NEW ALBANY, IN - Federal inspectors discovered Rolling Hills Healthcare Center failed to provide proper wound care for a resident with severe pressure ulcers, including missed treatments and inadequate monitoring despite active infections requiring antibiotics.
Stage 4 Pressure Ulcer Management Failures
The May 2025 inspection revealed significant lapses in care for a 53-year-old resident with a Stage 4 pressure ulcer on the sacrum and a Stage 3 pressure ulcer on the right hip. Records showed the sacral wound measured 4.5 cm in length, 1.2 cm in width, and 2 cm in depth at the time of inspection, with exposed bone and tissue visible.
The facility failed to complete ordered wound assessments and dressing changes on multiple dates throughout April and May 2025. Documentation showed missed treatments for the right thigh wound on April 7, 11, 23, May 2, and May 3. The sacral wound care was not completed on April 9, 28, and May 2, despite physician orders requiring daily treatment.
Stage 4 pressure ulcers represent the most severe category of pressure injury, involving full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds require meticulous daily care to prevent life-threatening complications including sepsis, osteomyelitis, and systemic infection. The depth of tissue damage in Stage 4 ulcers means healing can take months or years, making consistent treatment essential.
Vital Sign Monitoring Failures Despite Infection Risk
The resident's physician ordered vital signs to be obtained every shift for 72 hours, then daily to establish baselines. However, the last recorded blood pressure was January 28, 2025, at 95/66 mmHg - dangerously low readings that warranted immediate attention. No vital signs were documented for over three months despite this being a required intervention in care plans for both skin impairment and osteomyelitis.
Vital sign monitoring becomes critical when managing infected wounds and osteomyelitis. Blood pressure, temperature, and pulse readings provide early warning signs of sepsis or worsening infection. The absence of this basic monitoring for months prevented staff from detecting potentially dangerous changes in the resident's condition.
Infection Development and Treatment Gaps
On April 2, nursing staff documented green drainage and a "very strong foul odor" from the sacral wound - clear signs of bacterial infection. The wound culture resulted in prescriptions for Doxycycline and later Amoxicillin antibiotics. Despite active infection requiring antibiotic therapy, wound care documentation remained inconsistent.
Green drainage typically indicates Pseudomonas aeruginosa infection, a dangerous bacterium that thrives in wound environments and can cause rapid tissue destruction. The foul odor suggests anaerobic bacteria presence, often indicating deep tissue infection. These infections can progress to bacteremia and septic shock without proper treatment.
Pressure Relief Equipment Mismanagement
The resident's low air loss mattress, a specialized pressure-redistributing surface essential for healing Stage 4 ulcers, was removed on April 22 after the resident expressed discomfort. However, the order remained active on the electronic medication administration record, with staff falsely documenting checks "every shift for proper placement and function" even after the mattress removal.
Low air loss mattresses reduce interface pressure between the body and support surface through continuous air flow, decreasing moisture and maintaining optimal pressure distribution. For Stage 4 ulcers, these specialized surfaces are considered standard care. Their removal without physician consultation or alternative interventions violates basic wound care protocols.
New Pressure Injury Development
Despite existing severe wounds, the resident developed a new pressure injury to the right hip, first documented February 28, 2025. Initially unstageable, this wound progressed to Stage 3 by April, measuring 1.1 cm by 1.6 cm by 1.7 cm deep by May. Staff suspected the resident's previous wheelchair caused this injury, though the wheelchair had been replaced.
The development of new pressure injuries while under care indicates systemic failures in prevention protocols. Proper repositioning schedules, pressure mapping, and equipment assessment should prevent new wound formation. The progression from unstageable to Stage 3 over two months demonstrates inadequate intervention despite known risk factors.
Documentation and Assessment Failures
Multiple documentation gaps compromised care continuity. Daily wound assessments required by physician orders were not recorded on five separate dates in April and May. Dressing changes lacked proper dating, preventing staff from knowing when treatments were last completed. The Braden Scale assessments, used to evaluate pressure ulcer risk, incorrectly showed "low risk" scores despite the resident having multiple severe wounds.
Accurate documentation drives clinical decision-making in wound care. Missing assessments prevent identification of deterioration or improvement trends. Undated dressings risk leaving wounds unchanged beyond safe intervals, increasing infection risk. Incorrect risk assessments lead to inadequate preventive measures.
Blood Sugar Management Crisis
The inspection also revealed dangerous failures in diabetes management for another resident. Blood sugar readings exceeded 400 mg/dL on multiple occasions, reaching 502 mg/dL twice on April 30. Standing orders required physician notification for readings above 400 and blood sugar rechecks within 30 minutes of insulin administration. Neither requirement was consistently met.
Blood glucose levels above 400 mg/dL indicate severe hyperglycemia requiring immediate intervention. Sustained levels above 500 mg/dL can trigger diabetic ketoacidosis or hyperosmolar hyperglycemic state - both medical emergencies with high mortality rates. The facility's failure to recheck blood sugars after insulin administration risked dangerous hypoglycemic episodes.
Kitchen Sanitation Violations Affecting All Residents
Dietary services violations affected all 93 residents receiving meals. Inspectors found expired milk dated five days past expiration being used for mashed potatoes, leftover fish kept six days beyond safe consumption limits, and a refrigerator maintaining unsafe temperatures at 50 degrees Fahrenheit. Dust covered ventilation systems above food preparation areas, with one vent hanging loose from the ceiling.
Food safety violations create widespread infection risks in nursing homes where residents have compromised immune systems. Consuming expired dairy products can cause severe gastrointestinal illness. Fish kept beyond three days develops dangerous histamine levels causing scombroid poisoning. Temperatures above 40 degrees Fahrenheit allow rapid bacterial multiplication in stored foods.
Systemic Quality Failures
These violations represent fundamental breakdowns in basic nursing care. The facility demonstrated inability to complete physician-ordered treatments, maintain accurate documentation, prevent new injuries in high-risk residents, and ensure food safety. The pattern suggests inadequate staffing, poor supervision, and absent quality assurance processes.
Federal regulations require nursing homes to provide services meeting professional standards of quality. The documented failures at Rolling Hills Healthcare Center violated multiple federal requirements including pressure ulcer prevention and treatment standards, documentation requirements, and food safety regulations. These deficiencies placed vulnerable residents at risk for serious harm including sepsis, further tissue damage, and foodborne illness.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rolling Hills Healthcare Center from 2025-05-08 including all violations, facility responses, and corrective action plans.
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