Rolling Hills Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Millmont, Pennsylvania.
- Location
- 17350 Old Turnpike Road, Millmont, Pennsylvania 17845
- CMS Provider Number
- 395614
- Inspections on file
- 19
- Latest survey
- September 16, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Rolling Hills Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A nurse aide took a photo of a resident with severe cognitive impairment, who could not provide consent, and shared it electronically with other staff. Although the resident's face was obscured, the individual was still identifiable as a facility resident. The facility confirmed the unauthorized taking and sharing of the photo.
A resident with obstructive uropathy had physician orders for a coude foley catheter to be changed monthly by an RN, but documentation showed an LPN performed a catheter change and changes occurred outside the prescribed schedule without evidence of medical necessity. The facility did not ensure catheter care was provided by the appropriate licensed staff or according to the physician's orders.
The facility did not ensure that a resident received necessary dental services, resulting in a deficiency related to the provision or arrangement of dental care.
A resident who required extensive staff assistance with hygiene was repeatedly observed with long, unclean fingernails and evidence of dried blood, despite having a care plan for staff-assisted hygiene and grooming. The deficiency was confirmed through observation, record review, and staff interviews.
A resident with a history of cardiac disease and a surgically inserted pacemaker did not have a physician's order for pacemaker monitoring, and there was no evidence that pacemaker checks were being performed as required by the care plan. Facility leadership confirmed the absence of both an order and documentation of monitoring until the issue was identified by surveyors.
A resident's bed system was found to have a significant gap between the mattress and headboard, with no footboard present and the mattress having slid within the frame. Facility staff did not assess or document the risk of entrapment related to this gap, and leadership could not provide evidence of a review of mattress stability or changes to the bed system.
A resident's medication regimen review was not properly documented or communicated by the consultant pharmacist, who failed to provide separate written reports of irregularities to the physician and DON. Recommendations for medication changes and lab monitoring were directed to nursing staff instead of the physician, and the physician's response to a pharmacist's recommendation for a medication dose reduction was not documented in a timely manner.
Surveyors were unable to independently access a resident's nurse aide documentation in the EHR, requiring staff intervention to obtain records related to care tasks. The facility did not provide surveyors with the same read-only access to medical records as staff, resulting in a deficiency.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
A facility failed to ensure the privacy and confidentiality of a resident's personal and medical records. Clinical record review showed that a resident with severe cognitive impairment, who was unable to make decisions or provide consent, was photographed by a nurse aide. The photo, although the resident's face was obscured by a filter, was still identifiable as a facility resident and was electronically shared with other staff members. The facility's investigation confirmed that the photo was taken and disseminated without the resident's consent, and staff interviews corroborated these findings.
Failure to Follow Physician Orders for Indwelling Catheter Care
Penalty
Summary
The facility failed to follow physician orders regarding the care and management of an indwelling urinary catheter for a resident with obstructive uropathy. Physician orders specified that a 24 French coude foley catheter was to be changed monthly and as needed for blockage or obstruction, and that only a registered nurse (RN) was permitted to perform the catheter change. However, documentation revealed that a licensed practical nurse (LPN) changed the resident's coude catheter on one occasion, contrary to the physician's order. Additionally, the resident's catheter was changed by an RN on a date that did not align with the monthly schedule, and there was no documented evidence of a complication, such as blockage or obstruction, that would have warranted an earlier change. The clinical record also showed inconsistencies in documentation regarding who performed the catheter changes and when they occurred. The Director of Nursing (DON) performed a scheduled monthly catheter change, but previous changes were not consistently documented as being performed by an RN as required. The Nursing Home Administrator confirmed these findings during an interview. The facility did not ensure that the resident's indwelling urinary catheter was managed according to physician orders, both in terms of the appropriate licensed staff performing the procedure and adherence to the prescribed schedule.
Failure to Provide or Obtain Dental Services
Penalty
Summary
The facility failed to provide or obtain necessary dental services for each resident as required. This deficiency indicates that at least one resident did not receive appropriate dental care or access to dental services during their stay. The report specifically notes the lack of provision or arrangement for dental services, but does not provide further details about the residents involved or their medical conditions at the time of the deficiency.
