Rolling Hills Healthcare

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to identify, monitor, and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (3) who developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his buttocks.

Inspectors wroteBased on Payroll Based Journal (PBJ) reports, interview, schedule review, and facility assessment review, the provider failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours of coverage for six days in quarter four (July 1 through September 30) of fiscal year 2025 and for two of fourteen days (1/29/26 and 1/31/26) between 1/28/26 and 2/10/26.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding the storage of oxygen equipment for four of four sampled residents (1,18, 49, and 69) who required the use of oxygen.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the resident's medications were labeled and discarded for: Two of two sampled residents (7 and 18) who had opened boxes of nasal spray (Flonase) which that were not kept available for use after their use-by date. Two of two sampled residents (18 and 62) whose pain medications (hydrocodone and oxycodone) were not labeled according to their physician's order. One of one sampled resident's (15) inhaler that was expired and was not stored in a secure location.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding:*Hand hygiene (handwashing) by two of two certified medication aides (CMA) (K and L) during medication administration for three of three sampled residents (46, 55 and 65).*An indwelling urinary catheter (flexible tubing inserted into the bladder to drain urine) being kept off the floor for one of one sampled residents (49).*The use of enhanced barrier precautions (EBP), glove and gown use when providing contact care, by the staff for three of three residents (3, 7, and 9) who were on enhanced barrier precautions (EBP), and one of one sampled resident (3) who was transferred by two of two staff members (certified nursing assistant (CNA) O and care assistant W) without using EBP.

Inspectors wroteBased on observation, interview, record review, manufacturer's recommendations for use, and policy review, the provider failed to ensure residents were evaluated for the ability to safely administer their medications or had a physicians order for two of two sampled residents (55 and 65) who were observed self-administering their medications and for 0ne of one sampled resident (62) observed with a medication left at her bedside by one of one certified medication aide (CMA) (M).

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure a resident's advance directives (a legal document that expresses a person's health care wishes if they become unable to speak for themselves)/code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) was accurately documented for staff to implement the resident's chosen wishes for one of one sampled resident (20) with documented code status discrepancies.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan was reviewed with the resident or the resident's representative within 48 hours of the resident's admission to the facility for three of six newly admitted sampled residents (3, 61, and 69). 1. Review of resident 3's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *His baseline care plan scanned into his EMR on 9/22/25 and was not dated or signed by the staff member who completed it. *There was no signature from resident 3 or their representative to indicate resident 3's baseline care plan was reviewed with them. 2. Review of resident 69's EMR revealed: *She was admitted to the facility on [DATE]. *Her 1/30/26 baseline care plan signed by LPN/wound care nurse G. [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the staff followed nursing professional standards of practice for following physician's orders for insulin administration for one of one sampled resident's (67) who was administered according to the physician's order by one of one observed licensed practical nurse (LPN) (H).

Inspectors wroteBased on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, interview, record review, and policy review, the provider failed to ensure staff implemented interventions for one of one sampled resident (1) identified with risk for burns from hot liquids, who subsequently sustained a burn from hot coffee.

Inspectors wroteBased on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, record review, interview, job description review, and policy review, the provider failed to implement comprehensive trauma-informed care for one of one sampled resident (1) with post-traumatic stress disorder (PTSD-a disorder in which an individual has difficulty recovering after experiencing or witnessing a traumatic event).

Inspectors wroteBased on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, summary of investigation review, record review, interview, and policy review, the provider failed to ensure a resident's medication needs were met, which included ensuring:A physician-ordered PRN (as needed) medication for the treatment of prolonged seizure activity was available for administration to one of one sampled resident (1). A physician-ordered PRN medication was accurately transcribed in one of one sampled resident's (1) electronic medical record (EMR).

Inspectors wroteBased on record review, interview, observation, job description review, and policy review, the provider failed to promote the resident's right to quality of life to ensure:*Seven of eighteen sampled residents (1, 2, 3, 4, 5, 6, and 7) received staff assistance to have been bathed no less than weekly and per their individual preference. *There was an accurate and consistent process for documenting resident baths in each resident's electronic medical record (EMR).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, record review, interview, and personnel file review, the provider failed to protect the resident's right to be free from physical abuse by one of one registered nurse (RN) (B) while providing evening cares for one of one sampled resident (1). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on interview, observation, record review, and policy review, revealed the provider failed to ensure one of one sampled resident's (3) pressure injuries had been identified, assessed, documented, and her physician was notified.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Food plated for residents who received late, in-room mealtrays during one of one observed meal service were served at an appetizing temperature. *One of one resident's (43) room trays were delivered in a timely manner to ensure food temperatures were appetizing during two of two observed meal services.

Inspectors wroteBased on interview, observation, record review, and policy review, the provider failed to ensure: *Residents maintained a sense of dignity by providing assistance to bathe once per week for 3 of 6 sampled residents (3, 6, and 26). *One of one sampled resident (18) had received staff assistance to change her clothes following one of two observed meal services in the Bistro dining room. *Staff had not stood over 2 of 2 observed residents (26 and 32) to assist them during 2 of 2 observed meal services in the Bistro and main dining rooms. *Two of two observed residents (5 and 29) were dressed in a dignified manner during one of one observed meal service in the main dining room.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure food items in one of one Bistro refrigerator/freezer and one of one walk-in refrigerator in the kitchen were properly labeled, dated, and/or covered.

