Inspection Reports for Rocky Knoll Health Care Center
N7135 Rocky Knoll Pkwy, Plymouth, WI 53073, United States, WI, 53073
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
102% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to timely report an allegation of abuse involving two residents in the facility.
Complaint Details
The complaint investigation found that on 5/30/25, Resident 2 (R2) became agitated and grabbed Resident 1 (R1) in the dining room. The allegation of abuse was not reported to the State Agency until 6/1/25, exceeding the facility's policy requiring reporting within 2 hours. Interviews with multiple staff confirmed the incident and delay in reporting. No injuries were noted, but the incident had the potential to affect resident safety.
Findings
The facility failed to report an allegation of abuse timely to the State Agency for one resident after an incident where one resident hit another in the dining room. The incident was reported to the State Agency the day after it occurred, exceeding the required 2-hour reporting timeframe.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents sampled: 4
BIMS score: 10
BIMS score: 0
Incident date: 53025
Report date: 6125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Involved in managing Resident 2 during the incident and attempted to calm Resident 2 |
| LPN2 | Licensed Practical Nurse | Resident 2's primary nurse, notified after the incident |
| CNA3 | Certified Nursing Assistant | Witnessed the incident and ran to get a nurse |
| CNA4 | Certified Nursing Assistant | Witnessed the incident and assisted in separating residents |
| CNA5 | Certified Nursing Assistant | Witnessed the incident and confirmed reporting to nursing staff |
| Nursing Home Administrator | Administrator | Discussed the facility's abuse policy and admitted oversight in timely reporting |
Inspection Report
Routine
Census: 23
Deficiencies: 11
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, physician notification of changes in condition, privacy during medication administration, notification of hospital transfers to the Ombudsman, PASRR screening, pressure ulcer care, respiratory care, medication storage and administration, food safety and sanitation, infection prevention and control, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during dining assistance, failure to notify physicians of significant changes in condition, lack of privacy during medication administration, failure to notify the Ombudsman of hospital transfers, incomplete PASRR screening, inadequate pressure ulcer care, improper respiratory care, unsecured medications, unsafe food storage and handling practices, inadequate infection prevention and control practices, and failure to monitor antibiotic use appropriately.
Deficiencies (11)
Facility did not maintain dignity for 7 residents who required dining assistance; staff stood while feeding residents instead of sitting.
Facility did not ensure physician was notified of a change in condition for 1 resident with low blood pressure.
Facility did not provide privacy during medication administration for 2 residents; medications were administered in public areas.
Facility did not notify Ombudsman of emergency room or hospital transfers for 6 residents and lacked a process for notification.
Facility did not ensure 3 residents met PASRR requirements; delayed or missing Level II screens for residents prescribed psychotropic medications.
Facility did not provide appropriate pressure ulcer care for 1 resident; wound assessments and care plans were incomplete and wound treatments were inconsistently applied.
Facility did not ensure safe and appropriate respiratory care for 1 resident; oxygen order lacked flow rate, resident observed without oxygen, and care plan did not reflect continuous oxygen use.
Facility did not ensure medications were labeled and stored appropriately; medications were left unattended and unsecured in resident rooms and medication carts.
Facility did not ensure food was stored, prepared, and served in a sanitary manner; food items were unlabeled or undated, cooling logs were incomplete, sanitizing solution testing was inadequate, dishwashing temperature monitoring was incomplete, microwave heating procedures were not followed, hair restraints were inconsistently worn, and hand hygiene was inadequate.
Facility did not establish and maintain an infection prevention and control program; staff failed to follow enhanced barrier precautions, hand hygiene, and infection control policies for multiple residents.
Facility did not implement antibiotic stewardship program effectively; prophylactic antibiotic use for 1 resident was not routinely assessed and documentation was incomplete.
