may result in a foodborne illness. Findings include: The 2022 Food and Drug Administration (FDA) Food Code, Chapter 3-16, Section 3-305.11 Food Storage, stated, A. […]