Inspection Report Summary
The most recent inspection on September 29, 2025, identified deficiencies related to resident safety, trauma-informed care, and pharmaceutical services, including a burn from hot coffee, inadequate care planning for a resident with PTSD, and medication availability issues. Earlier inspections showed a pattern of issues involving resident care such as bathing assistance, medication management, environmental cleanliness, food service quality, and safety concerns including falls and elopement risks. Complaint investigations substantiated physical abuse by a staff member and other safety-related incidents, though enforcement actions like license suspensions or fines were not listed in the available reports. Most complaints were substantiated, with corrective actions taken, including staff termination and education. The facility’s inspection history shows ongoing challenges with resident care and safety, with no clear trend of consistent improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
188% worse than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 29, 2025
Visit Reason
The inspection was conducted based on complaints and incidents involving resident safety, trauma-informed care, and pharmaceutical services at Rolling Hills Healthcare.
Complaint Details
The complaint investigation was triggered by incidents involving a resident who sustained a burn from hot coffee due to failure to follow care plan interventions, inadequate trauma-informed care for the same resident with PTSD, and failure to ensure availability and accurate transcription of seizure medication orders.
Findings
The provider failed to ensure adequate interventions to prevent burns from hot liquids, failed to implement comprehensive trauma-informed care for a resident with PTSD, and failed to meet pharmaceutical service needs by not having a physician-ordered PRN medication available for seizure treatment.
Deficiencies (3)
Failed to ensure staff implemented interventions for a resident at risk for burns from hot liquids, resulting in an actual burn from hot coffee.
Failed to provide trauma-informed and culturally competent care for a resident with PTSD, leading to inadequate care planning and support.
Failed to provide pharmaceutical services meeting resident needs, including lack of availability of physician-ordered PRN Diazepam nasal spray for seizure treatment and inaccurate transcription of medication orders.
Report Facts
Resident admission date: Apr 15, 2025
Incident date: Sep 10, 2025
BIMS score: 14
Trauma Assessment score: 8
Physician order date: Jun 18, 2025
Medication order date: Jul 24, 2025
Medication order discontinuation date: Sep 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA H | Certified Nurse Aide | Named in hot coffee burn incident and post-incident interview |
| Cook E | Interviewed regarding coffee service and accommodations | |
| Dietary Manager D | Interviewed regarding kitchen coffee mugs and lids | |
| DON B | Director of Nursing | Observed resident post-burn, confirmed medication order issues, and interviewed multiple times |
| SSD G | Social Services Designee | Interviewed regarding trauma-informed care and resident's trauma history |
| CMA F | Certified Medication Aide | Interviewed regarding medication availability |
| LPN C | Licensed Practical Nurse | Interviewed regarding medication order and availability |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 3, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights and quality of life standards, specifically focusing on the provision of bathing assistance and documentation processes for residents at Rolling Hills Healthcare.
Findings
The provider failed to ensure that seven of eighteen sampled residents received staff assistance for bathing at least weekly according to their individual preferences. There was also a failure to maintain accurate and consistent documentation of resident baths in the electronic medical records, with scheduled baths often not provided or rescheduled, and bathing refusals not consistently documented.
Deficiencies (1)
Failure to promote the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights related to bathing assistance and documentation.
Report Facts
Sampled residents: 18
Residents affected: 7
BIMS assessment scores: 11
BIMS assessment scores: 14
BIMS assessment scores: 9
BIMS assessment scores: 1
BIMS assessment scores: 6
BIMS assessment scores: 8
BIMS assessment scores: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON C | Assistant Director of Nursing | Interviewed regarding bathing documentation and process |
| DON B | Director of Nursing | Interviewed regarding bathing documentation and process |
| E | Certified Nursing Assistant/Bath Aide | Interviewed regarding staffing and bathing responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
The inspection was conducted following a facility-reported incident of physical abuse by a registered nurse (RN B) against a resident during evening care on 1/14/25.
Complaint Details
The complaint investigation was substantiated based on the facility-reported incident, interviews with CNAs and staff, and review of resident records. RN B was found to have physically abused the resident and was terminated. The incident was reported to the South Dakota Board of Nursing and local law enforcement.
Findings
The provider failed to protect the resident from physical abuse by RN B, who slapped the resident's face. The incident was confirmed through interviews, observations, and record reviews. RN B was terminated, and corrective actions including staff education and care plan updates were implemented. The non-compliance is considered past non-compliance based on corrective actions confirmed on 1/28/25.
