Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Green Village Care Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, osteoporosis, and a care plan requiring two‑person assist for transfers was assisted to the floor by a CNA who later stated she did not consider the event a fall and therefore did not notify a nurse or initiate required fall procedures. The resident reported severe knee pain to PT, leading to x‑rays that showed a comminuted patella fracture, but the LPN who received the critical result only texted the on‑call management phone and did not call the provider or complete an incident report. Because the fracture and non‑weight‑bearing status were not promptly communicated, multiple staff, including nursing and therapy, continued to transfer and ambulate the resident with weight bearing on the injured leg until PT intervened, demonstrating failures in supervision, post‑fall assessment, and communication of critical diagnostic findings.
The deficiency involves the facility’s failure to immediately notify a family member and a physician of significant changes in condition for two residents. One resident with moderate cognitive impairment and multiple complex diagnoses fell during an assisted bathroom transfer, hit her head, sustained a leg skin tear, and complained of back pain; although the RN notified the on-call physician and later obtained an order to send the resident to the hospital for unmanaged pain, the resident’s daughter, listed as the primary emergency contact, was not called until about three hours after the fall. In a separate case, another resident with moderate cognitive impairment, osteoporosis, prior vertebral fracture, and recent knee pain after a reported fall had bilateral knee x-rays, which revealed a comminuted right patellar fracture marked as a critical finding; an LPN received the faxed result shortly after midnight but did not call the on-call provider, instead sending texts to management, and the provider was not notified of the fracture until later that morning by the Administrator. These actions did not comply with the facility’s policy requiring immediate notification of the resident, physician, and family for accidents, significant changes in status, or the need to significantly alter treatment.
The facility failed to assess and treat pressure ulcers for two residents. One resident on hospice care developed a stage 2 heel ulcer, which worsened due to lack of proper documentation and treatment orders. Another resident with a coccyx ulcer received improper wound care due to a nurse's failure to perform hand hygiene. The facility lacked a policy for pressure ulcer treatments, contributing to these deficiencies.
A facility failed to create a comprehensive care plan for a resident with major depressive disorder. The resident's MDS assessment showed symptoms of depression, and they were prescribed antidepressants and an antipsychotic. However, the care plan lacked details on mood or medications. The MDS Coordinator confirmed the omission, and the facility lacked a specific care plan policy, relying on standard practices.
A facility failed to update a resident's care plan after the resident, with intact cognition and dysphagia, requested a regular diet despite the risk of aspiration. The care plan continued to reflect a mechanically altered diet, contrary to the shared negotiated risk agreement signed by the resident, POA, and facility administrator.
A resident received another resident's medications due to a medication administration error. A CMA in training, under the supervision of another CMA, was instructed to administer medications without proper guidance or verification of resident identity. The resident, with multiple medical conditions, received incorrect medications, highlighting a failure in following professional standards during medication administration.
A resident with intact cognition and mobility issues was observed keeping smoking materials on his person instead of storing them at the nurse's station as required by facility policy. Despite being educated on smoking risks and having a care plan that required secure storage of smoking supplies due to oxygen in his room, the resident was non-compliant. Staff interviews revealed inconsistent enforcement of the smoking policy, leading to a deficiency in maintaining a safe environment.
A facility failed to document a physician's response to a GDR recommendation for a resident on psychotropic medications. Despite the pharmacy's request for a GDR for amitriptyline and bupropion, the physician disagreed but did not provide further documentation. The facility's policy required written communication and maintenance of medication regimen consultations, which were not adhered to, as acknowledged by the Administrator and ADON.
A medication error occurred when a CMA in training administered the wrong medications to a resident due to inadequate supervision and failure to verify the resident's identity. The resident, with a complex medical history, received medications intended for another resident, including a potassium supplement, which required emergency intervention. The facility lacked a specific medication administration policy, contributing to the error.
The facility failed to discard expired medications, including Rubbing Alcohol, a Blood Glucose Monitoring System, and Geri Dryl Allergy Relief. The ADON was unaware of a policy for preventing expired stock medications, and the Administrator confirmed the absence of such a policy.
