Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rolling Hills Care Center during CMS and state inspections, most recent first.
Improper food cooling, sanitizer use, and equipment sanitation were observed in the kitchen. Cooked rice in the reach-in refrigerator was not documented on the cooling log, a sanitizer bucket tested at 0 ppm before being refilled to 200 ppm, and a can opener had a thick black substance on the blade and was not included on the weekly cleaning schedule.
Incomplete Antibiotic Stewardship Surveillance Log: The DSD/IP did not ensure the antibiotic surveillance log was complete and accurate because urine C&S results for residents treated for UTI were not documented or followed up in the log. The DSD/IP stated she did not have access to the lab system and was unsure whether the ordered antibiotics were appropriate without knowing if the bacteria were susceptible or resistant. The MDSC, LVN, and DON all stated C&S results were important for confirming the correct antibiotic and that the IP was responsible for tracking and updating these results.
A resident with pneumonia and chronic respiratory failure with hypoxia had oxygen equipment in the room, but no oxygen-in-use sign was posted outside the door. Staff confirmed the sign should have been in place to alert others that oxygen was being used. In a separate finding, a sling stored in the clean linen closet was found with frayed edges and torn corners, and staff stated damaged slings should not be available for resident transfers.
Failure to post actual daily nurse staffing hours: the facility publicly posted projected staffing hours and NHPPD instead of the actual hours worked for the prior day. The IP stated she completed the staffing sheet each morning using projected hours, and the DON confirmed the facility posted expected/projected staffing rather than actual hours. The facility kept actual staffing hours internally, but they were not available for public review as required by the staffing posting policy.
Incorrect menu portions were served during lunch meal service when staff did not follow the written menu for several residents on puree, soft and bite sized, and renal diets. A food service worker used the wrong scoop sizes for cauliflower and oven browned potatoes, and residents received portions that did not match the menu. The RD stated staff were expected to follow menus and portion sizes, and the facility policy required menu items to be prepared according to the written menus.
A resident with recurrent major depressive disorder was ordered venlafaxine HCL 50 mg daily, but the Psychotherapeutic Drug Informed Consent form was missing the prescriber’s signature and was instead electronically signed by an LVN. The DON stated the form should be signed by the resident or RP and the prescribing physician after the resident is informed of the risks, benefits, and alternatives, and that without the physician signature there was no documentation the resident was informed of the side effects.
A facility failed to develop timely, comprehensive care plans for three residents. Two residents on dialysis had no EBP care plan for their dialysis access devices, and one resident’s duloxetine for depression was not care planned until weeks after the order was received. Staff interviews confirmed care plans should have been initiated right away to guide nursing care and monitor medication effects and infection control needs.
Missing EBP Orders for Residents Receiving Dialysis: Two residents admitted with dialysis-related devices did not have EBP orders in place on admission. One resident had a dialysis port and the other had a fistula, and both went to dialysis three times weekly. The MDSC, DSD/IP, and DON stated residents with dialysis ports, catheters, or similar devices should have EBP ordered on admission, and the facility policy required EBP for residents with indwelling medical devices including hemodialysis catheters.
Failure to act on a CPMRR recommendation: A resident with hypothyroidism had levothyroxine ordered for early morning and calcium ordered daily, but the Consultant Pharmacist recommended moving calcium to 10:00 a.m. or later due to interaction concerns. The DON could not find documentation that the MD reviewed the irregularity, and the MAR showed calcium was changed to 8:00 a.m. instead.
A resident receiving an anticoagulant for chronic embolism and thrombosis had no monitoring order for side effects or bleeding. The LVN and MDSC both confirmed they could not find monitoring in the record, and the DON stated licensed nurses were expected to ensure monitoring was in place when the medication order was received. The facility policy required routine labs and plan-of-care alerts for adverse consequences.
Failure to Maintain a Qualified Full-Time Dietary Manager: The facility did not have a full-time qualified DM when the RD was not employed full-time. The CDM worked only part time or as needed, the DM was still in training and not qualified, and the RD was present only about eight hours a week. This was associated with puree foods not being in the proper form, puree foods not being prepared to conserve nutritive value and flavor, menus not being followed, and food storage cool-down procedures not being monitored for 31 residents.
Puree foods were prepared with water for two residents on physician-prescribed puree diets. A cook blended pureed potatoes and cauliflower with hot water, butter, and in one case thickener, and the foods appeared thin and watery. The cook said she was looking for a creamy texture and had no way to determine the proper consistency. The residents had dx including dysphagia and protein-calorie malnutrition, and the facility recipes and diet manual stated not to use water when thinning puree items.
Pureed foods were not prepared in the proper form for two residents with dysphagia who were on therapeutic diets. Kitchen staff made pureed potatoes, cauliflower, and strawberry crisp using scoops, water, milk, butter, and thickener, but did not perform IDDSI testing and relied on visual judgment for consistency. The RD expected staff to follow IDDSI and recipe directions, but the observed foods appeared thin and inconsistent with the required puree texture.
A resident’s EHR contained an Annual H&P that included H&P records belonging to five other residents. The MR/AD and DON confirmed the documents were uploaded into the wrong chart and should not have been there. The MR/AD stated documents were expected to be verified by name and DOB before upload, and both leaders stated the mix-up was a HIPAA violation and that records must be placed in the correct resident’s chart.
