Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Rehab Ctr during CMS and state inspections, most recent first.
Unsafe Food Handling and Sanitation Practices: Surveyors observed an employee use a thermometer without allowing it to air dry between food temperature checks, serve mashed potatoes after microwaving them to only 151 degrees F, and find a mixer stored uncovered with food particles on the undercarriage. Surveyors also observed an employee remove gloves, use a marker, and return to handling onions without washing hands.
The facility did not maintain a QAA committee with the required members. The policy required the DON, Medical Director, Administrator, at least two other staff members, and the infection control and prevention officer, but the QA/QAPI attendance sheets did not include an IPC at two quarterly meetings. The NHA acknowledged that the IPC does not always attend and should attend the meetings, and the DON stated she was not certified in infection prevention and control.
A resident's advance directive paperwork was not on file, and the surveyor could not find documentation of a POAHC or evidence that the facility discussed establishing one with her. The DON and SW confirmed the paperwork was missing, and the SW said the facility would have had to pursue guardianship if the resident later could not make decisions for herself. The resident stated she had completed POA paperwork and that a family member had it, and the paperwork was later found in the clinical chart documents.
A resident with moderate cognitive impairment had two unwitnessed falls, but the MD was not notified after either event. Facility staff stated that unwitnessed falls require assessment and that the MD should be notified when there is concern for head injury, yet the fall reports documented that no MD notification was needed because the resident did not hit her head. The DON also stated the facility had not viewed a fall as a change of condition.
A resident with spinal stenosis, osteoarthritis, and intact cognition reported that a CNA was rough and pushed her while she was on the toilet. During the abuse investigation, the CNA was supposed to be with another staff member or under observation, but staff interviews showed she could still move around the unit and go out of sight without direct supervision, and the NHA acknowledged she could potentially enter a resident room without being watched.
Delayed Provision of Bed Side Rails: A cognitively intact resident with Parkinson's disease, restless leg syndrome, rheumatoid arthritis, and chronic pain requested bed side rails to help with bed mobility and repositioning. Therapy documented that the resident would lay in bed if rails were available, but the request was not communicated or acted on promptly, and the bed did not have side rails when observed. Staff later stated side rails are usually installed the same day a request is made, and the DON acknowledged the delay should not have taken so long.
Oxygen tubing/nasal cannula care was not ensured for one resident with acute and chronic respiratory failure, cor pulmonale, and COPD. Staff observed the resident using oxygen with no date label on the cannula/tubing, and RNs and the DON stated monthly changes are expected but could not verify when the tubing was last changed because it was unlabeled and not clearly documented.
The facility failed to report an alleged abuse incident to the State Agency within the required 2-hour timeframe. A resident with dementia and severe cognitive impairment was pinched on the arm by another cognitively impaired resident. Nursing documentation showed that leadership was informed mid-afternoon, but the formal abuse report to the State Agency was not submitted until that evening. Interviews with an RN, the DON, and the Administrator confirmed awareness of the 2-hour reporting requirement for abuse allegations and that the report was sent later than required by facility policy and regulation.
The facility failed to maintain an effective infection prevention and control program, with deficiencies in linen handling, PPE use, and hand hygiene. Clean linens were transported uncovered, PPE was improperly removed outside a resident's room, and an LPN did not perform hand hygiene or cleanse an injection site before administering insulin. The Nursing Home Administrator and Director of Nursing acknowledged these lapses.
The facility failed to provide consistent restorative services to maintain or improve ROM and mobility for four residents, as outlined in their care plans. Residents with conditions such as arthritis, muscular dystrophy, osteoarthritis, and Parkinson's disease did not receive the prescribed frequency of exercises, leading to potential declines in their functional abilities. Staffing issues and the absence of a Restorative Services Policy contributed to these deficiencies.
The facility failed to protect two residents from abuse. One resident with Alzheimer's was verbally abused by a CNA who threatened to carry them out of the room. Another resident was physically assaulted by a fellow resident during an altercation. Despite reports and staff intervention, the facility did not follow its abuse prevention policy, leaving residents unprotected.