Deficiencies (1)
Failure to protect resident from physical abuse by RN B who slapped resident during evening care.
Report Facts
Residents Affected: 1
Date of abuse incident: Jan 14, 2025
Date of facility-reported incident: Jan 15, 2025
Date of survey completion: Jan 28, 2025
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in physical abuse finding; terminated on 1/15/25 |
| CNA C | Certified Nursing Assistant | Witnessed incident and provided interview regarding abuse |
| CNA D | Certified Nursing Assistant | Witnessed incident and provided interview regarding abuse |
| LNHA A | Licensed Nursing Home Administrator | Interviewed regarding reporting and corrective actions |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 17, 2024
Visit Reason
The inspection was a routine survey of Rolling Hills Healthcare to assess compliance with regulatory requirements related to resident dignity, bathing assistance, safe environment, injury investigations, care planning, medication self-administration, restraint use, pressure ulcer care, food service quality, and food safety.
Findings
The survey identified multiple deficiencies including failure to consistently assist residents with dignity, incomplete bathing assistance, unclean and odorous resident rooms and public areas, lack of investigation for injury of unknown origin, incomplete and outdated care plans, inaccurate meal documentation, unassessed use of restraints, inadequate pressure ulcer care, and food service issues such as cold food temperatures and improperly stored food items.
Deficiencies (10)
Failure to ensure residents maintained dignity during meals and bathing assistance was inconsistent for sampled residents.
Failure to maintain a safe, clean, comfortable, and homelike environment including urine odors and clutter in resident rooms and public areas.
Failure to investigate one injury of unknown origin for a sampled resident and notify physician.
Failure to develop and update comprehensive care plans promptly to reflect current resident needs for 5 of 8 sampled residents.
Failure to ensure accurate meal intake documentation for one resident and unassessed use of Velcro straps as restraints for another resident.
Failure to ensure self-administration medication evaluation included all medications for one resident.
Failure to ensure oxygen use was ordered by physician for two residents and failure to ensure therapeutic boots were used as ordered for one resident.
Failure to identify, assess, document, and notify physician of pressure injuries for one resident.
Failure to ensure food served at late meal trays was at an appetizing temperature and timely delivered to residents, including one resident who received cold food and delayed alternative meal.
Failure to ensure food items in Bistro and kitchen refrigerators/freezers were properly labeled, dated, and covered.
Report Facts
Baths received: 3
Baths received: 3
Meal temperature: 78
Meal temperature: 80
Meal temperature: 102
Meal temperature: 122
Meal temperature: 100.4
Meal temperature: 103.7
Meal temperature: 90
Meal intake percentage: 26
Meal intake percentage: 50
Pressure ulcer size: 1.5
Pressure ulcer size: 1
Pressure ulcer size: 0.6
Pressure ulcer size: 0.3
Pressure ulcer size: 0.4
Pressure ulcer size: 1.4
Pressure ulcer size: 0.4
Pressure ulcer size: 0.2
Pressure ulcer size: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator A | Administrator | Interviewed regarding meal tray delivery, staff standing during meals, bathing documentation, and resident care plans. |
| Director of Nursing B | Director of Nursing | Interviewed regarding bathing documentation, care plans, injury investigation, restraint assessment, oxygen use, and pressure ulcer care. |
| Certified Nursing Assistant I | CNA | Interviewed regarding bathing assistance, meal intake documentation, Velcro strap use, and resident 18 precautions. |
| Certified Nursing Assistant N | CNA | Interviewed regarding bathing assistance, Velcro strap use, and resident 3 skin concerns. |
| Certified Nursing Assistant O | CNA | Interviewed regarding bathing assistance and resident 6 meal intake. |
| Certified Nursing Assistant G | CNA | Interviewed regarding standing during meal assistance. |
| Certified Nursing Assistant Q | Dietary Aide | Observed assisting resident 32 with feeding. |
| Maintenance Director D | Maintenance Director | Interviewed regarding plate warmer temperature and food holding temperatures. |
| Dietary Manager E | Dietary Manager | Interviewed regarding food labeling and removal of outdated food items. |
| Cook F | Cook | Interviewed regarding meal plating, food temperatures, and alternative meal requests. |
| Assistant Director of Nursing C | Assistant Director of Nursing | Interviewed regarding resident 5 skin concerns and meal tray delivery. |
| Registered Nurse J | RN | Interviewed regarding resident 18 precautions and skin assessments. |
| Registered Nurse T | RN | Interviewed regarding resident 3 skin condition. |
| Director of Rehab L | Director of Rehab | Interviewed regarding resident 18 therapeutic boots. |
| Unlicensed Medication Aide/CNA H | UMA/CNA | Observed assisting resident 26 with meals while standing. |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food service regulations, specifically ensuring that food and drink are palatable, attractive, and served at safe and appetizing temperatures.