A resident receiving oxygen via nasal cannula had a sterile water bottle attached to the oxygen concentrator that was not labeled with the open date. The resident had COPD, atelectasis, CHF, and renal dialysis dependence, and staff including an LVN, the IP, and the DON confirmed that oxygen humidification bottles should be dated when opened and changed when due.
A dietary cook in an LTC facility improperly thawed frozen meat by submerging it in a bucket of water without running cold water, contrary to safe food handling practices. The cook, who had limited training, was unaware of the correct procedure, which could have led to unsafe food being served to 29 residents. Interviews with the Certified Dietary Manager and Registered Dietitian confirmed the importance of following proper thawing methods as outlined in the facility's food safety policy.
The facility failed to follow food safety standards, including unlabeled pancake mix, resident snacks, and muffins, and improper storage of pesticides and uncooked meat. The CDM and RD acknowledged these lapses, which could lead to foodborne illnesses.
The facility did not meet the required square footage per resident in 11 out of 20 rooms, potentially affecting privacy and space for care. Some rooms lacked adequate storage and accessibility for wheelchairs and toilet facilities. A waiver is recommended to continue except for the room not meeting conditions.
The facility failed to maintain a pest-free environment as ants were observed in the kitchen, leading to potential cross-contamination of food. The Certified Dietary Manager confirmed the presence of ants and expressed concerns about food safety. The Maintenance Supervisor was notified of the issue but delayed contacting pest control. The Administrator acknowledged the lack of a pest control contract and the ineffectiveness of the current pest control program.
A facility failed to develop comprehensive care plans for three residents, leading to deficiencies. One resident's care plan lacked provisions for the use and storage of an Incentive Spirometer, posing an infection risk. Another resident's care plan did not address the use and storage of a nebulizer and oxygen tubing, also posing infection risks. Additionally, outside food was improperly stored in two residents' rooms, increasing the risk of food-borne illness. A third resident's care plan for an indwelling catheter was not developed in a timely manner, potentially leading to unmet needs.
The facility failed to follow physician orders for two residents. One resident's oxygen was set incorrectly, and another resident's refusal of a lidocaine patch was not reported to the physician. Additionally, the second resident was given medication for severe pain despite reporting moderate pain, without notifying the physician for a medication adjustment.
The facility failed to store and label medications properly, as observed with an unlabeled bottle of folic acid, an expired pill packet, and unlabeled artificial tears and inhaler. The LVN acknowledged the need for proper labeling and disposal of expired items, while the DON emphasized the importance of checking labels and expiration dates. The facility's policy mandates routine inspections by the consultant pharmacist.
Two residents in a LTC facility were at risk for infections due to improper storage of medical equipment. A resident's CPAP mask was found on the ground, and another resident's oxygen tubing and nebulizer were improperly stored, contrary to facility policy. Both residents had significant medical histories and were cognitively intact, highlighting the importance of proper infection control measures.
Two residents in a facility faced challenges due to inadequate room space and cluttered environments, hindering their access to personal belongings and medical equipment. One resident, with multiple medical conditions, struggled with movement and storage of personal items, while the other, with a history of hemiplegia and COPD, found it difficult to access necessary medical equipment. Staff confirmed the cramped conditions, and the room size was deemed insufficient for two residents with adaptive equipment.
A resident left the facility against medical advice without a post-discharge plan of care, despite having serious medical conditions. The facility's policy requires such a plan, but it was not completed, and the physician was not notified. Interviews with staff confirmed the oversight.
The facility failed to provide hot water for showers, affecting three residents' rights to dignity and self-determination. A resident reported the issue, confirmed by a CNA, but the Assistant Administrator and LVN were unaware. The Maintenance Director knew of the problem but did not notify leadership, leading to residents enduring cold showers or none at all, violating facility policies on resident rights.
Improper Food Cooling, Sanitizer Concentration, and Dirty Can Opener
Penalty
Summary
Food was not stored, prepared, and distributed in accordance with professional standards in the kitchen. During observation, a container of cooked rice in the reach-in refrigerator was dated 5/18/26 with a use-by date of 5/21/26 and measured 43 degrees Fahrenheit. The Certified Dietary Manager confirmed the rice should have been cooled and documented on the cooling log, but the cooling log was blank and nothing had been recorded for the month. The facility document for 2-stage cooling indicated food must be cooled from 140 degrees Fahrenheit to 70 degrees Fahrenheit within the first two hours, then from 70 degrees Fahrenheit to 41 degrees Fahrenheit within the next four hours. Food service sanitation practices were also not followed during observations in the kitchen. A Food Service Worker wiped down the food preparation counter, and when the sanitizer bucket was checked, it tested at 0 parts per million even though the worker had filled it about 30 minutes earlier; after refilling, it tested at 200 parts per million. In a separate observation, the can opener had a thick black substance on the blade, and the Certified Dietary Manager stated it was very dirty and should be cleaned after each use. The Dietary Manager later stated the can opener was not listed on the weekly cleaning schedule, and the facility policy and sanitation inspection documents did not include that equipment.
