Rolling Hills Health Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 16, 2021

  The facility identified a census of 43 residents. The sample included three residents with three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from abuse when the facility failed to prevent Resident(R)1 from inappropriately touching his roommate, R2, in an unwanted sexual nature. On 12/09/21 Activity Staff Y observed R1 seated next to R2's bed and R1 had his hand under R2's shirt on his chest. Activity Staff Y did not report this occurrence to the residents' nurse or Administrative Staff A. Subsequently, on 12/10/21 between 04:30 to 05:00 AM, R2 was awakened by R1, who was performing a sexual act on R2. R2 did not consent to this activity. […]

• Immediate jeopardy, isolatedF609Dec 16, 2021

  The facility identified a census of 43 residents. The sample included three residents with three residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure staff identified a situation of inappropriate touching as a possible incident of abuse. The facility further failed to ensure staff immediately reported the incident to the facility administrator. On 12/09/21 Activity Staff Y observed Resident (R)1 seated next to R2's bed and R1 had his hand under R2's shirt. Activity Staff Y did not report this occurrence to the residents' nurse or Administrative Staff A. […]

• Immediate jeopardy, isolatedF610Dec 16, 2021

  The facility identified a census of 43 residents. The sample included three residents with three residents reviewed for abuse. Based on record review, observation, and interview, the facility failed to ensure resident safety and provide protection when the facility failed to implement interventions and take immediate measures to protect Resident(R)2 from resident to resident sexual abuse. On 12/09/21 Activity Staff Y observed R1 seated next to R2's bed and R1 had his hand under R2's shirt. Activity Staff Y did not report this occurrence to the residents' nurse or Administrative Staff A. Because no immediate action was taken, R2 was awakened on 12/10/21 by R1, who was performing a nonconsensual sexual act on R2. […]

• Actual harm, isolatedF689Jun 2, 2025

  The facility documented a census of 41 residents. The sample included three residents reviewed for accidents. Based on record review and interview, the facility failed to ensure an environment free from accident hazards for Resident (R) 1, who required staff assistance and a mechanical lift for safe transfers. As a result, R1 sustained a humerus (upper arm bone) fracture. This deficient practice also placed R1 at risk for pain and impaired independence. Findings included: - The Electronic Medical Record (EMR) for R1 documented diagnoses of pleural effusion (abnormal accumulation of fluid in the lungs), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), rheumatoid… […]

• Actual harm, isolatedF689Mar 2, 2022

  The facility identified a census of 36 residents. The sample included three residents reviewed for falls. Based on record review, interview, and observation, the facility failed to ensure staff followed Resident (R)1's plan of care to have two staff members assist R1 with transfers using a sit to stand lift. On 11/03/22 Certified Nurse Aide (CNA) M transferred R1 using the lift without assistance from a second qualified staff member. During this transfer, R1 became weak, her legs buckled, and she slid to her knees. […]