Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Hills Health Center during CMS and state inspections, most recent first.
The facility did not ensure RN coverage for at least eight consecutive hours each day on multiple occasions, as confirmed by missing schedule and payroll documentation and staff interviews. This failure occurred despite facility policy requiring such coverage for all residents.
Surveyors found unsanitary conditions in the kitchen and food storage areas, including uncovered food in a dirty microwave, dusty refrigerator vents, unprotected napkins, sticky dessert sauce bottles, and gnats on bread. Dietary staff confirmed expectations for cleaning were not met, and facility policy required sanitary handling and storage of food and equipment.
Staff failed to follow infection control protocols by allowing a resident's urinary catheter bag to rest on the floor and by not properly storing or replacing nasal cannulas for two residents after they came into contact with unclean surfaces. These actions were not in line with facility policies for catheter and oxygen equipment management.
The facility did not provide direct, interactive activities based on resident preferences during weekends. Activity calendars listed repetitive activities, but staff and resident interviews revealed that scheduled activities were often not conducted, with only movies or television provided instead. Activities staff were generally not present on weekends, and direct care staff reported being too busy to lead activities, leaving residents with only independent options like puzzles and games.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights that the environment did not meet required safety standards.
A resident with severe cognitive impairment and a history of falls did not have their care plan updated with new interventions after experiencing two separate falls. Despite assessments and investigations following each incident, no additional fall prevention strategies were documented or implemented in the care plan, contrary to facility policy and staff statements.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures to avoid new ulcers were not consistently implemented. Observations and record reviews showed lapses in assessment, monitoring, and treatment, with necessary interventions not applied as required.
A resident with a suprapubic urinary catheter and multiple comorbidities was observed on several occasions with their catheter collection bag lying directly on the floor, despite care plans and facility policy requiring the bag to be secured in a privacy bag and kept off the floor. Staff interviews confirmed these requirements, but the deficiency persisted, resulting in unsanitary catheter care.
A resident with PTSD, bipolar disorder, and schizoaffective disorder did not have trauma-based triggers identified or individualized interventions implemented in the care plan. Although assessments documented the resident experienced nightmares and avoided trauma reminders, the care plan only included general monitoring and support. Facility staff were unclear about responsibilities for PTSD assessment and care planning, resulting in a lack of trauma-informed, personalized care.
The facility did not submit complete and accurate RN staffing information to CMS, with payroll records missing for several days when no RN hours were reported, despite policy requiring daily RN coverage.
A resident with multiple medical conditions and a care plan requiring mechanical lift assistance for transfers was injured when two CNAs, after the resident declined both the lift and a gait belt, attempted to reposition her by lifting under her arms during a shower transfer. This improper technique resulted in a humerus fracture, as confirmed by hospital evaluation.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week, as required. Review of the nursing schedules for April through September 2024 revealed that on six specific dates, there was no verifiable or auditable evidence of RN coverage for the required duration. Administrative staff were unable to provide payroll documentation to confirm RN presence on those days. Interviews with administrative staff indicated that ensuring RN coverage, particularly on weekends, was a persistent challenge. The facility's own policy required sufficient nursing staff, including RN coverage for at least eight consecutive hours every 24 hours, but this standard was not met on the identified dates for a census of 44 residents.
Failure to Maintain Sanitary Food Storage and Equipment Cleaning
Penalty
Summary
Surveyors observed multiple failures to maintain sanitary conditions in the facility's kitchen and food storage areas. During an inspection, a microwave oven was found with a bowl of uncovered green beans inside, along with old food debris spattered on the interior surfaces. The walk-in refrigerator unit had built-up dust and debris covering the blower vents. In the dry food storage area, unboxed packages of napkins were resting directly against the storage room wall without a protective barrier, and several syrup-based dessert sauce bottles had syrup residue caked on their lids while being stored on racks. Additionally, gnats were seen flying and landing on bread packages in the dry food storage room. Dietary staff confirmed that staff were expected to clean equipment and wipe down containers after use, and that kitchen staff were responsible for cleaning all surfaces after each meal service. The facility's policy required all food to be labeled and dated, and for cooking equipment to be maintained in a sanitary environment and stored to prevent contamination. These observations and staff statements indicated that the facility failed to follow its own policies and professional standards for food storage and equipment cleaning.