Incomplete Antibiotic Stewardship Surveillance Log
Penalty
Summary
The facility failed to promote and implement an antibiotic stewardship and surveillance program because the Infection Preventionist did not ensure the antibiotic surveillance log was complete and accurate to identify, track, and monitor resident antibiotic use. During a concurrent interview and record review, the DSD/IP stated she started as IP in August 2025 and shared the IP role with the MDSC. She stated that part of her responsibility was monitoring infections and keeping track of logs, but when reviewing the antibiotic surveillance log she did not have a record of urine analysis culture and sensitivity results for residents who were ordered antibiotics for urinary bladder infections. The DSD/IP stated she did not have access to the laboratory system to print the results and was not sure whether the antibiotics ordered were appropriate without knowing whether the bacteria were susceptible or resistant to the medication. She also stated she was not sure why the result was needed because residents were already ordered antibiotic medications. During interview, LVN 2 stated primary doctors usually order urine tests with C&S before antibiotics for residents with signs of bladder infections, and that it was the IP’s responsibility to update the primary doctor with the urine test results once completed. LVN 2 also stated all licensed nurses have access to lab results and was not sure why the DSD/IP did not have access. The MDSC stated she also shared the IP position, but the DSD/IP was responsible for the antibiotic surveillance log. The MDSC stated C&S results were important to make sure the correct antibiotic was ordered and that infection could re-occur if bacteria were resistant to the prescribed antibiotic. The DON stated the DSD/IP was responsible for ensuring the antibiotic surveillance log was accurate and complete so the antibiotic ordered was appropriate to treat the bacteria causing the infection, and that the DSD/IP should have followed up on C&S results and updated the primary doctor. The facility policy for the Antibiotic Stewardship Program stated the IP maintains documentation related to antibiotic use tracking and monitoring, and the CDC reference stated nursing homes should review medical records for new antibiotic starts to determine whether clinical assessment, prescription documentation, and antibiotic selection were in accordance with facility antibiotic use policies and practices.
Oxygen Signage Missing and Damaged Sling Left in Use Area
Penalty
Summary
Oxygen safety precautions were not implemented for one resident who had an order for nasal cannula oxygen therapy and diagnoses including pneumonia and chronic respiratory failure with hypoxia. During observation, an oxygen concentrator was present in the resident’s room, but the resident was not observed wearing oxygen and no oxygen-in-use sign was posted outside the room. The resident’s MDS indicated a BIMS score of 11, showing moderate cognitive impairment. Staff interviews confirmed that oxygen-in-use signage should have been posted on the door to alert staff, visitors, and others that oxygen was in use, and the DON stated the room should have had the oxygen equipment and sign available when oxygen therapy was being provided. One sling stored in the clean linen closet and ready for use was found with frayed edges and torn corners. The laundry aide stated she washed and dried slings and then placed them in the clean linen closet without inspecting them for wear and tear. She stated the sling was not safe for use and that the torn corners and frayed edges could get bigger. CNA staff stated slings with frayed edges and torn corners should be removed from the linen closet and not made available for use because they could fail during transfer and cause a resident to fall. The environmental director, DSD/IP, and DON all stated that slings should be inspected for wear and tear before being placed in the clean linen closet and that damaged slings should be removed from service. The facility’s policies for oxygen administration and safe resident handling/transfers stated that oxygen warning signs must be placed on the resident’s door when oxygen is in use and that damaged or unsafe slings must be removed from service and replaced. The fall prevention policy also stated that assistive devices are to be in good repair.
Failure to Post Actual Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to post actual direct care staffing hours worked for public review for 30 of 30 residents, instead posting projected DHPPD staffing information. During observation on 5/19/26 at 9:34 a.m., the publicly posted staffing document titled "Rolling Hills Care Center Tuesday, May 19th, 2026" showed a projected census of 30, projected staff hours of 127, and projected NHPPD of 4.23. The posting listed staff by shift with estimated hours and assigned names for licensed nursing and direct care staff, but it identified the information as projected/estimated staffing hours and did not reflect the actual hours worked for the prior day. During interviews, the IP stated she completed the staffing posting each morning and that the hours posted were projected staffing hours, with no designated area on the form to reflect actual hours worked. She stated the facility maintained actual staffing hours internally, but they were not posted daily for residents, visitors, and the public to review. The DON also stated the facility posted expected/projected staffing hours rather than actual hours worked and that the projected hours were intended to meet or exceed the facility's DHPPD. Review of the facility's policy titled "Nurse Staffing Posting Information" indicated the nurse staffing sheet was to be posted daily and contain the total number and actual hours worked by RN, LPN/LVN, and CNA staff directly responsible for resident care per shift.
Incorrect Menu Portions Served During Lunch Meal Service
Penalty
Summary
Menus were not followed during the lunch meal service when staff served incorrect portion sizes for multiple residents on therapeutic diets. During observation in the dining room, pans in the steam table contained pork chops with sauteed onions, oven browned potatoes with a #8 scoop, green peas with a #8 scoop, and steamed cauliflower with a #12 scoop. The lunch menu for the regular and puree diets specified smothered pork chop, #8 scoop oven browned potatoes, and #8 scoop seasoned green peas, while the liberalized renal diet specified smothered pork chop, #12 scoop oven browned potatoes, and #8 scoop seasoned green peas. Staff served puree cauliflower, potatoes, and pork to residents on puree diets, and one resident on a soft and bite sized diet received a #12 scoop of cauliflower instead of the expected #8 scoop portion. Four residents on liberalized renal diets received #8 scoop oven browned potatoes instead of the #12 scoop portion listed on the menu. During interview after lunch service, the food service worker confirmed using the #12 scoop for cauliflower and the #8 scoop for oven browned potatoes, and acknowledged the incorrect scoop sizes were used for cauliflower and potatoes. The registered dietitian stated staff were expected to follow menus and portion sizes and that menus needed to be available near lunch meal service for reference. The facility policy titled Food Preparation Guidelines stated the cook shall prepare menu items following the facility's written menus.
