Rolling Hills Healthcare

In the surveyor’s words

From the most serious findings on record at Rolling Hills Healthcare, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Sep 4, 2024

  Based 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. Findings include: 1. Observation on 9/3/24 at 12:15 p.m. […]

• Actual harm, isolatedF686Feb 12, 2026

  Based 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. Findings include:1. Observation on 2/10/26 at 11:09 a.m. of resident 3 in his room revealed:*There was a cushion in his wheelchair seat.*He had an air mattress on his bed.*Resident 3 was sitting in his recliner.*There was no pressure relieving cushion in his recliner.2. […]

• Actual harm, isolatedF689Sep 29, 2025

  Based 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. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: Her admission date was 4/15/25.The resident's Hot Liquid Safety Evaluation with an effective date of 9/8/25 indicated she required a cup with a lid or other adaptive cup and a clothing protector and/or lap protector when she drank hot liquids.Resident 1's 9/8/25 revised care plan revealed: I am at risk for hot liquid spills, please ensure I use a cup with a lid and am… […]

• Actual harm, isolatedF600Jan 28, 2025

  Based 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. Findings include: 1. Review of the provider's 1/15/25 SD DOH FRI revealed the provider had determined physical abuse had occurred when RN B slapped resident 1 while providing evening cares on 1/14/25. Observation on 1/28/25 at 10:00 a.m. […]

• Actual harm, isolatedF686Oct 17, 2024

  Based 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. Findings include: 1. Interview on 10/16/24 at 8:05 a.m. with director of nursing (DON) B regarding resident 3's Stage III pressure ulcer that was listed on the facility provided Matrix revealed that pressure ulcer was healed at the beginning of September 2024. Interview on 10/17/24 at 10:09 a.m. […]