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Complaint Investigation

Rolling Hills Healthcare And Rehabilitation Center

September 16, 2025 · Millmont, PA · 17350 Old Turnpike Road
Citations 2
CMS Rating 4/5
Beds 57
Provider ID 395614
Healthcare Facility
Rolling Hills Healthcare And Rehabilitation Center
Millmont, PA  ·  View full profile →
Inspection Summary

ROLLING HILLS HEALTHCARE AND REHABILITATION CENTER in MILLMONT, PA — inspection on September 16, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0583
Resident Rights Deficiencies
Potential for More Than Minimal Harm

Review of an incident investigation dated September 5, 2025, revealed that Employee 3 (nurse aide) reported to the Director of Nursing that Employee 5 (nurse aide) sent an electronic private message with a picture attachment of Resident 3. Resident 3's face was obscured by a filtering program; however, Employee 3 was able to identify that it was a facility resident.

Statements obtained by the facility during the investigation determined that Employee 5 sent the same photo to Employee 4 (nurse aide).

The facility substantiated that Employee 5 took and disseminated a photo of Resident 3 who was incapable of giving consent to be photographed.

Interview with the Nursing Home Administrator on September 16, 2025, at 3:15 PM confirmed the above findings. 28 Pa.

Code 201.18(b)(2)(e)(1) Management 28 Pa.

Code 201.29(a) Resident rights

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/16/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare and Rehabilitation Center

17350 Old Turnpike Road Millmont, PA 17845

SUMMARY STATEMENT OF DEFICIENCIES

Based on clinical record review and staff interview, it was determined that the facility failed to provide treatment and services for an indwelling urinary catheter as ordered by the physician for one of one resident reviewed for urinary catheter concerns (Resident 1).Findings include: Clinical record review for Resident 1 revealed physician orders to maintain a coude foley catheter (flexible tubing inserted into the bladder to drain urine; a coude catheter is equipped with a bent tip to allow passage beyond obstructions such as the prostate gland) for obstructive uropathy (blockage in the urinary system that hinders urine flow; commonly an enlarged prostate) as follows: 24 French (scale where one French unit corresponds to approximately 0.33 millimeters in diameter) coude foley with 10 cc (cubic centimeters, one cc equals one milliliter) balloon changed monthly every 30 days and as needed for blockage or obstruction.

This may only be changed by the registered nurse (dated May 31, 2025, to August 29, 2025). 24 French coude foley with 30 cc balloon changed monthly every 30 days and as needed for blockage or obstruction.

This may only be changed by the registered nurse (dated August 29, 2025).

Review of Resident 1's treatment administration record dated July 2025 revealed that Employee 1 (licensed practical nurse) documented that he changed Resident 1's coude catheter on July 30, 2025 (although Resident 1's physician order stipulated that the registered nurse complete the treatment).

Review of Resident 1's treatment administration record dated August 2025 revealed that Employee 6 (registered nurse) changed Resident 1's coude catheter on August 8, 2025.

Nursing documentation by Employee 6 dated August 8, 2025, at 10:02 PM indicated that changing Resident 1's coude catheter was effective for blockage/obstruction.

Nursing documentation dated August 29, 2025, at 9:59 AM revealed that the Director of Nursing changed Resident 1's catheter for monthly change. Resident 1's clinical record did not contain evidence of a complication (e.g., blockage or obstruction) that warranted changing the indwelling catheter sooner than 30 days from the previous change (that occurred on August 8, 2025).

Nursing documentation by Employee 2 (licensed practical nurse) dated April 30, 2025, at 2:03 PM reiterated that a registered nurse changed Resident 1's coude catheter on August 29, 2025.

The facility failed to ensure that Resident 1's physician ordered treatment for his indwelling urinary catheter was completed by the appropriate licensed staff at the appropriate schedule.

Interview with the Nursing Home Administrator on September 16, 2025, at 3:15 PM confirmed the above findings. 28 Pa.

Code 211.12(d)(1)(5) Nursing services

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MILLMONT, PA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from ROLLING HILLS HEALTHCARE AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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