Failure to Maintain Proper Infection Control for Catheter and Oxygen Equipment
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for three residents. One resident's urinary catheter collection bag was observed lying flat on the floor with visible urine in the bag and tubing, rather than being properly hung on the bed frame with a privacy bag. The same resident's catheter bag was later observed correctly hung, but the initial failure to keep the bag off the floor was not in accordance with facility policy, which requires cleansing or replacement if the bag or tubing contacts the floor. Additionally, two residents' nasal cannulas (NC) were not properly stored when not in use. One resident's NC tubing was found hanging over a walker railing without a storage bag, and another resident's NC was found lying on the floor. An administrative nurse picked up the NC from the floor and handed it back to the resident for use without replacing it, contrary to facility policy that requires replacement if oxygen equipment contacts the floor. These lapses in infection control practices were confirmed by the facility's infection preventionist and were not consistent with the facility's written policies.
Failure to Provide Direct, Interactive Activities on Weekends
Penalty
Summary
The facility failed to provide direct, interactive activities based on resident preferences during weekends for its census of 44 residents, as identified through observation, record review, and interviews. Activity calendars for several months showed repetitive scheduling of movies, games, social hours, puzzles, and a specific game on weekends. However, the Resident Council reported that these activities were often not conducted, with the activities coordinator only occasionally present on weekends. When the coordinator was absent, nursing care staff did not complete the scheduled activities, instead resorting to playing movies or television shows, and not engaging in staff-led activities. Residents reported frequent boredom on weekends due to the lack of interactive programming. Staff interviews confirmed that scheduled weekend activities were often not completed, as activities staff typically worked only Monday through Friday. Direct care staff, including CNAs and LNs, stated they were too busy with resident care to facilitate activities, and only provided materials like puzzles and games for residents to use independently. The facility's Activities Programming policy required activities to meet residents' needs and interests, but this was not consistently implemented on weekends, resulting in a lack of direct, interactive engagement for residents during those times.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions by staff or details about the residents involved are not provided in the report.
Failure to Revise Care Plan After Resident Falls
Penalty
Summary
The facility failed to revise the care plan for a resident with Alzheimer's disease, dementia with behavioral disturbance, and agitation after the resident experienced two falls. The resident had severely impaired cognition, required a wheelchair for mobility, and needed substantial to total assistance with activities of daily living. Despite being identified as at risk for falls due to poor cognition, incontinence, impaired mobility, and medication use, the care plan was not updated with new interventions following unwitnessed and witnessed falls. After the first fall, which occurred when the resident attempted to replace her shoe without locking the wheelchair brakes, no new interventions were added to the care plan. Similarly, after a second fall in the dining room, where the resident missed the wheelchair while attempting to sit, the care plan remained unchanged. Staff interviews confirmed that the facility's process required assessment and implementation of new interventions after each fall, with subsequent care plan revision. However, documentation and care plan review showed that no new fall prevention strategies were added after either incident. The facility's policy required ongoing updates to the care plan as residents' needs changed, but this was not followed in the resident's case, resulting in a lack of updated interventions after multiple falls.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that necessary interventions to prevent skin breakdown were not consistently applied, and existing pressure ulcers were not managed according to established protocols.