The facility failed to report two incidents of potential misconduct to the state agency. In one case, a CNA threatened a resident with severe cognitive impairment, and in another, a resident-to-resident altercation occurred. The facility did not follow its policy for reporting such incidents, and the administration was unaware of some events due to a breakdown in the reporting process.
A facility failed to investigate allegations of abuse and protect residents during the investigation. A CNA accused of verbal abuse continued working with a resident with severe cognitive impairment. Additionally, a resident with aggressive behavior was involved in multiple altercations without thorough investigations or identification of affected residents. Staff interviews revealed a lack of awareness and communication regarding these incidents.
The facility failed to transmit MDS assessments within the required timeframe for three residents, resulting in a deficiency. The assessments for these residents, who were either self-pay or on a Medicare Advantage Plan, were completed but not transmitted to CMS. The issue was identified through record reviews and interviews, with the facility's staff citing payor source as the reason for non-transmission.
A facility failed to ensure a safe environment and adequate supervision for two residents. One resident with cerebral palsy was left unattended while connected to a mechanical lift, and another resident with severe cognitive impairment exhibited aggressive behavior without increased supervision. Despite multiple incidents, no new interventions were documented, and staff acknowledged the inability to provide consistent 1:1 supervision due to staffing limitations.
The facility exceeded the acceptable medication error rate, with surveyors observing 4 errors out of 35 opportunities, resulting in an 11.4% error rate. Two residents received insulin injections from pens that were not primed, contrary to the manufacturer's instructions and facility procedures. The LPNs involved failed to follow proper priming protocols, and one insulin pen lacked an open date or expiration date label. The DON acknowledged previous training on insulin pen usage and expected staff to prime pens before use.
The facility failed to properly label and store insulin pens, affecting two residents. An insulin pen was found without an opened date and not refrigerated, while another was administered without proper labeling. Staff admitted to not following protocol, potentially impacting medication effectiveness.
A facility failed to thoroughly investigate a resident-to-resident altercation involving a cognitively impaired resident who became upset and squeezed another resident's hand. The facility did not interview witnesses, provide increased supervision for the involved resident, or educate staff following the incident, as required by their policy.
A resident with severe cognitive impairment left the facility without staff knowledge and was not added to the Wanderer's List for increased supervision, contrary to facility policy. The resident's care plan lacked interventions for wandering risk, and no prior risk assessment was noted. The IDT determined the resident was not at risk for future wandering, but the facility later acknowledged the resident should have been added to the list.
Unsafe Food Handling and Sanitation Practices
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food was prepared, stored, and distributed. During observation, surveyors saw [NAME] U use an alcohol wipe to clean a thermometer and then probe chicken noodle soup without allowing the thermometer to air dry, and later use another alcohol wipe on the thermometer and immediately probe mashed potatoes without air drying. The Dietary Manager stated that the thermometer should be allowed to air dry completely before probing the next food and that a clean wipe should be used each time it is sanitized. Surveyors also observed [NAME] U probe mashed potatoes that measured 121 degrees F, place them in the microwave, and then probe them again when the internal temperature was 151 degrees F before serving them at that temperature. In addition, the facility's mixer was observed stored uncovered with food particles on the undercarriage, and [NAME] BB was observed removing gloves, using a marker to label a plastic bag, and then returning to handling onion pieces without washing his hands. The Dietary Manager stated the mashed potatoes should be reheated to 165 degrees F and indicated [NAME] BB should have washed his hands after handling the marker and before returning to food handling.