The facility failed to provide meals in the required form for two residents with specific dietary needs. One resident received a steak sandwich with cut-up meat instead of ground meat, and another was nearly served the same until the Dietary Manager intervened. Despite the prescribed mechanically soft diet, one resident reported no issues with chewing or swallowing. The cook admitted to forgetting to prepare the ground meat, and the facility's policy required adherence to specified food consistencies.
Failure to Report Fall, Act on Critical X‑Ray Result, and Prevent Weight Bearing on Fractured Knee
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and to follow its fall occurrence policy after a resident was assisted to the floor and sustained a right patella fracture. The resident had moderate cognitive impairment (BIMS 12) and diagnoses including fractures, multiple trauma, renal insufficiency, arthritis, and osteoporosis. Her care plan identified her as at risk for falls and required substantial or maximal assistance of two staff with a gait belt and standard walker for ambulation and transfers, with MD notification for significant changes in pain. Despite these identified risks and care plan requirements, a CNA on night shift entered the resident’s room, observed her sliding from a lift chair, and used a gait belt to assist her to the floor, later stating she did not consider this a fall. The CNA reported that she assisted the resident to the floor and then back up alone without equipment, did not notify a nurse, and did not initiate any fall reporting or assessment. The facility’s fall occurrence policy required that each fall be reported and that a licensed nurse assess the resident prior to being moved, complete an incident report, and notify the physician and the resident’s representative. None of these steps occurred at the time of the event. The resident later told the PT that she had fallen the previous night while staff changed her brief and that she landed on her knees and was helped up by one staff member. The PT questioned the charge RN, who reported she had not been told of any fall. The PT documented that the resident reported severe bilateral knee pain (7/10 with movement) and could not participate in therapy. A mobile x‑ray was obtained, and imaging showed a comminuted fracture of the right patella, with the result faxed to the facility during the night. The LPN who received the faxed critical result texted a screenshot to the on‑call management phone but did not call the on‑call provider and did not complete an incident report, later acknowledging she should have called the provider. After the fracture result was available, multiple staff continued to transfer and ambulate the resident with weight bearing on the injured right leg because they were not informed of the fracture or any change in transfer status. The OT, unaware of the fracture, assisted the resident to walk to the bathroom with a 2‑wheeled walker and contact guard assistance; the resident reported pain 8/10 with movement, but only back pain was documented, and the OT stated she would not have walked the resident had she known of the fracture. Nursing and therapy staff who worked the morning after the x‑ray result reported they did not receive report of a fall or fracture and were not told to avoid weight bearing. A CNA attempted to transfer the resident for lunch with full weight bearing until the PT intervened and stopped the transfer, informing her of the injury. The DON, who was on call, acknowledged she did not immediately call the provider or notify therapy after learning of the fracture and confirmed the resident should not have borne weight on the fractured knee. Throughout this period, staff interviews and documentation showed that the fall was not reported as required, the resident was not promptly assessed by a nurse at the time of the event, the physician was not promptly notified of the fall and fracture, and staff were not timely informed of the non‑weight‑bearing status, resulting in ongoing weight‑bearing transfers after the fracture had been identified. Additional documentation and interviews further demonstrated breakdowns in communication and adherence to policy. The facility’s investigation confirmed that the CNA on the overnight shift did not view the event as a fall and therefore did not report it, despite the resident landing on her knees and requiring assistance to get up. The LPN who received the critical x‑ray result documented the fracture in a communication book and sent text messages to the on‑call management phone but did not verbally notify the on‑call provider or ensure that oncoming staff were informed. Multiple staff, including RNs, CNAs, a CMA, PT, and OT, stated they were unaware of the fracture or non‑weight‑bearing status during their care of the resident and continued to transfer or ambulate her with weight bearing. The DON and Administrator both acknowledged they did not hear or respond to the initial overnight text messages about the fracture in a timely manner. Collectively, these actions and inactions show that the facility did not ensure that the area was free from accident hazards and did not provide adequate supervision and appropriate post‑fall assessment and communication to prevent further harm after the resident’s fall and subsequent patella fracture.