Findings
The facility failed to maintain appropriate food temperatures during meal service, particularly for late in-room meal trays. Observations and interviews revealed that hot foods were served at temperatures below the expected 135 degrees Fahrenheit, frozen desserts were thawed, and meal delivery was delayed, resulting in residents receiving cold meals. Staff communication and food service processes were inadequate, contributing to these deficiencies.
Deficiencies (7)
Food plated for residents who received late, in-room meal trays were served at an unappetizing temperature.
One resident's room trays were delivered late, causing food temperatures to be unappetizing during observed meal services.
Plate warmer was not functioning properly, preventing plates from being warmed adequately.
Food containers on the steam table were left uncovered, contributing to low food temperatures.
Frozen ice cream cups were soft and runny by the time they were served to residents receiving late trays.
Resident meal trays were delayed significantly, with one resident waiting over 45 minutes past normal late tray delivery time.
Alternative meal request (soup) was forgotten and delayed nearly an hour.
Report Facts
Food temperature: 122
Food temperature: 102
Food temperature: 78
Food temperature: 80
Food temperature: 100.4
Food temperature: 103.7
Food temperature: 90
Meal delivery delay: 45
Meal delivery delay: 18
Fluid restriction: 1200
Dietary sodium restriction: 2
Ice cream cups: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cook F | Cook | Named in findings related to plating meals, food temperature issues, and oversight of alternative meal requests |
| Maintenance director D | Maintenance Director | Responsible for making temperature adjustments to the plate warmer |
| Dietary aide R | Dietary Aide | Assisted with drink orders and confirmed awareness of resident 43's soup request |
| Administrator A | Administrator | Interviewed regarding food holding temperatures and meal service issues |
| Assistant Director of Nursing C | Assistant Director of Nursing | Interviewed regarding resident 43's soup request and staff communication |
| Dietary aide Q | Dietary Aide | Interviewed regarding meal tray service timing |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to dietary services, food safety, and infection control at Rolling Hills Healthcare.
Findings
The provider failed to ensure the dietary supervisor met required qualifications, maintain proper water temperatures in the kitchen's three-compartment sink, and enforce proper infection control practices by kitchen staff, including glove use. Immediate jeopardy was identified related to improper water temperatures but was removed after corrective actions.
Deficiencies (3)
Dietary supervisor had not completed required dietary manager training or ServSafe certification and was unaware of relevant regulations.
Failed to maintain wash water temperature at 110°F and sanitizer water temperature at 75°F in the three-compartment sink, increasing risk of foodborne illness.
Infection control failures by cook including improper glove use, cross-contamination risks, and use of damaged food processor cover.
Report Facts
Recorded wash water temperatures below required minimum: 5
PPM sanitizer readings below expected range: 23
Sanitizer water temperatures not maintained: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Supervisor B | Dietary Supervisor | Named in findings related to incomplete training, lack of regulatory knowledge, and improper monitoring of sink temperatures. |
| Cook C | Cook | Named in findings related to improper glove use, cross-contamination risks, and handling of damaged equipment. |
| Administrator A | Administrator | Received immediate jeopardy notice and submitted removal plan. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 27, 2024
Visit Reason
The inspection was conducted based on facility-reported incidents involving two residents: one resident who fell from a tub chair due to improper use of a lap belt, and another resident who eloped from the facility by exiting through an alarmed door without staff knowledge.
Complaint Details
The complaint investigation involved two incidents reported by the South Dakota Department of Health facility-reported incidents (FRI). The first incident involved a resident falling from a tub chair on 5/15/24 due to an unsecured lap belt. The second incident involved a resident eloping on 6/24/24 by disabling door alarms and leaving the facility unnoticed. The elopement risk assessments were found to be inaccurate or insufficient. Both incidents resulted in minimal harm or potential for harm.
Findings
The provider failed to ensure the safety of one resident who fell from a tub chair when the lap belt was not properly placed, resulting in no apparent injuries but requiring ER evaluation. Additionally, the provider failed to ensure accurate assessment of elopement risk for another resident who eloped by disabling door alarms and walking away from the facility. Corrective actions and systemic changes were implemented for both incidents.
Deficiencies (2)
Failed to ensure the safety of a resident who fell from a tub chair due to improper placement of the lap belt.
