Rolling Hills Rehab Ctr
Rolling Hills Rehab Ctr in Sparta, WI — inspection on February 20, 2025.
Found 11 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.
Inspection Findings
Example 2
On 02/17/25, Surveyor's review of R35's medical record discovered a nursing progress note which notes the following: Nurse progress note states: .On 01/28/2025 at 4:38 PM, Late Entry for: 01/27/2025. DATE OF INCIDENT: 01/27/2025, TIME OF INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time.
Resident was grabbing at [R36's] walker during supper, [R36] tried to stop him by talking loudly. [R35] grabbed [R36]. [R36] stated if he grabs him again, he was going to, punch him.
Staff had intervened.
At 4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart from each other. At 10:13 PM, [R35] was aggressive and combative at the beginning of the shift.
Resident was found in another resident's room and will not follow redirection from the CNA.
Instead, he swung his hand on the CNA hitting the CNA on the chest .
On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, Yes, [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.
Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36 hitting R36 and grabbing R36's wrist.
Surveyor asked if R36 was injured. R36 indicated that he was not injured but, R35 is very strong, and it did frighten me.
Staff intervened and R36 grabbed walker and went to room. R36 indicated that R36 tends to stay in room more now because R36 doesn't want those interactions with R35 again. R36 indicated that R35 has outbursts all the time in the dining room. R36 indicated that R36 dislikes that kind of aggressive behavior and mostly stays in room because of the outbursts.
On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident to resident altercations and how residents are protected from abuse.
DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any potential verbal or physical abuse.
On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A asking NHA A how residents are protected from abuse.
Surveyor indicated to NHA A that the incident with R43 was verbal abuse.
Surveyor indicated to NHA A that the incident with R36 did in fact happen, R36 was grabbed and hit by R35 which is physical abuse.
Surveyor asked NHA A if NHA A thought abuse concerns from R35 had occurred. NHA A indicated that residents were not protected from abuse by not following through on the facility policy. NHA A indicated that everyone should be following the facility policy for abuse.
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Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656
supervisor. RN H indicated that RN H is the supervisor on nights but should be reporting to DON B the
supervisor know when supervisor is available is the appropriate measures.
On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what the expectations are for resident-to resident altercations and how are potential abuse concerns handled with staff to resident incidents. DON B indicated that staff follow facility policy and staff should let DON B, NHA A, or Social Worker I know about any incidents that are a concern for potential verbal or physical abuse. DON B said DON B was unaware of some of the incidents since nursing staff did not report these except for the more recent ones that occurred this year.
On 02/20/25 at 8:14 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked why facility did not report a few of the incidents of potential verbal and physical abuse concerns from staff to resident involving R43 and then R36 and then resident to resident altercations from R35 to the state. NHA A stated that usually staff report incidents and then between NHA A, DON B, and Social Worker I, us three decide the importance of the complaint and start a proper investigation if it's needed, and then report to state regulatory agency if needed. NHA A indicated that NHA A did not think the incidents with R43 or R36 were considered abuse concerns.
Surveyor indicated to NHA A that the incident with R43 had concerns with verbal abuse, and CNA D even admitted to verbally saying the threat to R43 and that she continued to work with R43 and other residents before investigation was complete. NHA A indicated that CNA D was joking, but that NHA A didn't realize CNA D continued to work with R43.
Surveyor asked NHA A if NHA A thought that some of the physical abuse concerns from R35 unto another unknown resident on Birchwood was concerning. NHA A indicated that NHA A was unaware of some of the incidents and that staff did not report this to administration. NHA A indicated that everyone should be following the facility policy for misconduct.
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facility did not thoroughly investigate the incidents of potential verbal, physical abuse concerns from
indicated to NHA A that the incident with R43 had concerns with verbal abuse, and CNA D admitted to
investigation was complete. NHA A indicated that CNA D was joking, but that NHA A didn't realize CNA D continued to work with R43.
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with MDS transmissions. MR M was provided a list of the residents above and asked for proof of
At 10:38 AM, MR M stated that the MDS assessments were not completed because those residents
A if there are more questions.
On 02/19/25 at 1:10 PM, Surveyor interviewed NHA A and asked why the MDS's were not transmitted. NHA A stated it was due to payor source.
Surveyor encouraged NHA A to visit chapter 5 of the Resident Assessment Instrument manual and F-F640 regulation. NHA A stated they will transmit them all from now on.
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stated, If a frequency is not identified, ideally residents would receive restorative services daily, so
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Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656
INCIDENT: 17:12, INJURY: no apparent injury There was an altercation during supper time. Resident
4:39PM, Today there was no further altercations between [R35] and [R36], they were kept apart
Resident was found in another resident's room and will not follow redirection from the CNA.
