Rollingbrook Rehabilitation and Health Care Center

In the surveyor’s words

From the most serious findings on record at Rollingbrook Rehabilitation and Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 12, 2023

  Based on observation, interview, and record review the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 3 residents reviewed for quality of care in that: The facility failed to ensure oxygen was administered to CR #1 when her oxygen saturation went down to 81% on [DATE]. The facility failed to assess CR #1's vital signs during change in condition on [DATE]. The facility failed to ensure CR #1 was sent to the hospital promptly, approximately more than an hour delay, when CR #1 had change in condition on [DATE] resulting in delayed care/intervention. […]

• Immediate jeopardy, isolatedF755Dec 12, 2023

  Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 residents (CR#1) reviewed for drug administration. 1. The facility failed to obtain vital signs for CR #1 on [DATE] . 2. The facility failed ensure CR #1's Midodrine medication (medication prescribed to increase blood pressure for residents with persistent low blood pressure) was not withheld. CR #1 continued to deteriorate and expired at the hospital on [DATE]. 3. The facility failed to ensure CR #1 received pain medication when she was in pain on [DATE]. […]

• Immediate jeopardy, isolatedF678Jan 11, 2023

  Based on observations, interviews, and record reviews, the facility failed to ensure personnel provided basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 15 residents (CR #1) reviewed for cardio-pulmonary resuscitation. LVN A failed to initiate life-saving measures (CPR) when CR #1, who was on hospice and had a code status of full code (meaning the person wants all resuscitation procedures provided if their heart stops beating and/or they stop breathing), was found unresponsive and died . An Immediate Jeopardy (IJ) situation was identified on [DATE] at 12:34 p.m. […]

• Actual harm, isolatedF686Oct 12, 2022

  Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 1of 1 resident reviewed for pressure ulcers. In that: 1. Facility failed to turn and reposition Resident #1 regularly to prevent skin breakdown. 2. Facility failed to make appropriate intervention to prevent missed wound care and to prevent wound infection for Resident #1. These failures placed resident at risk for developing worsening of pressure injuries, severe pain, infections, and sepsis. […]

• Actual harm, isolatedF656Apr 4, 2022

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 6 residents reviewed as evidenced by: Facility staff (LVN A, CNA A, CNA B) failed to place Resident #1's fall mat next to his bed. He had an unwitnessed fall in th facility that resulted [NAME] left femur fractur. The facility failed to follow Resident #1's person centered care plan intervention for a fall mat next to his bed. […]