Failure to Provide Nail Hygiene Assistance to Dependent Resident
Penalty
Summary
A dependent resident who required substantial to maximal staff assistance with personal hygiene and grooming was observed on two separate occasions to have long fingernails extending beyond the fingertips, with darkened material and dried blood present under several nails. The resident also had a skin injury with dried, smeared blood on the left forearm. These observations were made despite the resident having a care plan in place since October 2024, which identified a self-care deficit and a risk for skin integrity issues, and included interventions for staff to assist with daily hygiene and grooming. Clinical record reviews and Minimum Data Set (MDS) assessments confirmed the resident's need for extensive assistance with hygiene. Interviews with facility leadership and clinical staff acknowledged the concern regarding the resident's nail hygiene. The failure to provide adequate assistance with nail care and hygiene for this dependent resident constituted a deficiency under the cited nursing services regulation.
Failure to Ensure Pacemaker Monitoring for Resident with Cardiac History
Penalty
Summary
The facility failed to ensure the highest practicable care for a resident with a cardiac pacemaker. Upon admission, the resident had diagnoses including coronary artery disease, congestive heart failure, hypertension, and a surgically inserted pacemaker. The resident's care plan included instructions for pacemaker checks, but there was no specified intervention or method for performing these checks. Clinical record review showed no evidence of a current physician's order for pacemaker monitoring, and no documentation that pacemaker checks were being completed. This deficiency was identified when the surveyor discovered the lack of a physician's order and absence of documented pacemaker checks during a review and interviews with facility leadership. The facility confirmed that prior to the surveyor's inquiry, there was no order in place and no evidence that the required pacemaker monitoring was being conducted for the resident.
Failure to Assess and Address Bed System Entrapment Hazard
Penalty
Summary
The facility failed to properly assess and address potential accident hazards in a resident's bed system, specifically regarding the risk of entrapment. Observations revealed that a resident's bed had assist bars at the head, a trapeze device, and a significant gap of six to eight inches between the top of the mattress and the headboard, with no footboard present. Further measurement by an LPN confirmed a 10-inch gap between the mattress and the headboard, and the mattress appeared to have slid distally within the bed frame. The facility's prior assessment documentation only addressed gaps between head/foot boards and bed rails, stating they were within FDA limits, but did not evaluate the space between the mattress and the headboard or the stability of the mattress positioning. Interviews with facility leadership confirmed that there was no documentation regarding when the bed system was changed or whether a footboard had been removed. Additionally, the facility was unable to provide evidence of an assessment that considered the risk of mattress sliding and the resulting gap size, which could present a potential entrapment hazard. The deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) for failing to ensure the area was free from accident hazards and that adequate supervision and assessment were provided to prevent accidents.
Failure to Ensure Proper Pharmacist Irregularity Reporting and Physician Response
Penalty
Summary
The facility failed to ensure that the consultant pharmacist reported medication regimen irregularities to the attending physician and Director of Nursing on a separate, written report, as required by policy. For one resident, the consultant pharmacist's recommendations regarding medication adjustments and laboratory monitoring were included in lists with other residents' information and directed to nursing staff, rather than being provided to the physician on a separate report. The recommendations included updating a Seroquel order and ensuring periodic labs for Cholestyramine, but these were not referred directly to the physician, nor was a separate report documented in the resident's medical record for several months. Additionally, when the consultant pharmacist did request a physician review of Hydroxyzine for a possible gradual dose reduction, the physician did not document a review and response until more than a month later. The only evidence of the pharmacist's review for that month was a report listing multiple residents, without a separate report for the physician. The Director of Nursing confirmed the absence of required separate reports in the resident's chart for the months in question, and that the physician's response to the pharmacist's recommendation was not timely documented.
Failure to Provide Surveyors Independent Access to EHR Documentation
Penalty
Summary
Surveyors were unable to independently access three months of nurse aide documentation for a resident during a survey, despite being provided with the facility's federal Entrance Conference Worksheet and instructions for accessing the Electronic Health Record (EHR). The surveyors required read-only access to the same information available to staff, specifically documentation related to the completion of care tasks such as bathing, toileting assistance, bowel elimination records, incontinence care, behavior monitoring, oral hygiene, and application of medical devices. When the surveyors requested instructions for accessing this documentation, the Nursing Home Administrator responded that she would print the requested records, rather than providing direct access. A licensed practical nurse later printed the documentation for the surveyor, but the surveyor was still unable to independently view the information without staff intervention. This failure to provide surveyors with the same read-only access to residents' EHRs as staff constitutes a deficiency in maintaining and making medical records readily accessible for health oversight activities.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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