Rolling Hills Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689May 6, 2024

  Based on observation, interview and record review, the facility failed to ensure the environment remained free from accident hazards for one of three residents (Resident 1) when Certified Nurse Assistant 2 placed a hot cup of soup at Resident 1 bedside table without first ensuring the temperature of the soup would not burn. CNA 1 was aware of Resident 1's physical limit to reach safely and left the hot cup of soup on the bedside table. These failures resulted in Resident 1 reaching for the hot cup of soup in an unsafe manner, spilling the hot soup on his chest and stomach and suffering burns to the skin that required wound care. […]

• No harm, potential for more than minimal, widespreadF812May 22, 2026

  Based on observation, staff interviews and review of facility documents, the facility failed to ensure food was stored, prepared and distributed in accordance with professional standards for food service safety when:1. Leftover previously cooked rice was not monitored for cooling;2. One sanitation solution in a red bucket was not the appropriate concentration when the Food Service Worker (FSW 2) sanitized the food preparation counter; and3. The can opener was dirty with a thick black substance on the blade. This had the potential for the growth of microorganisms which can lead to food borne illness for the 31 residents admitted to the facility1. […]

• No harm, potential for more than minimal, widespreadF881May 22, 2026

  Based on interview and record review, the facility failed to promote and implement an antibiotic (ATB) stewardship and surveillance program (ATBS-designed to reduce unnecessary use of antibiotics and to limit the spread of antibiotic resistance in bacteria) for the use of antibiotics when the Infection Preventionist (IP) did not ensure the antibiotic surveillance log (chronological record used to continuous monitor antibiotic use) was complete and accurate to identify, track, and monitor resident antibiotic use. This failure had the potential to result in the administration of unnecessary and inappropriate antibiotic use, as well as inaccurate monitoring of antibiotic use which could lead to antibiotic-resistant organisms and inaccurate data monitoring and reporting. […]

• No harm, potential for more than minimal, widespreadF802Nov 25, 2024

  Based on observation, interviews and record review, the facility failed to ensure Dietary [NAME] (DC) 1 was competent to carry out the functions of the food and nutrition services safely and effectively when DC 1 thawed frozen meat without running cold water. This failure had the potential to result in unsafe food being served, consumed, and could have cause food borne illness (contamination of food and occur at any stage of the food production, delivery and consumption chain) to 29 residents who were served food from the kitchen. Findings: During a concurrent observation and interview on 11/20/24 at 11:17 a.m. in the kitchen, with Dietary [NAME] (DC) 1, frozen meat was submerged in a bucket of water. DC 1 stated she pulled out the frozen meat to make dinner for 11/20/24. […]

• No harm, potential for more than minimal, widespreadF812Nov 25, 2024

  Based on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards of practice for food service safety when: 1 One opened box of pancake batter mix was not labeled with an open on date. 2. Residents snacks were not labeled with prepared on date an in refrigerator for residents to eat. 3. A hornet and wasp pesticide (bug spray) bottle was found below kitchen sink cabinet. 4. Six bags of muffins in the freezer were not labeled with the received-on date. 5. Resident refrigerator contained unlabeled foods with no received on date, resident name and content. 6. Uncooked frozen meat were found inside the resident refrigerator. […]