Rolling Fields, Inc

In the surveyor’s words

From the most serious findings on record at Rolling Fields, Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 25, 2022

  Based on review of clinical records, facility documentation, and staff interviews, it was determined that the facility failed to provide adequate direct staff supervision as indicated on resident's plan of care summary related to going outside to the pond in their motorized wheelchair which resulted in actual harm of left femur fracture, a broken nose, and left hand and arm bruising and swelling. This failure presented an Immediate Jeopardy situation for one of six residents reviewed (Resident R1). […]

• Actual harm, isolatedF600Feb 25, 2022

  Based on review of facility policy, clinical and facility records, observations, and staff interviews, it was determined that the facility failed to ensure residents were free from neglect during care with the use of a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling) that resulted in actual harm of a fracture of the cervical spine and a three centimeter (cm) laceration to the posterior (back) head for one of one residents reviewed (Resident R1). […]

• Actual harm, isolatedF689Feb 25, 2022

  Based on review of facility policy, clinical and facility records, observations, and staff interviews, it was determined that the facility failed to provide adequate assistance to protect a resident from injury during a transfer with a mechanical lift (an assistive device that allows residents to be transferred between a bed and a chair or other similar resting places, by use of electrical or hydraulic power and a sling) that resulted in actual harm when the resident suffered a fracture of the cervical spine and a three centimeter (cm) laceration to the posterior (back) head for one of one residents reviewed (Resident R1). […]

• No harm, potential for more than minimal, widespreadF947Nov 2, 2023

  Based on review of facility employee in-service training records and staff interview, it was determined that the facility failed to assure staff completed all required mandatory trainings for the yearly Nurse Aide (NA) 12-hour mandatory trainings for the past year from December 2022 through November 2023. Findings include: Upon request, no records or evidence of mandatory in-service training for all NA's from December 2022 through November 2023, was provided for review. During an interview on 11/02/23, at 12:40 p.m. the Nursing Home Administrator confirmed that no evidence could be provided regarding NA's 12-hour mandatory in-service trainings as required. 28 Pa. Code 201.20(a)(d) Staff development

• No harm, potential for more than minimal, patternF657Sep 4, 2026

  Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to review and revise comprehensive care plans by their goal date to reflect the current necessary care and services for four of 14 residents reviewed (Residents R1, R2, R9, and R31).Findings include: Review of facility policy entitled Formation of Resident Care Plan dated 7/10/26, indicated Care plans must be reviewed and revised: Quarterly, after any significant change in condition. and Revisions must be documented in the EMR [electronic medical record] with: Updated goals/interventions. […]