Rolling Hills Rehab Ctr

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684May 21, 2026

  Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 19 sampled Residents (R2) and 1 of 1 supplemental Residents (R58) reviewed for change of condition. R58 was diagnosed with Covid 19 on [DATE] and then pneumonia on [DATE]. On [DATE], R58 had noted oxygen saturation levels in the low 80s, complained of shortness of breath (SOB), labored breathing and was also noted to be more fatigued than the day prior and disoriented at times. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2026

  Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 49 residents who reside in the facility.Surveyor observed [NAME] U not allow thermometer to air dry before probing food.Surveyor observed [NAME] U reheat mashed potatoes in the microwave and then serve them without getting the internal temperature to 165 degrees F (Fahrenheit).Surveyor observed the facility's mixer to have food particles on the undercarriage.Surveyor observed [NAME] BB remove gloves, use a marker to label a plastic bag and then go back to working with food without washing his hands. […]

• No harm, potential for more than minimal, widespreadF868May 21, 2026

  Based on record review and interview, the facility did not maintain a quality assessment and assurance committee consisting of the required members to identify issues through the committee. This deficient practice has the potential to affect all 49 residents currently in the facility.The IPC (Infection Prevention and Control nurse) did not attend Quality Assurance Performance Improvement (QAPI) meetings on 2 out of 4 quarterly meetings.This is evidenced by:The facility's policy Quality Assurance/Assessment and Performance Improvement Plan, undated, includes: The Quality Assessment and Assurance (QAA) Committee consist of the Director of Nursing Services, the Medical Director, the Administrator, at least two other members of the facility staff, and the infection control and prevention… […]

• No harm, potential for more than minimal, widespreadF880Feb 20, 2025

  Based on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections that has the ability to affect all 50 residents (R). -Facility staff failed to transport linens in a manner to prevent the spread of infection. -Facility staff did not properly doff personal protective equipment (PPE) for a resident on enhanced barrier precautions (EBP). -Facility staff demonstrated poor hand hygiene during medication administration. -Facility staff did not prep skin prior to administering a subcutaneous injection of insulin. […]

• No harm, potential for more than minimal, widespreadF880Sep 2, 2021

  Based on observation, interview and record review, the facility failed to ensure it maintained an infection prevention and control program designed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable disease and infections such as COVID-19. This has the potential to affect all 56 residents residing within the facility. The facility has not been screening employees since implementing the Attestation for Rolling Hills Staff in August 2021. The facility did not ensure staff completed self- screenings prior to coming to work. […]