Instead, he swung his hand on the CNA hitting the CNA on the chest .
Surveyor did not find any new intervention or increased supervision for R35 or 1:1 after R35 grabbed R36's walker and grabbed R36.
Interviews: On 02/19/25 at 10:25 AM, Surveyor interviewed R36 and asked R36 if there have been any resident-to-resident altercations that have occurred on the unit. R36 stated, 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.
Surveyor asked R36 to explain the incident in the dining room with R35. R36 indicated that R35 came at R36 and grabbed R36's walker and then swung at R36, hitting R36 and grabbing R36's wrist.
On 02/19/25 at 10:30 AM, Surveyor interviewed CNA F and asked how CNA F supervises difficult residents that may wander into others' rooms or become aggressive. CNA F indicated that CNA F tries to monitor residents such as R35 from becoming angry and wandering but sometimes CNA F is in rooms taking care of other residents and can't always monitor.
On 02/19/25 at 11:27 AM, Surveyor interviewed Licensed Practical Nurse (LPN) G and asked LPN G what is LPN G's process when there is an altercation between a resident to resident or if there is an incident that happens with a resident that may need extra supervision. LPN G indicated LPN G will intervene if LPN G observes the resident-to-resident altercation. LPN G would try to redirect R35 or any other resident who is aggressive and acting out.
Surveyor asked LPN G if LPN G does any kind of extra supervision for R35's outbursts. LPN G indicated that LPN G will try to observe from afar while in the common area.
Surveyor asked LPN G how LPN G intervenes if R35 is from afar in the common area and R35 is about to swing at another resident. LPN G indicated that LPN G tries to make sure R35 is within close proximity but that is not always feasible when LPN G has to go into other rooms to pass medications.
On 02/20/25 at 8:02 AM, Surveyor interviewed Director of Nursing (DON) B and asked what interventions for increased supervsion are in place for R35 due to his aggressive behaviors towards staff and residents.
DON B indicated that sometimes staff will keep a close eye on R35 in the common area and kind of perform a 1:1.
Surveyor asked DON B to explain what 1:1 means. DON B indicated that 1:1 means there is an actual staff member designated to 1:1 with R35 and staff do not let R35 out of sight.
Surveyor asked DON B if 1:1 was utilized on 06/22/24, 09/16/24, 01/10/25, and 01/28/25. DON B indicated that DON B was unsure, but that DON B doubts it since some of these events occurred.
Surveyor indicated to DON B that through review of documentation that Surveyor could not find that R35 was 1:1. DON B indicated that R35 was probably not 1:1 as we do not have enough staff to be 1:1 at this time. DON B acknowledged that increased supervision was not provided for R35 to prevent incidents with other residents.
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insulin pens did not need to be primed.
Surveyor observed LPN J administer the insulins
On 2/18/25 at approximately 8:30 AM, Surveyor interviewed Director of Nursing (DON) B on the type
training on how to use an insulin pen in Dec. 2022. DON B reported her expectation would be that nursing staff prime the insulin pen prior to injecting a resident with insulin. DON B reported awareness of LPN J not understanding the need to prime insulin pens prior to injecting insulin.
Example 2 On 02/18/25 at 8:00 AM, Surveyor observed LPN G administer a Humalog insulin pen into R39's abdomen.
Surveyor did not observe an open date or expiration date label on the used Humalog pen.
Surveyor did not observe LPN G prime the Humalog insulin pen with 2 units before prepping 6 units into the insulin pen.
On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for priming and administering insulin. LPN G indicated that LPN G forgot to prime and should have primed the Humalog insulin pen with 2 units and discard the 2 units first before prepping the 6 units for R39's Humalog insulin.
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According to the Food and Drug Administration (FDA), insulin pens should be discarded 28 days after opening the pen to ensure effectiveness of the medication.
According to the American Diabetes Association, insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 and 86 degrees F for up to 28 days and continue to work.
After 28 days the insulin should be discarded.
On 3/29/21, R29 was admitted to the facility with a diagnosis including type 2 diabetes mellitus.
R29's orders included Tresiba FlexTouch/ Insulin Deglu[DATE]u/ml Solution Pen-injector Dose 45 unit subcutaneous twice per day.
On 2/19/25 at 10:25 AM, during a tour of medication storage, with Registered Nurse (RN) K, Surveyor observed R29's insulin pen, Tresiba FlexTouch 100u/ml exp 8/31/26, pharmacy label reads, 45 units SQ BID, opened, not refrigerated, and not labeled with an opened date, in the drawer of the medication cart.