Report Facts
Residents affected: 7
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 134
Residents affected: 4
Residents affected: 1
Residents observed in dining room: 21
Residents observed in dining room: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA-R | Certified Nursing Assistant | Observed standing while feeding residents R29 and R5 |
| CNA-S | Certified Nursing Assistant | Observed standing while feeding residents R45 and R50 |
| RNM-K | Registered Nurse Manager | Observed standing and sitting while feeding resident R29 |
| CNA-L | Certified Nursing Assistant | Observed standing while feeding resident R29 |
| CNA-M | Certified Nursing Assistant | Observed standing while feeding resident R34 |
| DON-B | Director of Nursing | Interviewed regarding feeding practices, physician notification, medication privacy, Ombudsman notification, wound care, respiratory care, medication administration, infection control, and antibiotic stewardship |
| LPN-C | Licensed Practical Nurse | Observed administering medications without privacy and dropping medication on floor |
| DDS-H | Director of Dining Services | Interviewed regarding food storage, cooling logs, sanitizing solution testing, and food safety |
| DA-I | Dietary Aide | Observed microwaving soup without proper stirring or temperature checks |
| DAS-J | Dietary Assistant | Observed not wearing beard restraint and improper hair restraint |
| IP-V | Infection Preventionist | Interviewed regarding infection control program and antibiotic stewardship |
| RN-U | Registered Nurse | Interviewed regarding infection prevention and antibiotic stewardship |
| NHA-A | Nursing Home Administrator | Interviewed regarding care plan updates and infection control policies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 3, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and thoroughly investigate an allegation of sexual abuse involving two residents (R2 and R5).
Complaint Details
The complaint involved an allegation of sexual abuse where resident R5 kissed resident R2 on the mouth and R2 touched R5's breast. The facility did not report the incident to the State Agency within 24 hours as required and did not conduct a thorough investigation. The facility ruled out abuse based on no physical injury and lack of emotional harm but failed to complete capacity to consent assessments and did not interview other residents or staff witnesses. The facility also failed to consistently follow care plan interventions for supervision and separation of the residents involved.
Findings
The facility failed to report the sexual abuse allegation to the State Agency within the required timeframe and did not conduct a thorough investigation, including interviews with involved residents, other residents, and staff. Additionally, care plan interventions to supervise and separate the residents were not consistently followed, resulting in a resident-to-resident interaction.
Deficiencies (3)
Failure to timely report suspected abuse to proper authorities for two residents involved in a sexual abuse allegation.
Failure to respond appropriately to all alleged violations by not thoroughly investigating the sexual abuse allegation, including lack of interviews with involved residents, other residents, and staff.
Failure to ensure care plan interventions were followed, resulting in a resident-to-resident interaction between two residents.
Report Facts
Residents sampled: 3
Residents affected: 2
BIMS score for R2: 8
BIMS score for R5: 4
Date of incident: Apr 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA)-A | Nursing Home Administrator | Interviewed regarding reporting and investigation of the sexual abuse allegation |
| Assistant Administrator (AA)-C | Assistant Administrator | Interviewed regarding reporting and investigation of the sexual abuse allegation |
| Certified Nursing Assistant (CNA)-G | Certified Nursing Assistant | Interviewed about awareness of care plan and incident |
| Certified Nursing Assistant (CNA)-F | Certified Nursing Assistant | Interviewed about care plan and incident circumstances |
| Registered Nurse (RN)-E | Registered Nurse | Witnessed part of the incident and wrote progress notes |
| Certified Nursing Assistant (CNA)-D | Certified Nursing Assistant | Intervened after the incident and confirmed care plan non-compliance |
Inspection Report
Routine
Deficiencies: 1
Date: Feb 14, 2024
Visit Reason
The inspection was conducted to assess compliance with food service standards, specifically ensuring food and drink are served at a palatable, attractive, and safe temperature.
Findings
The facility failed to ensure food was served at a palatable temperature for 7 of 26 sampled residents during lunch meals on 2/12/24 and 2/13/24. Observations and interviews revealed that hot food was often served cold or barely warm, particularly in the back dining room where food was served last and steam tables could not be plugged in.
Deficiencies (1)
Facility did not ensure food was served at a palatable temperature for 7 residents (R9, R1, R57, R72, R83, R13, and R130).
Report Facts
Residents sampled: 26
Residents affected: 7
Food temperature: 95
Food temperature: 86
Food temperature: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DS-H | Dietary Staff | Observed serving food and handling reheating of rice; indicated no place to plug steam cart on Unit-J |
| CNA-I | Certified Nursing Assistant | Observed reheating rice for R9 and delivering it to the resident |
| RD-G | Registered Dietitian | Confirmed steam table carts cannot be plugged in on Unit-J and verified discussion about rotating dining room service order |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 14, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including medication notification, financial liability notices, resident assessments, nutrition and food service, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to notify a resident's POA of medication changes, failure to provide required financial liability notices, inaccurate resident assessments, inconsistent monitoring of resident weight and nutritional supplement administration, serving food at improper temperatures, unsafe food storage and preparation practices, and failure to review and offer recommended pneumococcal vaccinations to residents.