QAA Committee Missing Required IPC Member
Penalty
Summary
The facility did not maintain a quality assessment and assurance committee with the required members, including the infection control and prevention officer, as outlined in its policy. Record review showed the facility's Quality Assurance/Assessment and Performance Improvement Plan required the QAA Committee to include the Director of Nursing Services, the Medical Director, the Administrator, at least two other staff members, and the infection control and prevention officer. During the entrance conference, the DON identified IPC T as the facility's infection prevention and control nurse, but the QA committee attendance sign-in sheets dated 10/24/25 and 4/24/26 did not include an IPC. The DON stated she was not certified in infection prevention and control, and the NHA stated the Medical Director, NHA, pharmacist, and DON were the required QAPI members, while also acknowledging that IPC T does not always attend and should attend the meetings.
Advance Directive Paperwork Not on File for Resident
Penalty
Summary
The facility failed to have a system in place to ensure advance directive paperwork was on file for 1 of 19 sampled residents, R7. R7 was admitted to the facility and was her own person with no activated POA. During the initial pool record review, the surveyor could not find documentation of a POAHC for R7 or evidence that the facility discussed establishing one with her. The facility's policy states that advance directives, including a HCPOA, POST form, or living will, are to be reviewed on admission and offered on quarterly assessments or as requested by the resident if the resident does not have a POA. Staff interviews showed the facility expected to obtain POA paperwork from the hospital when a resident was admitted from there and offered assistance with completing POA documents at admission or upon request. However, the SW and DON confirmed R7 did not have POA paperwork on file, and the SW stated that without it the facility would have to pursue guardianship if R7 had a sharp decline and could no longer make decisions for herself. R7 told the surveyor she had previously completed POA paperwork and that a family member had it. Later, the SW located R7's POA paperwork in her clinical chart documents and confirmed the facility had never had it on file before that day.
Failure to Notify Physician After Unwitnessed Falls
Penalty
Summary
The facility failed to notify and consult the resident’s physician when there was a change in condition for one resident, R25, who had two unwitnessed falls and no medical provider notification documented. R25 was admitted on 10/29/24 and had diagnoses including hallucinations and generalized anxiety disorder. Her MDS with ARD of 1/28/26 showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The facility’s fall reports for 1/2/26 and 3/26/26 both stated that the MD did not need to be notified because the resident did not hit her head, even though both falls were unwitnessed. During interviews, RN K stated that if a fall was unwitnessed, she would assess the resident and environment but could not be sure the resident did not hit her head, and that the MD would be notified within 4 hours if there was concern for head injury. RN E stated that if a resident could not tell whether they hit their head, the MD would be notified within 4 hours. DON B stated that the resident’s representative was called after falls and that the MD was called if there was an injury, and also stated that the facility had never looked at a fall as a change of condition. The report states that R25 had two unwitnessed falls without any indication that the physician was updated.
Failure to Directly Supervise Accused CNA During Abuse Investigation
Penalty
Summary
The facility failed to fully prevent further potential abuse, neglect, exploitation, or mistreatment of a resident while an investigation into an alleged abuse incident was in process. The incident involved a cognitively intact resident with spinal stenosis with neurogenic claudication and osteoarthritis, whose most recent BIMS score was 15 out of 15. The resident reported that a CNA was rough and pushed her over to the side while she was on the toilet, and the allegation was reported to nursing staff after the event. According to the facility’s own report and staff interviews, the accused CNA had been instructed not to work with the resident and to only provide care to other residents with a second staff person present during the investigation. However, the Social Worker stated that the CNA could be seen by nursing staff on the unit when she was not with residents, and that it was not 100% guaranteed she was never around residents by herself. The CNA stated that when she was not working with residents, she stocked linen carts, wiped hallway railings, and wiped wheelchairs within view of the nurses’ station, but if she needed to go to a hallway closet or out of eyesight, she would notify a nurse and would not be followed. The Nursing Home Administrator stated the CNA was not supposed to be working with anyone or doing anything by herself and was only supposed to work with other staff present, whether in a room or with nurses keeping an eye on her. The surveyor noted that the CNA’s own description showed she could go down the hallway without someone watching her, and the administrator acknowledged that this meant she could potentially enter a resident room without being observed. The RN also stated staff were told to keep an eye on staff members and residents to ensure no further incidents occurred.