Failed to ensure accurate assessment for elopement risk for a resident who eloped from the facility.
Report Facts
Date of fall incident: May 15, 2024
Date of elopement incident: Jun 24, 2024
SLUMS score: 14
Brief Interview of Mental Status score: 15
Elopement Risk Assessment date: Jun 14, 2024
Inspection Report
Routine
Deficiencies: 9
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, medication management, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including unsafe wheelchair maintenance, lack of accessible clothing for residents, inadequate bathing frequency, delayed call light response times, poor room environment and decoration, medication labeling discrepancies, unclean dining and kitchen areas, and improper infection control practices.
Deficiencies (9)
One resident's wheelchair had unpadded metal armrest poles extending beyond padded armrests, cracked vinyl fabric, and exposed screws that caused skin abrasions.
Resident's call light was not within reach and they were unable to summon assistance.
Resident's clothing was inaccessible due to high closet rod and lack of lighting, preventing independent dressing.
Three residents did not receive baths or showers according to their preferred frequency, with some waiting up to 15 days between baths.
Six residents had call lights answered in a delayed manner, with wait times up to an hour or more.
Two resident rooms and common areas had unclean conditions including stained carpets, recliners with urine odors and stains, and wheelchairs with dried food particles.
Medication labels for four residents did not match the medication administration records, risking incorrect dosing.
Two kitchens and food serving areas were not maintained in a clean and sanitary manner, with stained counters, dirty microwaves, and sticky surfaces.
Improper infection prevention and control practices were observed including expired hand sanitizer dispensers, improper hand hygiene by staff, and use of sanitizing wipes past expiration.
Report Facts
Sampled residents with bathing deficiencies: 3
Sampled residents with delayed call light response: 6
Sampled residents with medication labeling issues: 4
Sampled residents with nail care deficiencies: 3
Bath frequency interval: 15
Bath frequency interval: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN M | Licensed Practical Nurse | Observed medication administration with labeling discrepancies. |
| CMA N | Certified Medication Aide | Observed medication administration with labeling discrepancies. |
| Administrator A | Provided information on wheelchair maintenance policy, bathing staffing, call light complaints, room decoration, and infection control. | |
| Director of Nursing B | Director of Nursing | Provided information on medication labeling, call light complaints, and infection control. |
| Occupational Therapist P | Occupational Therapist | Interviewed regarding resident wheelchair safety and call light adaptations. |
| Housekeeping Director F | Housekeeping Director | Provided information on carpet and recliner cleaning. |
| Housekeeping Staff T | Housekeeper | Provided information on carpet and recliner cleaning. |
| Dietary Aide J | Dietary Aide | Observed improper hand hygiene during meal service. |
| Speech Therapist S | Speech Therapist | Observed improper hand hygiene during meal service. |
| Activities Director D | Activities Director | Provided information on bathing frequency and staffing. |
| Maintenance Director L | Maintenance Director | Provided information on maintenance walk-throughs and work orders. |
| Corporate Registered Nurse K | Corporate Registered Nurse | Interviewed regarding call light complaints and infection control. |
| Social Services Director C | Social Services Director | Interviewed regarding resident room decoration. |
| Social Service Assistant U | Social Service Assistant | Interviewed regarding resident room decoration. |
| Cook R | Cook | Provided information on kitchen cleaning responsibilities. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Rolling Hills Healthcare to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Routine
Deficiencies: 2
Date: Sep 7, 2022
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality, infection prevention and control practices, and medication administration policies at Rolling Hills Healthcare.
Findings
The provider failed to ensure proper medication administration by an unlicensed assistive personnel (UAP C), including incorrect eye drop technique, improper documentation of medication administration, and lack of adherence to medication instructions. Infection prevention and control practices were also deficient, including improper glove use, use of uncleanable blood pressure cuff, and inadequate cleaning of shared vital signs equipment.
Deficiencies (2)
Failure to follow provider's policies when administering medication to six residents, including improper eye drop administration and incorrect documentation of medication administration.
Failure to maintain infection prevention and control practices, including improper glove use, use of uncleanable blood pressure cuff, and inadequate cleaning of shared vital signs equipment.
Report Facts
Residents affected: 6
Residents affected: 5
Residents affected: 3
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| UAP C | Unlicensed Assistive Personnel | Named in findings related to medication administration errors and infection prevention deficiencies. |
| Administrator A | Administrator | Interviewed regarding observations and facility policies. |
| Director of Nursing B | Director of Nursing and Infection Control Nurse | Interviewed regarding observations and facility policies. |
Viewing
Loading inspection reports...