Failure to Immediately Notify Family and Physician of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s family member and a resident’s physician of significant changes in condition, as required by facility policy. Resident #1, who had moderate cognitive impairment and multiple complex medical diagnoses including heart failure and respiratory failure, required assistance with ADLs and use of a gait belt for transfers and ambulation. On 3/30/26 at approximately 3:48 AM, an incident report documented that Resident #1 fell during an assisted transfer in the bathroom, hit her head on the wall, sustained a skin tear on her leg, and complained of back pain. Staff A, an RN, notified the on-call physician around 8:00 AM and obtained orders for pain medication and treatment of the skin tear, and later obtained an order to send the resident to the hospital due to continued pain. However, Staff A did not notify the resident’s daughter, listed as the primary emergency contact, until around 11:00 AM, approximately three hours after learning of the fall, despite acknowledging that family should be contacted as soon as possible. The deficiency also includes failure to promptly notify a physician of a critical diagnostic result for Resident #2. Resident #2 had moderate cognitive impairment and diagnoses including fractures and multiple trauma, renal insufficiency, arthritis, osteoporosis, and a history of wedge compression fracture of T11–T12. The care plan directed staff to notify the physician if pain interventions were unsuccessful or if there was a significant change in pain, and to assist with ambulation and transfers due to fall risk. On 3/12/26, PT documentation indicated the resident reported a nighttime fall and could not complete therapy due to knee pain, and x-rays of both knees were ordered. A mobile x-ray taken later that day showed a comminuted fracture of the right patella, and the x-ray report, marked as having critical significant findings, was faxed to the facility shortly after midnight on 3/13/26. Staff B, an LPN working the overnight shift, received and read the faxed x-ray report shortly after midnight and noted the right knee fracture but did not call the on-call provider, despite the facility having a provider on call at all times. Instead, Staff B sent text messages to the management phone number during the night. The DON, who was the management staff on call, acknowledged receiving text messages about the x-ray result but did not notify the provider upon arriving at the facility and did not become aware that the provider had not been notified until later that morning, when the Administrator contacted the provider at approximately 9:41 AM. The facility’s written policy on Notification for Change of Condition, revised June 2023, requires immediate consultation with the resident’s physician and notification of the resident and legal representative or interested family member when there is an accident with potential need for physician intervention, a significant change in status, a need to significantly alter treatment, or a decision to transfer or discharge. The actions and inactions described for both residents did not follow this policy.
Failure to Properly Assess and Treat Pressure Ulcers
Penalty
Summary
The facility failed to properly assess and treat pressure ulcers for two residents, leading to deficiencies in care. Resident #50, who was on hospice care, developed a stage 2 pressure ulcer on the right heel, which was initially identified by hospice staff before the facility documented it. Despite a meeting involving hospice, the facility, and the resident's family, the necessary orders for heel protectors and wound treatment were not transcribed into the Treatment Administration Record (TAR). The resident's heel ulcer worsened, and the facility did not intervene effectively to prevent the decline, as the physician's orders were to continue monitoring without further treatment. Resident #9, who had intact cognition and a history of heart disease, respiratory failure, and depression, was observed to have a pressure ulcer on the coccyx. During a wound treatment, a registered nurse failed to perform proper hand hygiene between removing the old dressing and applying the new one, which is against the facility's infection prevention and control policy. This lapse in protocol was acknowledged by the nurse and the Assistant Director of Nursing (ADON). The facility's lack of a policy for pressure ulcer treatments and failure to transcribe orders into the TAR contributed to the deficiencies. The ADON and Administrator acknowledged the issues but did not provide explanations for the lapses in documentation and treatment orders. The facility's infection control policy requires hand hygiene before and after direct patient contact, which was not followed in Resident #9's case.
Failure to Develop Comprehensive Care Plan for Resident with Depression
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with major depressive disorder, as identified during a clinical record review and staff interviews. The resident's Minimum Data Set (MDS) assessment indicated symptoms of depression and included diagnoses of medically complex conditions and depression. The resident was prescribed antidepressants and an antipsychotic medication, but the care plan lacked information related to their mood or the medications. The MDS Coordinator acknowledged that the care plan should have included a focus and interventions for the resident's antidepressant medications, mood, and behaviors, but confirmed it did not. The facility did not have a specific policy on care plans, relying instead on standard practices.
