Rolling Hills Rehab: Wrong Dialysis Location - OH
Resident 51 at Rolling Hills Rehab and Care Center requires hemodialysis three times weekly — every Monday, Wednesday, and Friday — to survive. But the facility's care plan from April listed the wrong location for this life-sustaining treatment.
The resident suffers from an extensive list of serious conditions: respiratory failure, diabetes, chronic obstructive pulmonary disease, heart disease, kidney failure, schizophrenia, major depressive disorder, and borderline personality disorder. Despite these complex medical needs, she scored 15 on a cognitive assessment, indicating she remained mentally intact.
Her care plan specified that she "receives dialysis at (dialysis center) in St Clairsville on Monday, Wednesday, Friday at 10:30 A.M." The plan instructed staff to encourage her attendance at scheduled appointments and monitor for complications from the treatment.
Staff were directed to watch for signs of kidney problems — changes in consciousness, skin condition, and heart and lung sounds. They were also supposed to check her arteriovenous fistula, the surgically created connection that allows blood to flow during dialysis.
But when inspectors called the St. Clairsville dialysis center on July 30 at 7:30 a.m., staff there said Resident 51 no longer came to their facility. She hadn't received treatment there "for quite some time."
A follow-up call to a Bridgeport dialysis center confirmed the truth: Resident 51 had been receiving her treatments there instead.
When inspectors interviewed the resident herself that afternoon, she confirmed she attended dialysis in Bridgeport, not St. Clairsville.
The error meant nursing home staff were following outdated instructions about where to coordinate her care. For a patient requiring dialysis three times weekly, accurate location information is critical for ensuring she receives treatment and monitoring for complications.
Rolling Hills' own policy emphasizes the importance of accurate care planning. The facility's interdisciplinary team is "responsible for the development of an individualized comprehensive care plan for each resident," according to the undated policy document.
The team includes the resident, attending physician, registered nurse, social service worker, director of nursing, and others necessary to meet the resident's needs. The policy states care plans must be based on comprehensive assessments.
Federal regulations require facilities to develop complete care plans within seven days of assessment and keep them current through regular review and revision by health professionals.
The outdated dialysis location represented a failure to maintain accurate care plans, inspectors concluded. The error affected one of nine residents reviewed during the investigation at the 52-bed facility.
For Resident 51, the consequences of this administrative failure could extend beyond paperwork. Dialysis patients face serious risks when treatment is delayed or interrupted. Missing sessions can lead to dangerous fluid buildup, electrolyte imbalances, and potentially life-threatening complications.
The inspection occurred as part of a complaint investigation, though the care plan deficiency was discovered incidentally during the review. Inspectors classified the violation as causing minimal harm or potential for actual harm to few residents.
The case illustrates how seemingly minor documentation errors can have serious implications for patient safety in nursing homes. When care plans contain wrong information, staff cannot properly coordinate treatment or respond to emergencies.
Resident 51's multiple serious medical conditions make accurate care coordination especially important. Her combination of kidney failure, heart disease, respiratory problems, and mental health conditions requires careful monitoring and timely intervention when problems arise.
The dialysis schedule error also raises questions about how thoroughly the facility reviews and updates care plans. Federal inspectors found the plan dated from April, but the resident had apparently changed dialysis locations well before the July inspection.
Rolling Hills operates under regulations requiring nursing homes to maintain current, accurate care plans for all residents. The facility's interdisciplinary team process is designed to catch and correct such errors before they affect patient care.
The wrong dialysis location remained in Resident 51's official care plan despite her actual treatment occurring elsewhere for an extended period, suggesting gaps in the facility's review and update procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rolling Hills Rehab and Care Ctr from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Rolling Hills Rehab and Care Ctr
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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 14, 2026 · Our methodology
ROLLING HILLS REHAB AND CARE CTR in BRIDGEPORT, OH was cited for violations during a health inspection on August 11, 2025.
Resident 51 at Rolling Hills Rehab and Care Center requires hemodialysis three times weekly — every Monday, Wednesday, and Friday — to survive.
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.
Frequently Asked Questions
- What happened at ROLLING HILLS REHAB AND CARE CTR?
- Resident 51 at Rolling Hills Rehab and Care Center requires hemodialysis three times weekly — every Monday, Wednesday, and Friday — to survive.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in BRIDGEPORT, OH, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from ROLLING HILLS REHAB AND CARE CTR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 365559.
- Has this facility had violations before?
- To check ROLLING HILLS REHAB AND CARE CTR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.