Missing Physician Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that Resident 15 was informed in advance of the risks and benefits of a proposed psychotropic medication before venlafaxine HCL was administered. During a concurrent interview and record review with the DON, Resident 15’s Psychotherapeutic Drug Informed Consent Form for venlafaxine HCL, dated 5/5/26, was found to be missing the physician’s signature in the prescriber signature section and was instead electronically signed by LVN 3. The DON stated the form should be signed by the resident or responsible party and the prescribing physician after the resident is informed of the risks, benefits, and alternatives, and stated there was no physician signature on the form. Resident 15’s record showed admission to the facility with a diagnosis of major depressive disorder, recurrent, and an order for venlafaxine HCL oral tablet 50 mg, to be given once daily for major depressive disorder. The facility’s policy on Use of Psychotropic Medications stated that prior to initiating a psychotropic medication, the resident must be informed in advance of the benefits, risks, and alternatives, and that the facility will document that the resident was informed in a format such as a written consent form. The DON stated the expectation was that the PDIC should be signed by the physician and that without a signature on Resident 15’s PDIC there was no documentation the resident was informed of the side effects.
Incomplete Care Plans for Dialysis Precautions and New Medication
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and implemented for three sampled residents. Resident 20 and Resident 35 were both dialysis residents, and neither had a care plan for Enhanced Barrier Precaution (EBP) related to their dialysis access devices. Resident 20 was observed sitting at the edge of his bed with a dialysis port on his right chest covered with gauze and medipore tape, and he stated he went to dialysis three days a week. Resident 35 was observed with a fistula on his left upper arm and stated only dialysis staff checked the site. The Minimum Data Set Coordinator reviewed both records and stated Resident 20 was a dialysis resident and an EBP, that no EBP care plan was found for him, and that Resident 35’s EBP care plan was not initiated until 5/20/26. The DSD/IP stated residents with medical devices such as catheters, dialysis ports, tube feeding, and wounds are automatically placed on EBP and should be care planned right away on admission. Resident 21 had duloxetine ordered for depression, but the care plan for that medication was not initiated until 4/29/26 after the order was received on 3/10/26. Resident 21 was observed lying in bed watching TV and stated he had been in the facility for about two months, was working with therapy for a broken left hand/arm from a fall at home, got out of bed daily for therapy, and sometimes ate in the dining room but preferred his room. His record showed diagnoses including depression, fracture of the shaft of the left ulna, and muscle weakness, and the medication order specified duloxetine 60 mg at bedtime for self-isolation related to depression. His BIMS score was 14 out of 15, indicating no cognitive deficit. During interviews, LVN 1 stated Resident 21 was admitted with duloxetine and that the care plan should have been initiated within 24 hours of admission. LVN 2 stated care plans are the responsibility of all licensed nurses and should direct staff on how to care for residents and monitor for side effects of medications and complications. The DON stated care plans should be initiated as soon as an issue is identified and immediately for any new medications received. Facility policy stated the comprehensive care plan must be developed and implemented for each resident and include measurable objectives, timeframes, and resident-specific interventions, and the hemodialysis policy stated staff will ensure appropriate PPE is worn and follow current infection control practices when assessing dialysis access sites.
Missing EBP Orders for Residents Receiving Dialysis
Penalty
Summary
The facility failed to meet professional standards of practice when two residents admitted with hemodialysis-related medical devices did not have an order for Enhanced Barrier Precautions (EBP) in place on admission. One resident was observed sitting at the edge of the bed with a dialysis port on the right chest covered with gauze and tape, and stated he went to dialysis three days a week. His admission record showed diagnoses including dependence on renal dialysis, shortness of breath, and diabetes mellitus. The second resident stated he went to dialysis every Tuesday, Thursday, and Saturday, and had a fistula in the left upper arm; no EBP precautions were observed on the door. His admission record showed diagnoses including ESRD, COPD, and hyperkalemia. During record review and interviews, the MDS Coordinator stated the first resident did not have an EBP order and that there should have been one. She also stated the second resident’s EBP order was dated after admission and should have been placed on admission. The DSD/IP stated both residents should have been placed on EBP immediately because they went to dialysis three days a week, and that residents with medical devices like dialysis ports, catheters, and wounds are automatically placed on EBP. The DON stated the admission nurse was expected to ensure an EBP order was in place for residents with medical devices or lines such as dialysis ports and wounds, and that the IP then followed up to ensure the order was in place. The facility policy stated an order for EBP would be obtained for residents with indwelling medical devices including hemodialysis catheters.