Failure to Maintain Sanitary Catheter Care
Penalty
Summary
A deficiency occurred when staff failed to maintain a resident's indwelling suprapubic urinary catheter in a safe and sanitary manner. The resident had multiple diagnoses, including major depressive disorder, diabetes mellitus, chronic kidney disease, and congestive heart failure, and required substantial to maximal assistance with activities of daily living. The resident's care plan and urinary incontinence assessment specifically instructed staff to monitor the catheter for infection and skin breakdown, ensure the catheter drainage bag and tubing were secured in a privacy bag, and prevent the bag from touching the floor. Despite these instructions, observations on multiple occasions showed the resident's urinary catheter collection bag lying directly on the floor with visible urine in the bag and tubing, rather than being hung on the bedframe as required. Staff interviews confirmed that facility policy required catheter collection bags to be placed in a privacy bag and kept off the floor, and that the system should be maintained in a sanitary manner to prevent infections. The facility's policy also emphasized the importance of maintaining unobstructed urine flow and frequent emptying of the catheter bag. However, the observed failure to follow these procedures resulted in the resident's catheter bag being left on the floor for extended periods, contrary to both the care plan and facility policy.
Failure to Provide Trauma-Informed, Individualized Care for Resident with PTSD
Penalty
Summary
The facility failed to identify trauma-based triggers and implement individualized interventions for a resident diagnosed with post-traumatic stress disorder (PTSD), bipolar disorder, and schizoaffective disorder. The resident's care plan included general monitoring for hallucinations and adverse medication side effects, as well as providing opportunities for the resident to talk about feelings when upset. However, the care plan did not include personalized interventions specifically addressing the resident's PTSD or strategies to prevent re-traumatization, despite documentation in the medical record and assessments indicating the resident experienced nightmares and avoided situations that reminded her of past trauma. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for completing PTSD assessments and updating care plans with trauma-specific information. Staff members were unsure who was responsible for ensuring that the type of trauma and individualized interventions were included in the care plan. The facility's policy required trauma-informed care and screening for trauma experiences, but this was not consistently implemented for the resident in question.
Failure to Submit Complete and Accurate RN Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through Payroll Based Journaling (PBJ) for a census of 95 residents. CMS reports for two consecutive quarters indicated that the facility had no Registered Nurse (RN) hours reported for 10 days. While payroll documentation was provided for RN coverage on four of those days, administrative staff were unable to provide payroll documentation for the remaining six days. The facility's policy required a sufficient number of nursing staff, including RN coverage for at least eight consecutive hours every 24 hours, seven days a week. This deficiency was identified through interview and record review.
Failure to Ensure Safe Transfer Results in Resident Fracture
Penalty
Summary
A deficiency occurred when staff failed to ensure an environment free from accident hazards for a resident who required staff assistance and a mechanical lift for safe transfers. The resident, who had multiple diagnoses including pleural effusion, COPD, rheumatoid arthritis, polyosteoarthritis, and osteoporosis, was dependent on staff for transfers, toileting, and mobility. The care plan indicated the need for a Hoyer lift for transfers, but also noted the resident often declined its use, in which case two staff and a gait belt were to be used. On the day of the incident, the resident declined both the Hoyer lift and gait belt, insisting on standing and pivoting for the transfer. During a shower transfer, two CNAs assisted the resident, who requested to be scooted back in the shower chair. The CNAs placed their arms under the resident's arms and attempted to move her back, at which point a popping noise was heard and the resident experienced severe pain in her right upper arm. The CNAs did not use a gait belt during this maneuver, and their arms were misplaced in relation to the resident's arms. The incident resulted in a humerus fracture, confirmed by hospital assessment and subsequent surgery. Staff interviews confirmed that proper transfer techniques were not followed, as staff are trained not to lift residents by or under the arms due to the risk of injury. The care plan and therapy notes specified the use of mechanical lifts or, if refused, a gait belt with two staff. Despite these instructions, the transfer was performed without the required equipment, directly leading to the resident's injury.
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What surveyors actually found near you
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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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Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Excel Healthcare And Rehab Topeka | 1 mi | — | 0 | 0 |
| The Gardens At Aldersgate | 1.1 mi | ★★★★★ | 32 | 0 |
| Plaza West Healthcare And Rehab | 1.5 mi | ★★★★★ | 0 | 0 |
| Tanglewood Nursing & Rehabilitation | 2.3 mi | ★★★★★ | 0 | 0 |
| The Healthcare Resort Of Topeka | 2.4 mi | ★★★★★ | 8 | 0 |
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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.