Failure to Update Care Plan Following Dietary Change Request
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident #47, following a change in dietary preferences and a shared negotiated risk agreement. The resident, who had intact cognition and required assistance with eating, was diagnosed with hypertension, traumatic brain injury, and dysphagia. Initially, the resident was on a mechanically altered diet with pureed meats and honey consistency liquids as per a physician's order. However, the resident and their Power of Attorney (POA) requested a regular diet with regular consistency liquids, acknowledging the increased risk of aspiration and potential death. This agreement was documented and signed by the resident, POA, and facility administrator, with a physician noting the high risk of aspiration and recommending adherence to the speech-recommended diet. Despite the documented agreement, the resident's care plan was not updated to reflect the changes agreed upon in the shared negotiated risk agreement. The care plan continued to direct staff to provide a mechanical soft diet with pureed meats and honey thickened liquids, without addressing the resident's request for a regular diet. The MDS Coordinator confirmed the omission, and the Nurse Consultant acknowledged the lack of a specific care plan policy, stating that the facility followed standard nursing practice and the Resident Assessment Instrument (RAI) manual for updates.
Medication Administration Error Due to Inadequate Training and Supervision
Penalty
Summary
The facility failed to meet professional standards of quality during medication administration for a resident, identified as Resident #51. The incident involved Resident #51 receiving another resident's medications, which was discovered through a clinical record review and interviews. Resident #51 had a BIMS score indicating intact cognition and had multiple medical diagnoses, including anemia, atrial fibrillation, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, seizure disorder, respiratory failure, and metabolic encephalopathy. The medication error occurred when Resident #51 was given medications intended for another resident, Resident #46. The error was attributed to the actions of Staff K, a Certified Medication Assistant (CMA) who was in training and had only worked at the facility for a few days. Staff K was instructed by Staff L, another CMA, to administer medications without proper supervision. Staff L prepared the medications and directed Staff K to deliver them to residents based on descriptions rather than accompanying her to ensure correct administration. Staff K expressed discomfort with this process, as she was unfamiliar with the residents and did not prepare the medications herself. This lack of supervision and guidance led to the administration of incorrect medications to Resident #51. Interviews with Resident #51 and her husband revealed that the CMA did not verify Resident #51's identity before administering the medication and was unable to identify the medications being given. Resident #51 experienced difficulty swallowing the medications, which were not administered with the usual applesauce, leading to gagging. The CMA attempted to give medications to Resident #51's husband, who was not a resident, further highlighting the lack of proper identification and verification procedures during medication administration.
Failure to Secure Resident's Smoking Materials
Penalty
Summary
The facility failed to maintain a safe environment for a resident by not securing smoking materials as required. Resident #30, who has intact cognition and uses a wheelchair for mobility, was observed keeping his smoking materials on his person instead of storing them at the nurse's station as per facility policy. Despite being educated on the risks of smoking and having a care plan that required him to store his smoking supplies at the nurse's station, Resident #30 was non-compliant and kept his cigarettes and lighter in his pocket. The facility's care plan for Resident #30 included interventions to ensure he followed smoking guidelines, such as storing his smoking materials at the nurse's station due to the presence of oxygen in his room. However, Resident #30 reported that he rarely turned in his smoking supplies because he felt the wait for staff to retrieve them was too long. Staff interviews revealed that while some staff were aware of Resident #30's non-compliance, others were not, indicating a lack of consistent enforcement of the smoking policy. The facility's smoking policy, revised in September 2023, stated that it was a non-smoking facility with designated smoking areas. However, the policy did not clearly define these areas, and Resident #30 was allowed to smoke independently. The facility's failure to enforce the policy and ensure Resident #30's smoking materials were stored securely at the nurse's station resulted in a deficiency related to maintaining a safe environment free from accident hazards.