Failure to Act on Pharmacist Drug Regimen Review Recommendation
Penalty
Summary
The facility failed to act upon a Medication Regimen Review irregularity for one of seven sampled residents, Resident 24, when the Consultant Pharmacist recommended that the resident’s calcium administration time be changed to 10:00 a.m. or later because of an interaction with levothyroxine scheduled for 6:00 a.m. During a concurrent interview and record review with the DON, the Consultant Pharmacist Medication Regimen Review dated 12/23/25 was reviewed and the DON stated that recommendations received during medication regimen review are reviewed for the nursing aspect and then faxed to the physician for review and documentation. The DON stated she was responsible for following up on all recommendations. Resident 24’s MAR for 01/2026 showed the calcium administration time was changed on 1/4/26 from 10:00 a.m. to 8:00 a.m. The DON stated she was unable to locate documentation that the physician was aware of the Consultant Pharmacist’s recommendation to change the calcium administration time to 10:00 a.m. or later. Resident 24’s record showed diagnoses including hypothyroidism, and the OSR listed active orders for calcium/D3 once daily and levothyroxine 100 mcg by mouth in the morning for hypothyroid. The facility’s policies stated staff shall act upon all MRR recommendations and that the attending physician must document in the medical record that the identified irregularity has been reviewed.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that one sampled resident was free from unnecessary drugs when the resident’s anticoagulant medication had no monitoring for side effects. Resident 37 was observed sitting in a wheelchair in the hallway with the left foot wrapped in gauze dressing, and the resident stated the left small toe had been surgically amputated. The resident’s admission record showed diagnoses including absence of other left toe(s), chronic embolism, and thrombosis of other specified veins. The MDS assessment documented a BIMS score of 15 out of 15, indicating no cognitive deficit. The resident’s order summary showed an oral tablet, 20 mg, related to chronic embolism and thrombosis, with an order date of 5/14/26 and start date of 5/15/26. During record review and interviews, the LVN and MDSC both stated they did not find an order for monitoring the anticoagulant medication and that monitoring should have been in place to watch for bleeding and other side effects. The DON stated her expectation was that licensed nurses would ensure monitoring of anticoagulant use was in place as soon as the medication order was received. The facility policy for high-risk medications stated anticoagulants shall have routine labs ordered and the resident’s plan of care shall alert staff to monitor adverse consequences.
Failure to Maintain a Qualified Full-Time Dietary Manager
Penalty
Summary
The facility failed to ensure there was a full-time qualified Dietary Manager who met California Health and Safety Code requirements when the Registered Dietitian was not employed full-time. The report states that the facility did not have a full-time dietetic services supervisor meeting state requirements, and that the DM was still enrolled in a program, about halfway complete, and under the supervision of the RD. The RD stated she was usually at the facility once a week, and later said the plan was for her to be at the facility at least eight hours a week, depending on need. During interviews and record review, the Certified Dietary Manager stated she worked at the facility only part time or as needed and helped with clinical duties only. The Administrator stated the RD worked about eight hours a week, the CDM had another job and only worked as needed, and the DM was in school and not qualified at that time. The deficiency was associated with puree food not being in the proper form, puree foods not being prepared by methods that conserve nutritive value and flavor, menus not being followed, and food storage not being monitored for cool down procedures for the 31 residents admitted to the facility.
Puree Foods Prepared With Water
Penalty
Summary
The facility failed to ensure puree foods were prepared by methods that conserve nutritive value and flavor when a cook prepared pureed roasted potatoes and cauliflower with water for two residents on physician-prescribed puree diets. During a kitchen observation and concurrent interview, the cook scooped two #8 portions of potatoes into a blender, added a #24 scoop of butter and five ounces of hot water, then blended the mixture. The potatoes contained flecks of skin and appeared very thin and watery. The cook stated she was looking for a creamy texture, only used a plastic spoon to stir the food, and would determine later whether thickener was needed, adding that there was not a way to determine if the food was the proper consistency and she was just looking for creamy. During a later observation, the cook prepared pureed cauliflower using two #8 scoops of cooked cauliflower, three ounces of hot water, two pumps of thickener, and a #24 scoop of butter, and the cauliflower also appeared thin. At lunch, six bowls of puree food items were on the steam table, and the meal tickets showed one resident on a consistent carbohydrate puree diet with thin liquids and another on a no added salt puree diet with mildly thick liquids. The residents had diagnoses including dysphagia and protein-calorie malnutrition. The facility's pureed potato recipe directed staff to use an appropriate hot liquid such as broth, gravy, hot milk, sauce, or reserved cooking liquid if thinning was needed, and the pureed cauliflower recipe stated that any liquid added should not be water. The RD stated water should never be used when preparing puree foods, and the facility diet manual also stated to never use water as the liquid added to a pureed item.
Pureed Foods Not Prepared to Required Texture Standards
Penalty
Summary
The facility failed to ensure pureed food was prepared in the proper form to meet individual resident needs for two sampled residents, both of whom had physician-prescribed therapeutic diets and diagnoses of dysphagia. Resident 4 had dysphagia, unspecified, and Resident 26 had dysphagia, oropharyngeal phase. On the lunch meal tray, both residents were served pureed foods that were prepared in a manner that did not match the expected IDDSI level 4 texture standards described in the facility documents. During kitchen observations, staff prepared pureed potatoes, pureed cauliflower, and pureed strawberry crisp using scoops, butter, hot water, milk, and thickener, but did not test the foods for the proper consistency. The pureed potatoes had flecks of skin and appeared very thin and watery. The pureed cauliflower also appeared thin. The strawberry crisp puree was prepared by eyeing the milk amount and blending without measuring the liquid, and staff stated they were looking for pudding consistency but did not test it. The Certified Dietary Manager later measured the strawberry crisp puree and found the amount in the cups was about one ounce short of filling a #8 scoop, prompting more puree to be made. Staff interviews and facility records showed that the Registered Dietitian expected staff to test pureed foods according to IDDSI and to use the spoon test after preparation. The recipes for the pureed potatoes, cauliflower, and strawberry peach crisp also directed staff to perform IDDSI testing to ensure texture standards were met. Facility in-services on IDDSI and pureed diets were documented, but no competency evaluation was provided for the staff involved in the preparation observed by surveyors.