Delayed Provision of Bed Side Rails
Penalty
Summary
The facility did not ensure that R25 received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing when requested side rails for bed mobility were not provided in a timely manner. R25 was admitted with diagnoses including Parkinson's disease, restless leg syndrome, rheumatoid arthritis, and chronic pain, and his BIMS score of 15 indicated he was cognitively intact. During interview, R25 stated he had asked for side rails to help him get into bed, reposition himself, and move around in bed, and he reported he could not get into bed without them. Survey observation confirmed that his bed did not have side rails at that time. Record review showed the PT discharge summary documented that R25 reported he would lay in bed if he had bed rails to assist him with rolling and scooting. Therapy staff stated they had requested side rails from maintenance on 4/27/26 so R25 could have increased independence with bed mobility and had also discussed the need with nursing. However, maintenance staff reported they were unaware of the request, and environmental services stated she was only notified on 5/6/26 and then transferred a bed with side rails into R25's room. Nursing leadership acknowledged that once a request is made, side rails are usually installed the same day and stated R25's side rails should have been addressed sooner.
Oxygen Tubing Not Verified as Changed Monthly
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for one of two residents reviewed for oxygen. R6 was admitted with diagnoses including acute and chronic respiratory failure with hypercapnia, chronic cor pulmonale, and COPD, and had physician orders for oxygen at 2 L/min at rest and 3 L/min with activity to keep oxygen saturation above 90%. The facility's Oxygen Therapy policy stated that the nasal cannula should be replaced monthly, and R6 also had an order for the nasal cannula on the portable and concentrator to be changed one time per month. During observation, R6 was seen wearing a nasal cannula attached to an oxygen concentrator, but no date labeling was noted on the tubing or cannula. RN staff stated the cannula/tubing is changed every 30 days and should be labeled, but when asked when R6's tubing had last been changed, staff could not verify it from the tubing and noted there was no label. The DON also stated that if tubing is unlabeled, it cannot be verified that it was changed.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an alleged abuse incident to the State Agency (SA) as required by regulation and its own policy. The facility’s “Misconduct Investigation and Reporting” policy required staff to immediately report incidents to a nurse or supervisor, for the nurse/supervisor to immediately notify the Administrator after ensuring resident safety, and for any allegation involving abuse or resulting in serious bodily injury to be reported within two hours of discovery. Resident 2, who had dementia, anxiety disorder, and severe cognitive impairment (BIMS score of 3/15) and was mobile with a walker, was involved in an incident in which another resident pinched their arm. Nursing documentation for Resident 2 on the date of the incident showed that the DON and social worker were updated at 3:00 PM, and the care plan was revised the same day to keep Resident 2 an arm’s length away from Resident 1. Resident 1 had cerebral palsy, seizures, and moderate cognitive impairment with short- and long-term memory loss. The facility’s Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report showed the report was submitted to the SA at 8:50 PM on the date of the incident. During interview, RN1 stated she became aware of the pinching incident sometime after breakfast and reported it to management but could not recall the exact time. The DON stated that such incidents are typically reported within two hours and that the Administrator manages reporting to the SA. The Administrator stated that incidents with injuries or serious injuries must be reported to the state within two hours and characterized this incident as not involving serious injuries but still subject to the two-hour reporting requirement. The Administrator confirmed the initial report to the SA was made at 8:50 PM and acknowledged, after reviewing the facility policy, that the incident should have been reported within two hours.