Failure to Document Physician Response to GDR Recommendation
Penalty
Summary
The facility failed to ensure a physician responded to a gradual dose reduction (GDR) recommendation for a resident receiving psychotropic medications. The resident, identified with intact cognition and diagnosed with heart disease, respiratory failure, metabolic encephalopathy, and depression, was receiving amitriptyline for nerve pain and bupropion for depression. The pharmacy review requested a GDR for these medications, but the physician disagreed with the recommendation and claimed to have addressed it previously. However, the clinical record lacked documentation of any further physician response to the GDR. The facility's Medication Regimen Review policy required the consultant pharmacist to review medication regimens and communicate recommendations to the attending physician in writing. The policy also mandated that completed medication regimen consultations be maintained in the resident's clinical record. During an interview, the Administrator and Assistant Director of Nursing acknowledged the absence of documented physician responses to pharmacy recommendations and were unable to locate the necessary documents, indicating a failure in maintaining complete clinical records for review.
Medication Error Due to Inadequate Training and Supervision
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving a Certified Medication Aide (CMA) in training, Staff K, who administered the wrong medications to a resident. During her second day of training, Staff K was instructed by her trainer, Staff L, to deliver medications to a specific resident, but due to a lack of proper identification and supervision, she mistakenly gave the medications to another resident, Resident #51. This error occurred because Staff L did not accompany Staff K to verify the correct resident and relied on verbal descriptions rather than established protocols for medication administration. Resident #51, who received the incorrect medications, had a complex medical history including conditions such as anemia, atrial fibrillation, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, seizure disorder, respiratory failure, and metabolic encephalopathy. The medications intended for another resident included Donepezil, Calcium Carbonate with Vitamin D, and Potassium. The administration of the potassium supplement was particularly concerning due to Resident #51's existing high potassium levels, which required emergency medical intervention to normalize. Interviews with facility staff and the resident revealed that the error was not immediately recognized, and the resident's husband, who was present, was mistakenly offered medications as well. The facility lacked a specific policy for medication administration, relying instead on professional standards and physician orders. This oversight in training and procedural adherence led to the medication error, which, although deemed low risk by the Advanced Registered Nurse Practitioner (ARNP), necessitated emergency care for the resident.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to discard expired stock medications, compromising the integrity of the medications. During an observation of the medication room, it was found that there were expired items, including an unopened bottle of Rubbing Alcohol 70% with an expiration date of March 2024, an unopened box of Assure Prism Blood Glucose Monitoring System with an expiration date of August 2024, and two unopened bottles of Geri Dryl Allergy Relief with an expiration date of September 2024. The Assistant Director of Nursing (ADON) was unaware of a facility policy regarding the prevention of expired stock medications in the medication storage area and stated that she would implement one if it did not exist. The Administrator confirmed that the facility did not have a policy relating to expired medications.
Failure to Provide Properly Prepared Meals for Residents
Penalty
Summary
The facility failed to provide food in a form designed to meet the individual needs of two residents, as required by their physician diet orders. Resident #51 was prescribed a mechanical soft, ground meat diet, while Resident #50 was prescribed a mechanical soft texture diet. However, during the noon meal service, the steam table did not contain ground steak meat as required. Instead, the steak meat was observed to be cut into various sizes. Staff A, the cook, initially prepared a steak sandwich with cut-up meat for Resident #51 and served it on a room tray. Later, Staff A ground the meat using a robot coupe and returned it to the steam table. Despite this, Staff A prepared another steak sandwich with cut-up meat for Resident #50, which was only corrected after the Dietary Manager intervened. Resident #51 and her husband reported that she had no difficulty chewing or swallowing meat, despite the prescribed mechanically soft diet. They mentioned that she had eaten chicken on the bone without any issues the previous night. The Dietary Manager expected staff to follow the menu and ensure the meat was ground as indicated. Staff A admitted to forgetting to prepare the ground meat before the meal service and acknowledged the mistake in serving Resident #50. The facility's policy on altered textured diet orders required that diet orders specify the appropriate consistency of food to meet residents' safety, tolerance, and preferences.
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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.
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| Story Medical Senior Care | 1.2 mi | ★★★★★ | 6 | 0 |
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| Green Hills Health Care Center | 9.9 mi | ★★★★★ | 1 | 0 |
| Northridge Village | 10.9 mi | ★★★★★ | 4 | 0 |
| Zearing Health Care, Llc | 13.1 mi | ★★★★★ | 9 | 0 |
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