Incorrect Upload of H&P Records into Wrong Resident Chart
Penalty
Summary
Resident 15’s electronic health record contained an Annual H&P Examination dated 12/28/2025 that included H&P documents belonging to Residents 6, 17, 24, 40, and 41. During a concurrent interview and record review, the MR/AD stated those records had been uploaded into the wrong resident’s chart and should not have been in Resident 15’s EHR. The MR/AD also stated the facility expected each resident document to be verified by name and DOB before upload into the EHR. During a concurrent interview and record review, the DON confirmed that the H&P records for Residents 6, 17, 24, 40, and 41 were uploaded into Resident 15’s EHR and should not have been there. The DON stated medical records should be placed into the correct resident’s chart and that it was important for chart information to be correct because medications, orders, or treatments could be missed or performed on the wrong resident. The facility’s Medical Records Clerk job description stated resident health information is to be protected and confidentiality and PHI maintained, and the facility’s Documentation in Medical Record policy stated each resident’s medical record shall contain an accurate representation of the resident’s actual experiences and complete, accurate, timely documentation.
Unlabeled Oxygen Humidification Water Bottle
Penalty
Summary
The facility failed to ensure a sterile water bottle used for oxygen humidification was labeled with the open date for one resident receiving oxygen therapy. During an interview in the resident’s room, the resident was observed wearing a nasal cannula connected to an oxygen concentrator and stated he had been admitted to the facility approximately six days earlier and used oxygen at the facility as needed. The sterile water bottle attached to the oxygen concentrator was not labeled with the date opened. Record review showed the resident was admitted with diagnoses including COPD, atelectasis, CHF, and dependence on renal dialysis. The resident’s MDS assessment indicated a BIMS score of 15. The OSR showed an order for oxygen therapy to change concentrator bottles on oxygen bottles as needed. Interviews with an LVN, the IP, and the DON confirmed that sterile water bottles used for oxygen humidification should be dated when opened and changed when due, and that an unlabeled bottle created an infection control concern because staff could not determine how long it had been in use.
Improper Thawing of Meat by Dietary Cook
Penalty
Summary
The facility failed to ensure that a dietary cook was competent in carrying out the functions of the food and nutrition services safely and effectively. During an observation, it was noted that the dietary cook thawed frozen meat by submerging it in a bucket of water without running cold water, which is not in accordance with safe food handling practices. The dietary cook had been working for nine months and had received only a rapid three-day training from a previous supervisor. The cook was unaware of the requirement to have cold water running when thawing meat submerged in water and typically thawed meat in the refrigerator. However, on this occasion, the cook had to thaw the meat in a bucket of water due to the kitchen staff not having thawed it in advance. Interviews with the Certified Dietary Manager and the Registered Dietitian revealed that the correct procedure for thawing meat involves submerging it in running cold water, thawing it in the refrigerator, using a microwave, or cooking it directly. The facility's policy and procedure for food safety require adherence to these methods to prevent foodborne illness. The dietary cook did not follow the established policy and procedure, which could have led to unsafe food being served to 29 residents. The facility's job description for dietary cooks and its food safety policy emphasize the importance of following proper food service practices and procedures.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of practice for food service safety, as evidenced by several observations and interviews. An open box of pancake batter mix was found without an open date label, which the Certified Dietary Manager (CDM) acknowledged should have been labeled to prevent the use of expired food. The Registered Dietitian (RD) confirmed the importance of labeling to avoid foodborne illnesses. Additionally, residents' snacks in the refrigerator were not labeled with a prepared-on date, which the CDM admitted was necessary to ensure snacks were not consumed past their expiration date. Further deficiencies were noted with the storage of a hornet and wasp pesticide bottle under the kitchen sink, which the CDM and RD both stated could lead to cross-contamination and foodborne illnesses. Six bags of muffins in the freezer lacked a received-on date, which the CDM and RD agreed was crucial for preventing the serving of expired food. The facility's policy required all food to be appropriately dated to ensure proper rotation by expiration dates, which was not followed in this instance. The resident refrigerator contained unlabeled foods, including a raisin carrot salad, beef and potatoes, yogurt, a hot pocket, and mozzarella, which were not labeled with resident names or received dates. The CDM stated that labeling was essential to ensure residents received their correct food and to prevent cross-contamination. Additionally, uncooked frozen meat was found in the resident refrigerator, contrary to facility policy, which prohibited raw meat in resident refrigerators. The CDM acknowledged that the dietary and housekeeping staff were responsible for maintaining compliance with these policies.
