Rolling Hills Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF686Jun 9, 2022

  Based on interview and record review, the facility failed to ensure appropriate interventions were implemented for a resident (Resident B) with a moderate risk for impaired skin integrity which resulted in a stage 3 pressure ulcer (full thickness skin loss) to the sacrum, an unstageable pressure ulcer (full thickness skin loss either covered by extensive necrotic tissue or by eschar) to the upper sacrum, and a deep tissue injury (localized area of discolored skin caused by damage to underlying tissue from pressure and/or shear) to the right heel, and to ensure pressure ulcer treatments were completed for residents (Resident B and H) for 2 of 3 residents reviewed for pressure ulcers. Findings include: 1. The clinical record for Resident B was reviewed on 6/7/22 at 12:37 p.m. […]

• Actual harm, isolatedF689Feb 21, 2022

  Based on observation, record review, and interview, the facility failed to ensure appropriate interventions were identified and implemented to prevent accidents for 3 of 10 residents (Residents C, D, and E) reviewed for accidents, which resulted in Resident C and Resident E sustaining fractures to their wrists. Findings include: 1. During an observation, on 2/14/22 at 10:00 a.m., Resident C was observed in a high-backed wheelchair with anti-tippers in his room. The resident would attempt to converse with nonsensical speech and was only oriented to person. The head of his bed was against the wall, with both sides open to the room. There were no skid-strips observed anywhere in the resident's room or bathroom. The clinical record for Resident C was reviewed on 2/17/21 at 11:11 a.m. […]

• No harm, potential for more than minimal, widespreadF725Mar 3, 2023

  Based on observation, record review, and interview, the facility failed to ensure adequate staffing which contributed to the lack of resident care, the distribution of fluids, and supervision. This deficient practice had the potential to affect 104 of 104 residents residing in the facility. Findings include: During an interview on 2/27/23 at 11:45 a.m., Resident N's family member indicated the resident did not get the help and care needed without having to wait a long time. The family member indicated in the morning, the resident would have brown rings from urine on the sheets. It took bleach to launder them. The night shift would just let the residents lay in bed unchanged. Family felt the need to stay with the resident from 10:30 p.m. to 2:00 a.m., to provide care for the resident. […]

• No harm, potential for more than minimal, widespreadF804Mar 3, 2023

  Based on observation and interview, the facility failed to ensure meals were healthy and appetizing for residents, during 1 of 2 meal test trays. This had the potential to affect all 104 residents who ate meals at the facility. Findings include: During an interview on 2/27/23 at 9:38 a.m., Resident 63 indicated the food was bad and it was cold sometimes. During an interview on 2/27/23 at 9:40 a.m., Resident 211 indicated the food was not good. During a lunch meal test tray observation and tasting on 3/2/23 at 11:26 a.m., the residents were served chicken salad sandwiches, broccoli salad, and potato salad. All 3 of the salads had mayonnaise in the recipe. […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2022

  Based on observation, record review and interview, the facility failed to ensure the scheduled cleaning of kitchen equipment was conducted and failed to monitor food products for expiration dates for 3 of 3 kitchen observations with the potential to effect 99 of 99 residents that resided in the facility Findings include: During the tour of the kitchen on [DATE] at 9:28 a.m., the following was observed: -An open cabinet had rust on the top half of a shelf which had clean water pitchers, sitting on their tops, resting on the rusty areas. Cook 11 indicated the shelves needed to be painted again. -2 bags of iceberg lettuce with chopped carrots and cabbage in the refrigerator, were observed with, use by dates of [DATE]. […]