Deficiencies (7)
Failure to notify a resident's power of attorney of medication changes.
Failure to provide written notification of financial liability via Advanced Beneficiary Notice (ABN) when Medicare Part A benefits ended.
Minimum Data Set (MDS) assessments did not accurately reflect a resident's status, including incomplete cognitive and mood assessments.
Failure to ensure residents received necessary care and services to prevent or monitor weight loss, including inconsistent weight monitoring and nutritional supplement administration.
Food was not served at palatable temperatures for multiple residents; food service procedures and meal timing contributed to cold food being served.
Food was stored and prepared in an unsafe and unsanitary manner, including improper reheating procedures, incomplete cook temperature documentation, food stored on the floor, and unclean equipment.
Failure to review, offer, or administer recommended pneumococcal vaccinations (PCV20) to residents as per CDC guidelines.
Report Facts
Residents sampled: 26
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 7
Residents affected: 113
Residents affected: 2
Weight loss percentage: 10.6
Weight measurements: 169.8
Weight measurements: 190
BIMS scores: 5
BIMS scores: 12
BIMS scores: 11
BIMS scores: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-E | Registered Nurse | Interviewed regarding medication discontinuation and POA notification for Resident R89 |
| RN-D | Nurse Manager | Confirmed lack of POA notification for Resident R89 |
| DON-B | Director of Nursing | Interviewed regarding expectations for notification of medication changes and weight/supplement monitoring |
| NHA-A | Nursing Home Administrator | Interviewed regarding ABN completion for Resident R69 |
| DS-H | Dietary Staff | Observed reheating and serving food at improper temperatures |
| CNA-I | Certified Nursing Assistant | Observed reheating food and not taking temperature prior to serving Resident R9 |
| RD-G | Registered Dietitian | Interviewed regarding food service procedures and cook temperature documentation |
| IP-F | Infection Preventionist | Interviewed regarding vaccination policies and practices |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 28, 2022
Visit Reason
The inspection was conducted due to multiple food-related concerns expressed by residents, including issues with meal service, food temperature, menu adherence, and provision of special eating equipment.
Complaint Details
The visit was complaint-related due to multiple food-related concerns expressed by residents during screening and interviews, including running out of food, cold food, use of disposable dishware, and lack of special eating equipment.
Findings
The facility was found to have multiple deficiencies related to meal service including use of disposable dishware on most units, inconsistent serving sizes, failure to follow menus, serving food at unsafe temperatures, failure to provide special adaptive eating equipment, and improper food storage and handling practices.
Deficiencies (5)
Facility did not maintain dignity of residents by serving meals on disposable dishware on 3 of 4 units and residents were not served timely.
Menus were not consistently updated or followed; serving sizes were incorrect and not communicated to staff.
Food was not served at a safe and appetizing temperature; holding temperatures were not monitored and steam tables were sometimes unplugged.
Special assistive eating equipment such as weighted utensils and divided plates were not provided as indicated in residents' care plans.
Food was not procured, stored, prepared, and served in accordance with professional standards; expired, undated, and open foods were found; facial hair restraints were not used by food preparer; and food service equipment was not properly cleaned.
Report Facts
Residents affected: 102
Residents affected: 11
Temperature readings: 53.4
Expired food days past discard date: 5
Expired food days past discard date: 1
Expired food days past thaw based usage date: 42
Refrigerator temperatures above 41F: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DM-N | Dietary Manager | Observed preparing food without facial hair covering and interviewed regarding holding temperatures. |
| RD-I | Registered Dietician | Interviewed about menu adherence, food temperatures, and provision of weighted utensils. |
| CNA-J | Certified Nursing Assistant | Interviewed about lack of meal tickets and adaptive equipment provision. |
| DC-G | Dietary Staff | Interviewed about scoop sizes, food storage, and steam table cleanliness. |
| NM-D | Nurse Manager | Interviewed about use of paper plates and adaptive equipment. |
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