Inadequate Room Size and Space in Facility
Penalty
Summary
The facility failed to provide the minimum required square footage per resident in multiple resident bedrooms and single resident rooms for 11 out of 20 rooms. Specifically, rooms 1, 5, 6, 8, 9, 10, 11, 12, 18, 19, and 20 did not meet the regulatory requirements of at least 80 square feet per resident in shared rooms and 100 square feet in single rooms. This deficiency was identified during an environmental tour with the Maintenance Director. The lack of adequate space had the potential to compromise residents' privacy and space for ambulation and nursing care. Additionally, certain rooms lacked sufficient closet and storage space, and accessibility for wheelchairs and toilet facilities was inadequate in some instances. The report suggests that a waiver should continue except for the room that did not meet the necessary conditions, although specific room numbers were not provided for these exceptions.
Ant Infestation in Kitchen Due to Ineffective Pest Control
Penalty
Summary
The facility failed to maintain a pest-free environment in accordance with its Pest Control Program policy and procedure, as ants were observed in the kitchen. During an observation and interview with the Certified Dietary Manager (CDM), multiple live and dead ants were found on the kitchen floor and under the sink cabinet. The CDM acknowledged that ants should not be present in the kitchen and confirmed the presence of ants. The CDM expressed concerns about the potential for cross-contamination of food, which could lead to residents becoming ill. The CDM also noted that kitchen staff were responsible for cleaning up the dead ants and that the Maintenance Supervisor (MS) should have been notified to contact pest control. The Administrator (ADM) confirmed that the facility did not have a pest control contract and stated that the MS was informed of the ant issue on 11/19/24 but should have contacted pest control immediately. The MS admitted to being notified about the ants on 11/17/24 and acknowledged that pest control should have been contacted sooner. The pest control company was eventually contacted on 11/19/24, and the kitchen was baited for ants. The ADM and MS both agreed that the current pest control program was ineffective, and the kitchen required more frequent pest control services due to the pest issue.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to several deficiencies. Resident 9's care plan did not address the use and storage of an Incentive Spirometer (IS), which posed a risk of infection due to improper storage and use. Additionally, Resident 9's care plan lacked provisions for changing the IS mouthpiece and tubing, which should have been done periodically to prevent infection. Furthermore, Resident 9 and another resident had outside food stored in their rooms for more than three days, increasing the risk of food-borne illness and pest attraction. Resident 23's care plan was also found lacking in several areas. There was no care plan for the use and storage of a nebulizer, which was observed on the floor, posing an infection control problem. Additionally, Resident 23's care plan did not address non-compliance with the proper use and storage of oxygen tubing and nasal cannula, which were improperly stored and used, increasing the risk of infection. The facility's policy required care plans to be developed and implemented to address such issues, but this was not done. Resident 3's care plan was not developed in a timely manner to address the use of an indwelling catheter. The care plan should have been completed within 48 hours of admission, but it was delayed, potentially leading to unmet needs and missed goals and interventions for the resident's catheter care. The facility's policy emphasized the importance of developing care plans promptly to guide resident care and interventions, but this was not adhered to, resulting in deficiencies in the care provided to Resident 3.
Failure to Follow Physician Orders and Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to adhere to professional standards of practice in the care of Resident 23 by not following the prescribed oxygen flow rate. Resident 23's oxygen was set at 3 liters per minute instead of the ordered 2 liters per minute. This discrepancy was observed during an interview and record review, where it was confirmed that the nurse responsible did not adjust the oxygen rate according to the physician's orders. Resident 23, who was cognitively intact, had a history of chronic obstructive pulmonary disease and other respiratory conditions, which necessitated precise oxygen management. In the case of Resident 3, the facility did not notify the attending physician of the resident's repeated refusal of a prescribed lidocaine patch for pain management. Despite the resident's refusal on multiple occasions, the nursing staff failed to inform the physician, which prevented any potential adjustments to the pain management plan. Resident 3, who was also cognitively intact, had a complex medical history including chronic pain and other serious health conditions, making effective pain management crucial. Additionally, the facility did not follow the physician's orders regarding pain medication for Resident 3. The resident was administered oxycodone-acetaminophen, a medication intended for severe pain, despite reporting moderate pain levels. The nursing staff did not contact the attending physician to adjust the medication to better suit the resident's pain level, which was a deviation from the prescribed care plan. This oversight in medication administration could have impacted Resident 3's quality of life, as the pain management was not aligned with the resident's reported pain levels.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional standards. During an observation, a bottle of folic acid was found without a readable expiration date, and a pill packet was expired. The Licensed Vocational Nurse (LVN) acknowledged the need to discard these items, expressing concern about the potential loss of efficacy and the risk of fungal development in expired medications. Additionally, a bottle of artificial tears and an inhaler were found without labels indicating the resident's name or expiration date. The LVN confirmed that these items should have been properly labeled. The Director of Nursing (DON) stated that no expired medications should be present in the medication cart and emphasized the importance of checking labels and expiration dates before administering medications. The facility's policy requires routine inspections by the consultant pharmacist to identify and destroy discontinued, outdated, or improperly labeled medications.
