Rolling Hills Rehab: Medication & Safety Failures - WI
The nurse told the inspector these insulin pens didn't need to be primed. She was wrong.
Federal inspectors found a pattern of medication and safety failures at Rolling Hills Rehab Center during a February inspection that affected multiple residents. Nurses repeatedly failed to follow basic insulin administration protocols, left a quadriplegic resident unattended while suspended in mechanical lift equipment, and failed to prevent an aggressive resident from attacking other residents four separate times.
The insulin violations alone created an 11.4 percent medication error rate — more than double the federal limit of 5 percent.
Manufacturer instructions for Basaglar Kwikpen insulin require priming before each injection to ensure accurate dosing. "If you do not prime before each injection, you may get too much or too little insulin," the instructions warn. The facility's own policy requires nurses to "prime pen with 2 units" and look for "drop of insulin at needle tip."
But on February 18, inspectors watched LPN J skip the priming step entirely for resident R11's morning insulin doses. When asked about priming, the nurse insisted the pens didn't require it.
Director of Nursing B later told inspectors she expected staff to prime insulin pens before injections. She acknowledged awareness that LPN J "did not understand the need to prime insulin pens prior to injecting insulin." The facility had provided insulin pen training in December 2022 — more than two years earlier.
Another nurse, LPN G, made the same error while administering Humalog insulin to resident R39. When questioned, LPN G admitted forgetting to prime and acknowledged "should have primed the Humalog insulin pen with 2 units and discard the 2 units first."
The insulin problems extended beyond priming failures. Inspectors found insulin pens without required opening dates, making it impossible to determine if the medication remained effective. Both residents R29 and R39 received insulin from improperly labeled pens.
R29's Tresiba FlexTouch insulin pen sat in the medication cart opened but undated. Registered Nurse K admitted she "forgot to date it when it was originally opened." Insulin pens must be discarded after 28 days once opened to ensure effectiveness.
LPN G gave R39 Humalog insulin from a pen with no opening date. When asked about this, the nurse said, "That is a good question. I guess I would figure out when the pen was opened before giving to [R39]." She admitted she probably should have discarded the undated insulin and obtained a new pen, "but LPN G did not."
The medication errors occurred alongside infection control violations. LPN J failed to wash her hands before putting on gloves, performed finger stick blood tests on two residents, then removed her gloves and immediately handled insulin pens without hand hygiene. She also skipped cleaning the injection site with alcohol before injecting insulin into R11's abdomen.
"I did not do it, you make me nervous," LPN J told the inspector when questioned about hand hygiene. She acknowledged usually cleaning injection sites with alcohol but said, "I just forgot."
More serious safety violations involved mechanical lift equipment. On February 18, inspectors found resident R13 alone in his room, seated in a broda chair with a mechanical lift sling positioned under him and attached to the lift. No staff member was present.
R13 has spastic quadriplegic cerebral palsy and muscle weakness. His assessment shows moderate cognitive impairment requiring supervision and complete dependence for transfers.
The inspector watched for six minutes as R13 remained unattended while connected to the mechanical lift. CNA C eventually returned from another hallway, checked the sling attachment, looked both ways in the hallway, then returned to the still-suspended resident.
Another CNA finally arrived to help complete the transfer at 12:53 PM.
FDA safety guidance for patient lifts states clearly: "Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes."
CNA C told inspectors she was waiting for help with the two-person transfer but acknowledged this wasn't common practice. Director of Nursing B called the situation disappointing and concerning, saying it "could have resulted in harm from entrapment."
The facility's most troubling safety failure involved resident R35, who has dementia and a history of aggressive behavior toward staff and other residents. Despite four documented attacks between June 2024 and January 2025, staff never implemented adequate supervision measures.
The incidents escalated over time. On June 22, 2024, R35 "yelled at resident across the table" during dinner, "kicked the table and was swearing," then "came up behind" another resident "and hit the back of the chair hard." The victim "got up with his walker and went to his room" frightened.
By September 16, nurses documented that R35 "walked by another resident and apparently swung as to hit him but did not." Staff noted difficulty providing care "even with two staff" but made no changes to supervision.
On January 10, 2025, R35 "attempted to pick up a chair as if he was going to throw it" during dinner, then later "grabbed another resident by the wrist and staff intervened before he could hurt the resident."
The final documented incident occurred January 27, when R35 "grabbed [R36] walker during supper" and "grabbed [R36]." The victim responded by threatening to "punch him" if R35 grabbed him again. That same evening, R35 "swung his hand on the CNA hitting the CNA on the chest."
Resident R36 told inspectors about the dining room attack: "Yes, with [R35]! Who has not had an altercation with [R35]. One time [R35] came at me in the dining room, but I put him in his place. I yelled to tell him not to ever touch me again or I'd punch him."
CNA F acknowledged difficulty monitoring residents like R35, saying "sometimes CNA F is in rooms taking care of other residents and can't always monitor." LPN G admitted trying to observe R35 "from afar while in the common area" but said "that is not always feasible when LPN G has to go into other rooms to pass medications."
Director of Nursing B acknowledged the facility failed to provide adequate supervision for R35. When asked about implementing one-on-one supervision after the incidents, she said staff "probably not 1:1 as we do not have enough staff to be 1:1 at this time." She admitted "increased supervision was not provided for R35 to prevent incidents with other residents."
The facility also failed its restorative therapy program, which helps residents maintain physical abilities. Four residents with conditions including arthritis, muscular dystrophy, osteoarthritis, and Parkinson's disease received far fewer therapy sessions than their care plans required.
Resident R25, admitted with arthritis in May 2024, declined from needing partial assistance with transfers to requiring substantial assistance by January 2025. Her care plan called for restorative services three times weekly, but she received them only 6 days in December 2024, 5 days in January 2025, and 5 days through February 20.
"I am supposed to receive exercises with Restorative Aide L, three times per week, but sometimes she doesn't come at all," R25 told inspectors.
R30, who has osteoarthritis and chronic pain, received restorative services aimed at maintaining transfer ability. His care plan called for daily exercises, but he received them only 5 days in October 2024, 7 days in November, 9 days in December, and 7 days in January.
"No, not too much. Not even once a week. I want to be able to transfer and stand," R30 told inspectors about his therapy sessions.
The facility's sole restorative aide worked only Thursdays, Fridays, and every other weekend. She told inspectors she often got "pulled to work on the floor as a CNA a lot" — about one day per week. With approximately 13 residents needing restorative services, she admitted it was "difficult to complete the restorative program."
Director of Nursing B acknowledged the aide's schedule had been reduced to part-time and said the facility was "working on a plan to have more than one restorative aide." She confirmed the facility lacked a written policy for restorative services.
Infection control violations extended beyond medication administration. Staff transported clean linens through hallways on uncovered carts, and improperly removed personal protective equipment while caring for a resident on enhanced barrier precautions.
The inspection covered all areas of care at the 50-bed facility. Federal inspectors returned to Rolling Hills Rehab Center on February 20, 2025, to complete their review of the facility's compliance with federal safety and care standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rolling Hills Rehab Ctr from 2025-02-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ROLLING HILLS REHAB CTR in SPARTA, WI was cited for violations during a health inspection on February 20, 2025.
The nurse told the inspector these insulin pens didn't need to be primed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.