Rolling Green Village Care Center

In the surveyor’s words

From the most serious findings on record at Rolling Green Village Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 6, 2026

  Based on clinical record review, facility document review, resident interview, staff interviews, and policy review, the facility failed to assess and intervene when a resident reported a new complaint of rib pain in a timely manner for 1 of 3 residents reviewed (Resident #1) for assessment and intervention. Resident #1 continued to have pain in her chest when coughing or taking deep breaths for approximately 2 days. After Resident #1 went to the emergency room for the reports of pain, the hospital admitted her with a diagnosis of an acute (new) left 9th and right 10th rib fractures. […]

• Actual harm, isolatedF689Aug 6, 2026

  Based on clinical record review, facility document review, resident interview, staff interviews, and policy review, the facility failed to transfer a resident, as outlined in their Care Plan for 1 of 4 residents reviewed (Resident #1) for transfer technique. The staff failed to transfer Resident #1 with an assistance of 2 staff and transferred her with a bear hug instead. While transferring with the bear hug technique, Resident #1 and the staff member heard a loud pop. Approximately 2 days after the incident, Resident #1 admitted to the hospital due to rib fractures. The facility reported a census of 38.Findings include: Resident #1's Minimum Data Set (MDS) assessment completed on 6/17/26 documented an admission date of 5/13/26 due to a fractured femur (broken thighbone). […]

• Actual harm, isolatedF689Apr 16, 2026

  Based on clinical record review, written staff statement, staff interviews and policy review, the facility failed to provide adequate nursing supervision related to a fall and failed to ensure appropriate steps were taken after a fall to ensure resident safety for 1 of 3 residents reviewed for falls (Resident #2).The facility corrected the noncompliance prior to the start of the survey on 3/13/26 by completing the following:3/13/26: The facility started educating their employees on falls.3/13/26: The facility started educating their employees on the fall occurrence policy. […]

• Actual harm, isolatedF686Nov 14, 2024

  Based on observation, interviews, record reviews and policy the facility failed to assess and treat a pressure ulcer for 2 of 2 residents observed with pressure ulcers (Residents #9 and #50). Resident #50 documentation indicated the facility found their pressure wound on 11/1/24. Interviews determined hospice found the pressure wound before that date. The facility, hospice staff, and Resident #50's family had a meeting before the facility documented the pressure ulcer. At the meeting, hospice reported the got an order for heel protectors for Resident #50. Resident #50's clinical record lacked documentation of the order. When the facility reported the concern to the physician, the directed to monitor the wound. Resident #50 reported she didn't like the boots because they made her feet hot. […]

• No harm, potential for more than minimal, patternF727Oct 26, 2023

  Based on facility document review, and staff interviews the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 5 of 31 days reviewed (September 23rd through October 23rd). The facility reported a census of 37 residents. Findings include: Review of a facility provided document titled Nurse Dept (9/23/2023-10/23/2023) revealed the facility had no RN coverage on 9/24/23, 10/7/23, 10/21/23, and 10/22/23. The document further revealed that the facility only had 4.5 hours of RN coverage on 10/8/23. During an interview on 10/26/23 at 11:21 AM with the Administrator revealed that there was no RN coverage for 8 hours on 9/24/23, 10/7/23, 10/13/23, 10/21/23, and 10/22/23. […]