Infection Control Deficiencies in Linen Handling, PPE Use, and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed by surveyors. One issue involved the improper handling of clean linens. A Nursing Support Aide was observed transporting clean linens in the hallway without using a covered cart, which is against federal regulations that require linens to be handled in a manner that prevents the spread of infection. The Nursing Home Administrator acknowledged the oversight, noting that the change in linen handling practices might have contributed to the lapse. Another deficiency was noted in the use of Enhanced Barrier Precautions (EBP) for a resident. A Certified Nursing Assistant was observed donning personal protective equipment (PPE) before entering a resident's room but removing it outside the room, contrary to the facility's policy and CDC guidelines, which require PPE to be removed inside the room to prevent contamination. The Director of Nursing admitted that the current practice did not align with the facility's policy and acknowledged the potential risk of infection transmission. Additionally, poor hand hygiene practices were observed during medication administration. A Licensed Practical Nurse failed to perform hand hygiene before and after gloving and did not cleanse the injection site with an alcohol pad before administering insulin to a resident. The nurse admitted to the oversight, citing nervousness as a reason for the lapse. The Director of Nursing was aware of these deficiencies and expected staff to adhere to infection control procedures.
Inadequate Restorative Services for Residents
Penalty
Summary
The facility failed to provide appropriate restorative services to maintain or improve the range of motion (ROM) and mobility for four residents, as required by their care plans. Resident 25, who was diagnosed with arthritis, was supposed to receive restorative services at least three times per week but only participated in the program on a limited number of days over several months. During the survey period, the resident was not observed participating in any restorative services, and she reported inconsistencies in receiving the exercises from the Restorative Aide. Resident 26, diagnosed with muscular dystrophy, had a care plan that lacked specific frequency and duration for restorative services. The resident participated in the program sporadically, and during the survey period, was not observed receiving any restorative services. The resident expressed a desire for more frequent exercises to maintain his abilities and had previously communicated this to the nursing staff without any changes being made. Residents 30 and 31 also experienced deficiencies in their restorative care. Resident 30, with a history of osteoarthritis and blood clots, was supposed to receive daily exercises but participated infrequently. Resident 31, diagnosed with Parkinson's disease, was to receive services five times per week but similarly had limited participation. The facility's Director of Nursing confirmed the lack of a Restorative Services Policy and acknowledged staffing issues, including the part-time schedule of the Restorative Aide, which contributed to the inconsistency in providing the necessary services.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by the actions of a Certified Nursing Assistant (CNA) and an altercation between residents. One resident, who was admitted with Alzheimer's dementia and severe impaired cognition, was verbally abused by a CNA. The CNA threatened to physically carry the resident out of the room if they did not comply with the CNA's demands. This incident was reported by another resident with intact cognition, who witnessed the CNA's behavior and reported it to another staff member. Despite the report, the facility did not take adequate steps to protect the resident from further verbal abuse. In another incident, a resident was not protected from physical abuse during an altercation with another resident. The aggressor grabbed the victim's walker and physically assaulted them by swinging and hitting them. Although staff intervened, the victim expressed fear and chose to stay in their room to avoid further interactions. The Director of Nursing and the Nursing Home Administrator acknowledged that the facility's policy for preventing abuse was not followed, resulting in the residents not being adequately protected from abuse.
Failure to Report Abuse and Resident Altercations
Penalty
Summary
The facility failed to report two incidents of potential misconduct to the State's Office of Caregiver Quality (OCQ) via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incidents. The first incident involved a Certified Nursing Assistant (CNA) who threatened a resident with severe cognitive impairment by stating that the CNA would throw the resident over her shoulder if the resident did not comply with her instructions. This incident was reported by another resident with intact cognition, who witnessed the event and expressed fear for the threatened resident. Despite the seriousness of the threat, the facility did not report the incident to the state agency, and the CNA continued to provide care to the resident involved. The second incident involved a resident-to-resident altercation where one resident grabbed another resident's walker and swung at them, hitting and grabbing their wrist. The facility's nursing progress notes documented the altercation, but there was no evidence that the incident was reported to the state agency or that a supervisor was notified. Interviews with staff revealed a lack of clarity on the reporting process for such incidents, with some staff indicating they would only report severe incidents to a supervisor. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) were unaware of some of the incidents due to a failure in the reporting process. The facility's policy required immediate reporting of such incidents to the administration and the state agency, but this was not followed. The NHA admitted to not considering the incidents as abuse concerns and was unaware that the CNA continued to work with the resident involved in the first incident. The lack of reporting and failure to follow facility policy contributed to the deficiency identified by the surveyors.