Surveyor interviewed RN K, who reports she forgot to date it when it was originally opened. RN verbalized understanding that insulin pens should be labeled with an opened-on date when they are taken out of the refrigerator and used within 28 days.
Example 2 On 02/18/25 at 8:00 AM, Surveyor observed Licensed Practical Nurse (LPN) G administer a Humalog insulin pen into R39's abdomen.
Surveyor did not observe an open date or expiration date label on the used Humalog pen.
On 02/18/25 at 8:05 AM, Surveyor interviewed LPN G and asked what LPN G's process is for administering insulin without an open date. LPN G stated, That is a good question. I guess I would figure out when the pen was opened before giving to [R39].
Surveyor asked LPN G was it the correct process to still give the Humalog insulin without an open date to R39. LPN G indicated that LPN G probably should have discarded the Humalog insulin and got another one, but LPN G did not.
after contact with blood, body fluid, mucous membranes, secretions, excretions and equipment or
must follow both application and removal of gloves.
The facility procedure document titled Insulin Injection, procedure reviewed date 2/25, states, in part, C.
Injection of Insulin .
- Take insulin alcohol pad to resident.
Wash hands, put on gloves.
- Cleanse injection site with alcohol pad.
Allow to dry before injecting. On 2/18/25 at 7:28 AM, during medication administration pass, Surveyor observed Licensed Practical Nurse (LPN) J apply gloves without using hand hygiene prior to gloving. LPN J obtained a finger stick blood sample for R27.
After performing the test, LPN J removed her gloves, did not sanitize or wash her hands and proceeded to move medication cart to the next resident's door.
On 2/18/25 at 7:32 AM, Surveyor observed LPN J put on gloves, without hand hygiene prior, and obtain a finger stick blood sample for R11. LPN J then removed her gloves, did not sanitize or wash her hands, removed 2 insulin pens from the medication drawer and administer the insulins subcutaneously into R11's abdomen. LPN J did not use an alcohol pad to cleanse injection site prior to injecting.
On 2/18/25 at 7:34 AM, Surveyor interviewed LPN J about hand hygiene practices, and she reported hand hygiene should be performed before and after gloving. LPN J stated, I did not do it, you make me nervous.
Surveyor also asked if she used an alcohol wipe on the injection site prior to injecting insulin. LPN stated she did not wipe R11's injection site with alcohol prior to administering insulin. I usually do, I just forgot.
On 2/18/25 at approximately 8:30 AM, Surveyor interviewed DON B. DON B reported her expectation would be that staff follow infection control procedures. DON B reported she is aware that LPN J did not follow appropriate infection control practices.
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F-F640 regulation. NHA A stated they will transmit them all from now on.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525430 B.
Wing 02/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656
During the survey period of 02/17/25-02/20/2025, Surveyor did not observe R25 participating in restorative services.
On 02/19/25 at 1:46 PM, Surveyor interviewed R25. R25 stated she participates in a restorative program to help strengthen her muscles. R25 reported she is supposed to receive exercises with Restorative Aide (RA) L, three times per week, but sometimes she doesn't come at all.
Example 2
R26 was admitted to the facility on [DATE] and diagnoses included muscular dystrophy. MDS assessment confirmed R26 scored 15/15 during BIMS, indicating intact cognition.
R26's MDS assessment completed on 01/22/25 indicated R25 is dependent on staff for all transfers.
R26's Restorative Aide Program documentation indicated restorative goal to prevent decline, contractures, and falls. GOAL: Participate in exercises and transfers to maintain ability to safely transfer and ambulate with staff assist. (Surveyor noted R26's restorative care plan did not include a frequency or duration).
R26's Restorative Aide Program documentation indicated R26 participated in restorative program as follows:
-10/2024, 13 of 31 days.
-11/2024, 8 of 30 days.
-12/2024, 4 of 31 days.
-01/2025, 7 of 31 days.
-02/2025, 3 of 20 days.
During the survey period of 02/17/25-02/20/2025, Surveyor did not observe R26 participating in restorative services.
On 02/17/25 at 10:40 AM, Surveyor interviewed R26. R26 stated he had not received his exercise program last week. R26 reported he usually receives exercise program once weekly, but stated twice weekly would be better for him to maintain his abilities. R26 stated he reported this to a nurse sometime this winter but had not received any updates related to frequency of his weekly exercises.
Example 3
525430
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 525430 B.
Wing 02/20/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Rolling Hills Rehab Ctr 14400 Cty Hwy B Sparta, WI 54656
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.