Rolling Hills Rehab and Care CTR

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 11, 2025

  Based on medical record review, hospital record review, review of data found at www.kidneyfoundation.org, policy review and interviews, the facility failed to prevent an incident of neglect when Resident #51 did not receive hemodialysis treatments as ordered due to a lack of facility provided transportation. This resulted in Immediate Jeopardy and actual harm with risk of death beginning on 07/21/25 when Resident #51, who was dependent on hemodialysis due to end stage renal disease, was not transported to a scheduled dialysis treatment. The resident subsequently missed hemodialysis on 07/23/25 again due to a lack of facility provided/arranged transportation. As a result, Resident #51 developed symptoms of fluid volume overload, shortness of breath, fatigue and weakness. […]

• No harm, potential for more than minimal, widespreadF761Jul 13, 2026

  Based on observation, interview, review of facility temperature logs, and facility policies, the facility failed to safely store drugs at proper temperatures to preserve their integrity. Further, the facility failed to proper ensure controlled medications were stored in a separately locked, permanently affixed compartment. This affected four residents (Resident #13, 19, 25, and 42), and had the potential to affect all residents of the facility due to stock medications. Findings include:An observation of the North Medication Room on 07/08/26 from 7:06 A.M. to 7:45 A.M. revealed a medication refrigerator with a temperature of 50 degrees Fahrenheit. The refrigerator held resident medications and stock medications which could be used for any resident if ordered. […]

• No harm, potential for more than minimal, widespreadF881Jul 13, 2026

  Based on review of facility infection control logbook, review facility policy, and interview with the facility infection preventionist, the facility failed to maintain standardized surveillance of its antibiotic stewardship program. This had the potential to affect 52 residents residing in the facility. The facility census was 52. Findings Include: Review of the infection control logbook from January 2026 to July 2026 revealed a monthly log sheet containing a list of residents with infections, type of infection, type of organism if available, treatment ordered and completed, and available laboratory data. Further review of the logbook revealed blank copies of the McGeer's infection surveillance tool in the back of the logbook. […]

• No harm, potential for more than minimal, widespreadF725Mar 11, 2026

  Based on observation, interview, record review, review of the Facility Assessment, and review of the facility's admission agreement, the facility failed to provide sufficient nursing staff was available to ensure resident safety and effectively care for residents. This had the potential to affect all residents residing in the facility. The facility census was 65.Findings include: 1.Review of the closed medical record for Resident #73 revealed an admission date of 02/20/26 with medical diagnoses including peritoneal abscess, anemia, and a history of substance abuse. Resident #73 discharged from the facility against medical advice (AMA) on 02/27/26.Review of a progress note dated 02/27/26 at 10:05 P.M. […]

• No harm, potential for more than minimal, widespreadF727Mar 11, 2026

  Based on observation, interview, and record review, the facility failed to ensure the services of a Registered Nurse (RN) were provided for at least eight consecutive hours a day, seven days a week. Additionally, the facility failed to ensure a full time Director of Nursing (DON) was employed and actively working within the facility. This had the potential to affect all residents residing in the facility. The facility census was 65. Findings include: Review of the Facility Assessment completed 01/30/26 revealed the facility must have a full-time DON, a full-time ADON, a full-time wound care nurse, and full-time Minimum Data Set (MDS) nurse.Review of staff clock in times and resident record review in times revealed no documentation of a Registered Nurse being in the building for eight… […]