Failure to Investigate Abuse Allegations and Protect Residents
Penalty
Summary
The facility failed to ensure that allegations of verbal and physical abuse were thoroughly investigated and that residents were protected during the investigation process. Specifically, a Certified Nursing Assistant (CNA) was accused of verbally abusing a resident with severe cognitive impairment, yet the CNA continued to work with the resident during the investigation. The facility's policy required immediate action to protect residents from potential abuse, but this was not followed, as evidenced by the CNA's continued interaction with the resident and the lack of a clear investigation completion date. Additionally, the facility did not conduct thorough investigations into multiple incidents involving a resident with a history of aggressive behavior. This resident, who had severe cognitive impairment, was involved in several altercations with other residents, yet there was no documentation of a proper investigation or identification of affected residents. The facility's policy required staff to report such incidents and conduct thorough investigations, but this was not done, leading to a lack of preventative measures to avoid further incidents. Interviews with staff revealed a lack of awareness and communication regarding the incidents and the necessary steps to address them. The Director of Nursing and Social Worker were unaware of some incidents, and the Nursing Home Administrator did not consider certain incidents as abuse concerns. This lack of communication and adherence to policy contributed to the failure to protect residents and thoroughly investigate allegations of abuse.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessments within the required 14 days of completion for three residents, resulting in a deficiency. Resident 40 had two quarterly MDS assessments completed on 10/02/24 and 12/31/24, neither of which were transmitted to the Centers for Medicare & Medicaid Services (CMS) by the survey's end on 02/20/25. Similarly, Resident 47 had a Prospective Payment System (PPS) discharge assessment completed on 11/08/24 and a quarterly MDS completed on 12/23/24, both of which were not transmitted. Resident 31 also had two quarterly MDS assessments completed on 10/02/24 and 12/31/24 that were not submitted. These assessments were marked as completed but were not transmitted or accepted by CMS. The deficiency was identified through record reviews and interviews conducted by the surveyor. During the interview, the Medical Records staff member stated that the MDS assessments were not transmitted because the residents were either self-pay or on a Medicare Advantage Plan. The Nursing Home Administrator confirmed that the non-transmission was due to the payor source. The surveyor advised the administrator to refer to the Resident Assessment Instrument manual and F640 regulation, highlighting the requirement to transmit MDS data regardless of the payor source.
Inadequate Supervision and Safety Hazards in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. Resident R13, who has spastic quadriplegic cerebral palsy and muscle weakness, was left unattended while connected to mechanical lift equipment. The surveyor observed R13 in his room, seated in a broda chair with a mechanical lift sling positioned under him and attached to the lift, without any staff present. This situation persisted for six minutes until a Certified Nursing Assistant (CNA) returned with another CNA to assist with the transfer. The Director of Nursing (DON) expressed concern over this practice, acknowledging that it could have resulted in harm from entrapment. Resident R35, who has severe cognitive impairment and a history of aggressive behavior, did not receive increased supervision to prevent resident-to-resident altercations. Despite multiple incidents of aggression and altercations with other residents, there was no documentation of new interventions or increased supervision being implemented. The incidents included R35 yelling and kicking a table, attempting to hit another resident, and grabbing another resident's walker. Interviews with staff revealed that while they attempted to monitor R35, they were often unable to provide consistent supervision due to other responsibilities. The facility's failure to implement adequate supervision and interventions for R35's aggressive behavior was acknowledged by the DON, who admitted that 1:1 supervision was not feasible due to staffing limitations. This lack of supervision and intervention left other residents vulnerable to potential harm from R35's actions. The surveyor's review of documentation confirmed that no new measures were put in place to address the ongoing safety concerns related to R35's behavior.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, as surveyors observed 4 errors out of 35 medication opportunities, resulting in an error rate of 11.4%. This deficiency affected two residents during the medication administration process. One resident, who was admitted with a diagnosis of type 2 diabetes mellitus, received two insulin injections using pens that were not primed before administration. The Licensed Practical Nurse (LPN) responsible for administering the insulin did not follow the manufacturer's instructions or the facility's procedure for priming the insulin pens, leading to the improper administration of insulin. Another resident also received insulin from a pen that was not primed before administration. The LPN administering the insulin failed to prime the Humalog insulin pen with 2 units before preparing the prescribed dose. Additionally, the surveyor noted that the Humalog pen used did not have an open date or expiration date label. The Director of Nursing (DON) acknowledged that there had been previous training on insulin pen usage and expressed an expectation that staff should prime the pens before use, indicating a lapse in adherence to proper procedures by the nursing staff.