Inspectors wroteBased on observation, interview, and policy review the provider failed to ensure: *One of three public areas (300 wing) was free of urine odor, a chair did not have a urine odor, and carpet stains. *Two of three sampled residents rooms (12 and 18 ) were kept in a clean and homelike manner. *Two of three sampled residents rooms (6 and 18) were free of urine odor. 1. Observation on 10/15/24 from 9:30 a.m. through 9:45 a.m. of the public area located in the 300 wing revealed: *Lounge chairs in the common area that were made of cloth fabric. -A burgundy lounge chair smelled of urine. *A strong odor of urine was present throughout the area. *Brown stains were on the carpet in multiple locations. 2. Random observations on 10/15/24 from 12:45 a.m. through 4:34 p.m. of resident 18's room revealed: *There was a strong odor of urine in resident's 18's room. [...]

Inspectors wroteBased on interview, record review and policy review the provider failed to investigate one of one injury of unknown origin for one of one sampled resident (12)

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure 5 of 8 sampled residents (6, 18, 26, 29, and 46) had their care plans followed, updated, and revised promptly to reflect their current status and care needs.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure: *Two of two residents (12 and 35) who had an oxygen concentrator in their room and did not have a physicians order for oxygen administration. *One of one sampled resident (18) used a physician's ordered therapeutic boots. *One of one sampled resident (6) meal documentation was accurate for one of one meal by one of one certified nursing assistant (CNA) (I). *One of one sampled resident (29) had been assessed for restraint use of Velcro straps holding his foot and arm in a secure position. *One of one sampled resident (25) who self-administered medication had his self-administration assessment completed accurately. 1. Observation on 10/15/24 at 11:24 a.m. of resident 12's room revealed: *An oxygen concentrator was at her bedside. [...]

Inspectors wroteBased on observation, interview, record review, job description review, and policy review, the provider failed to: *Maintain the temperature of the water in the three-compartment wash sink in the kitchen at a minimum of 110 degrees Fahrenheit (F). *Maintain the temperature of the water in the three-compartment sanitizer sink in the kitchen at a minimum of 75 degrees F. Those failures increased the potential risk of foodborne illnesses for the entire resident population who received meals that were prepared in the kitchen.

Inspectors wroteBased on interview and job description review, the provider failed to ensure the dietary supervisor had completed the necessary requirements to manage their food and nutrition services.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection control and prevention practices were maintained by one of one cook (C) during one of one observed meal service.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure the safety of one of one sampled resident (2) who had fallen from a tub chair when the lap belt (a belt to secure the resident into the chair) was not appropriately placed. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure accurate assessment for the elopement risk for one of one sampled resident (1) who eloped (left the facility without staff knowledge) when he entered the code to turn off the alarms on the door to the enclosed patio and courtyard, exited that enclosed courtyard, and walked approximately two blocks from the facility before he was found.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure: *Two of twenty-four sampled resident's (23 and 30) rooms had been maintained in a homelike environment. *One of one carpeted resident daytime use area (300 wing) had carpet that was free from stains and odors. *Four of twenty-four facility recliners located throughout two of two resident daytime use areas (300 wing and the Day room) had been free from stains or odors. *Three of three resident wing hallways (200, 300, and 400) had resident room doorways that were free from missing paint. *Two of two residents (30 and 46) specialized wheelchairs were kept in a well maintained condition. *One of one resident rooms (213) had a window free from broken glass and a warped windowsill with exposed nails.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *Six of twenty-four sampled residents (8, 22, 23, 24, 27, and 31) had their call lights answered in a timely manner. *Three of twenty-four sampled residents (6, 29, and 30) had received baths as they preferred or on at least a weekly basis. *Three of twenty-four sampled residents (20, 33, and 202) had received nail care to maintain nail hygiene.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure: *One of twenty-four sampled residents (30) had their wheelchair maintained in a safe condition and had a call call light placed within their reach and their functional ability. *One of twenty-four sampled residents (27) had clothing that was accessible and visible to allow for independent choices with dressing.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure three of twenty-four sampled residents (6, 22, and 30) had received a bath or shower according to their desired frequency preferences.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure four of eight sampled residents (7, 23, 39, and 42) had prescription medications that were accurately labeled.

Inspectors wroteBased on observation, interview, job description review, and policy review, the provider failed to maintain two of two kitchens and food serving areas (main dining room and the Bistro) in a clean and sanitary manner.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Proper use of hand sanitizer gel in three of three resident dining areas. *Proper use of sanitizing clothes in one of one resident dining area. *Appropriate hand hygiene by one of one dietary aide (J) and one of one speech therapist (ST) (S) during one of one observed meal service.