Infection Control Deficiencies in Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper storage of medical equipment for two residents. Resident 30's CPAP mask was found on the ground next to the bed, rather than being stored in a bag as required. This was confirmed by both the resident and a Certified Nursing Assistant (CNA), who acknowledged the risk of cross-contamination and infection due to the mask's improper storage. The Director of Staff Services and the Director of Nursing both confirmed that the CPAP mask should have been stored in a bag and disinfected once found on the ground. The Infection Preventionist also noted the risk of respiratory infection due to the mask's condition. Resident 30 had been in the facility for three weeks and had a history of type 2 diabetes, asthma, hypertension, and anemia. The resident was cognitively intact, with a BIMS score of 13, and used the CPAP mask nightly to assist with breathing. The facility's policy required the CPAP mask to be cleaned daily and stored in a bag when not in use, but this was not adhered to, placing the resident at risk for respiratory infections. Similarly, Resident 23's oxygen tubing was improperly stored, wrapped around the bed rail, and the nebulizer was found on the ground. The CNA and the Minimum Data Set Nurse both recognized the infection control issue and the risk of infection due to the equipment's condition. Resident 23 had a history of hemiplegia, COPD, and other serious health conditions, and was also cognitively intact with a BIMS score of 15. The facility's policy required oxygen and nebulizer equipment to be stored in a bag when not in use, but this was not followed, increasing the risk of infection for the resident.
Inadequate Room Space and Cluttered Environment for Residents
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents, resulting in their inability to access and use personal belongings and medical equipment. Resident 9, who was admitted with multiple medical conditions including osteomyelitis, schizoaffective disorder, and anxiety disorder, was observed in a room cluttered with plastic grocery bags, food, and a wheelchair obstructing movement. Resident 9 expressed difficulty moving around due to the cramped space and had to store personal items in inconvenient locations, such as under his pillow and on his bed, leading to a non-homelike environment. Similarly, Resident 23, who had a history of hemiplegia, COPD, and heart failure, faced challenges in accessing necessary medical equipment like a nebulizer due to the room's layout. The resident's power strip was out of reach, and the room was cluttered with boxes, papers, and medical equipment, making it difficult for the resident to move around safely. Both residents reported feeling that their rooms were too small and not conducive to a homelike atmosphere, with Resident 23 specifically mentioning the danger of moving around in such a confined space. Interviews with facility staff, including the Infection Preventionist Nurse and a Certified Nursing Assistant, confirmed the residents' concerns about the cluttered and cramped conditions. The Maintenance Director verified the room's small size, measuring only 110 square feet, which was inadequate for two residents with adaptive equipment. The Director of Nursing acknowledged the safety risks posed by the room's size, especially in emergencies, and the Administrator noted the need for a safe environment for residents. The facility's policies emphasized the importance of providing a safe and homelike environment, which was not achieved in this case.
Failure to Provide Post-Discharge Plan for Resident Leaving AMA
Penalty
Summary
The facility failed to ensure that a resident, who left the facility against medical advice (AMA), had a post-discharge plan of care. This deficiency was identified during a review of the resident's records, which revealed that there was no post-discharge summary plan available for the resident. The resident, who had been admitted with multiple serious medical conditions including osteomyelitis, gas gangrene, cellulitis, dyspnea, anxiety disorder, acute kidney failure, and chronic pain, left the facility without the necessary documentation to assist in their transition to a new living environment. Interviews with facility staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), confirmed that the required discharge summary plan of care was not completed. The facility's policy and procedure for transfers and discharges, including those against medical advice, mandates that a post-discharge plan of care be developed with the participation of the resident and their representative. However, this was not adhered to, as the physician was not notified, and the discharge summary was not documented, resulting in a failure to follow the established protocol.
Failure to Provide Hot Water for Resident Showers
Penalty
Summary
The facility failed to honor the residents' rights to a dignified existence and self-determination by not providing hot water for showers, affecting three residents. On the evening of September 19, 2024, Resident 1 reported that the facility did not have hot water, preventing her from taking a scheduled shower. Observations confirmed that the shower water was not hot, and a Certified Nursing Assistant (CNA) acknowledged the lack of hot water, stating that residents could only receive cold bed baths. The Assistant Administrator and Licensed Vocational Nurse were unaware of the issue, indicating a communication breakdown. Resident 6 expressed dissatisfaction with taking cold showers, which he endured to maintain personal hygiene. He mentioned that the hot water issue had persisted for weeks and had been reported to maintenance. The Maintenance Director was aware of the problem by 11 a.m. on September 19, 2024, and had called a plumber, but failed to notify facility leadership or follow emergency procedures. This lack of communication and action resulted in residents being unable to take hot showers, compromising their dignity and personal preferences. The Director of Nursing and Administrator were informed of the issue only after it had been ongoing, highlighting a failure in the facility's communication and emergency response protocols. The facility's policy on resident rights emphasizes the importance of providing a safe, comfortable, and respectful environment, which was not upheld in this instance. The deficiency was further compounded by the Maintenance Director's failure to report the issue promptly, as required by the facility's emergency operations plan.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 410 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Selma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Lutheran Home | 0.7 mi | ★★★★★ | 19 | 0 |
| Kingsburg Center | 4.3 mi | ★★★★★ | 3 | 0 |
| Fowler Care Center | 4.6 mi | ★★★★★ | 2 | 0 |
| Vineyards At Fowler | 5 mi | ★★★★★ | 25 | 0 |
| Manning Gardens Care Center, Inc | 8.1 mi | ★★★★★ | 21 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rolling Hills Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.