Improper Labeling and Storage of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling and storage of insulin pens, which is a violation of accepted professional practices. During a medication storage tour, a surveyor observed an insulin pen for a resident with type 2 diabetes mellitus that was not labeled with an opened date and was not refrigerated. The insulin pen, Tresiba FlexTouch, was found in the medication cart drawer without the required labeling, which is necessary to track its usage within the 28-day period after opening. The registered nurse responsible for the medication admitted to forgetting to date the pen when it was initially opened, acknowledging the requirement for labeling. In another instance, a surveyor observed an LPN administering a Humalog insulin pen to a resident without an open date or expiration date label. When questioned, the LPN was unsure of the correct procedure and admitted that the insulin should have been discarded and replaced with a new one. This lack of proper labeling and adherence to protocol for insulin administration could potentially affect the effectiveness of the medication for the residents involved.
Failure to Investigate Resident Altercation and Implement Protective Measures
Penalty
Summary
The facility failed to conduct a thorough investigation of a resident-to-resident altercation, as required by their policy. The incident involved a resident with a diagnosis of cerebral vascular accident and aphasia, who has a moderate cognitive impairment. This resident became upset after being unable to locate the TV remote and subsequently threw items off a dining table and squeezed another resident's hand. The facility's policy mandates that all resident witnesses or victims should be interviewed as part of the investigation, but this was not done. Additionally, the facility did not provide evidence of increased supervision for the involved resident for 48 hours following the incident, as per their report. There was also a lack of staff education following the incident to prevent further potential abuse. The Nursing Home Administrator confirmed that interviews with resident witnesses did not occur, and there was no documentation of increased supervision or staff education, indicating a failure to implement necessary interventions to protect residents during the investigation process.
Inadequate Supervision for Resident Elopement Risk
Penalty
Summary
The facility failed to ensure adequate supervision to reduce the risk of wandering or elopement for a resident who left the facility without staff's knowledge. The resident, who had severe cognitive impairment and was admitted with diagnoses including hemiplegia and aphasia, was not added to the facility's Wanderer's List for increased supervision after the incident, as required by the facility's policy. The resident's care plan did not include interventions for wandering or elopement risk, and no risk assessment for wandering or elopement was noted in the medical record prior to the incident. The facility's Interdisciplinary Team (IDT) reviewed the incident and determined that the resident was upset about a chair being moved, which led to the elopement. Despite this, the IDT decided not to add the resident to the Wanderer's List or implement additional safety measures like a Wanderguard, as they assessed the resident not to be at risk for future wandering. The Director of Nursing and Nursing Home Administrator acknowledged that the resident should have been added to the Wanderer's List after the incident, recognizing a lapse in following the facility's policy.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 100 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sparta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morrow Memorial Home | 0.4 mi | ★★★★★ | 0 | 0 |
| Lakeview Health Center | 13.3 mi | ★★★★★ | 2 | 0 |
| Mulder Health Care Facility | 13.8 mi | ★★★★★ | 8 | 0 |
| Tomah Nursing And Rehab | 14.8 mi | ★★★★★ | 20 | 1 |
| Norseland Nursing Home | 19.9 mi | ★★★★★ | 0 | 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.