Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rolling Hills Healthcare during CMS and state inspections, most recent first.
Failure to identify and monitor a resident’s buttock pressure ulcer care. A resident with DM, CKD on dialysis, reduced mobility, and impaired cognition had hospital wound-care instructions for barrier cream, dressing coverage, repositioning, and a waffle cushion, but the care plan did not include those interventions. Staff documented incomplete skin checks without measurements or wound descriptions, did not consistently apply the ordered dressing, and the resident was observed sitting in a recliner without a pressure-relieving cushion while sleeping there because his air mattress leaked.
RN coverage was not scheduled for eight consecutive hours on multiple days identified in PBJ and schedule review. The administrator and ADON confirmed that an RN had not been scheduled on several dates, and the schedule showed partial RN shifts that did not add up to the required coverage. The facility assessment stated 2-6 floor direct care RN/LPN per day, including at least 1 RN daily.
Improper Storage of Oxygen Cannulas: A resident with COPD and three other residents who required oxygen had nasal cannulas observed lying on the floor, draped over wheelchair handles and seats, or resting on bed rails and wheelchair wheels instead of being kept covered when not in use. A CNA stated the cannulas were supposed to be stored in plastic bags attached to the oxygen equipment, but bags were not available, and the ADON confirmed staff were expected to use storage bags for oxygen delivery devices when not in use.
Medication labeling and storage were not maintained as required. Two residents had opened Flonase boxes with use-by dates that had passed, two residents had pain med blister packs that did not match the MAR orders, and an expired albuterol inhaler was found in a resident room where it was not ordered or secured. Staff interviews confirmed they were expected to compare blister pack labels to the MAR, remove expired meds, and avoid storing meds in resident rooms without an order and self-administration assessment.
The facility failed to follow infection prevention and control practices during medication administration, catheter care, and EBP use. A CMA administered nebulizer treatment and prepared another resident’s meds without hand hygiene, another CMA prepared meds without hand hygiene, a resident’s urinary catheter drainage bag was observed on the floor without a protective barrier, and residents ordered for EBP were observed without gowns, gloves, or door signage during high-contact care and transfers.
A facility failed to ensure proper assessment and physician authorization for medication self-administration for three residents. One resident with severe cognitive impairment was set up for a nebulizer treatment and left for staff to return later, another resident with intact cognition improperly self-administered an inhaler without assessment or order, and a third resident with moderate cognitive impairment had Prostat left at the bedside without an assessment or order supporting bedside placement.
A resident with severely impaired cognition had conflicting advance directive and code status documentation: the EMR banner, care plan, physician order, hall cheat sheet, and room icon all indicated DNR, while the signed advance directive stated CPR/full resuscitative measures. The SSD acknowledged the mismatch had existed for over four years, and staff used the DNR status in daily references.
Failure to document review of baseline care plans within 48 hours. Three newly admitted residents had no record that their baseline care plans were reviewed with them or their representatives, and one resident with a BIMS score of 10 had no documentation that a copy was provided. EMR review showed missing staff signatures on some plans, and the ADON confirmed the lack of documentation and stated she was not aware the review and copy requirement had to be documented.
An LPN failed to follow a physician's order for a resident's Novolog by giving it after the resident had already eaten breakfast, even though the order required it before meals based on the resident's blood sugar of 232. The LPN acknowledged the error and said morning blood sugar checks and insulin administration were difficult to complete on time because many residents needed them; the ADON stated the medication should have been given as ordered.
A resident identified as at risk for burns from hot liquids was served excessively hot coffee in a lidded Thermos without a clothing protector, contrary to her care plan. The coffee, sourced from an unmonitored employee breakroom, caused the resident to sustain burns when she expelled it onto her chest. Staff did not consistently follow required interventions, and the kitchen lacked a system to ensure residents received appropriate accommodations for hot beverages.
A resident with PTSD, developmental disabilities, and a history of childhood abuse did not receive comprehensive trauma-informed care. Staff failed to identify and address the resident's trauma history and mental health needs in her care plan, and did not obtain relevant psychiatric or therapeutic information. The lack of a trauma-informed approach contributed to an incident where the resident was burned by hot coffee, triggering distress and thoughts of self-harm.
A resident did not have access to a physician-ordered PRN Diazepam nasal spray for prolonged seizures because the medication was not available in the medication cart due to incomplete pre-authorization paperwork. Additionally, the resident's PRN Ativan order was changed to exclude seizure disorder as an indication, and the new order was incorrectly transcribed in the EMR, leaving the resident without an appropriate PRN medication for seizure management.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A registered nurse (RN) physically abused a resident during evening care by slapping her after the resident hit the RN. The resident, who had conditions such as hemiplegia and dementia, was forcefully handled by the RN despite her refusal to go to bed. The incident was witnessed by two CNAs, who reported feeling uncomfortable and were instructed by the RN not to report the incident. The RN was terminated, and the incident was reported to the South Dakota Board of Nursing and local law enforcement.
A facility failed to identify, assess, document, and notify a physician about a resident's pressure injuries. Despite reports from CNAs about sores on the resident's body, the DON and nursing staff were unaware of the current pressure injuries, and no documentation or physician notification was completed. The facility's policies for pressure injury management were not followed.
The facility failed to maintain proper food temperatures and timely delivery of meal trays to residents' rooms. A resident experienced delays in receiving meals, which were often cold and not as per his preferences. The steam table was left uncovered, and the plate warmer was malfunctioning, contributing to the issue. Additionally, a request for an alternative meal was delayed, highlighting a lack of coordination between dietary and nursing staff.
The facility failed to maintain resident dignity by not providing adequate assistance with bathing, clothing changes, and meal assistance. Several residents did not receive their preferred weekly baths, and staff were observed standing over residents during meals, contrary to policy. Additionally, two residents were observed with exposed stomachs due to improperly fitting clothing, and staff did not assist them in maintaining their dignity.
The facility failed to ensure proper labeling, dating, and covering of food items in the Bistro refrigerator/freezer and the walk-in refrigerator. Observations revealed undated and unlabeled food items, some past their best by dates, and uncovered items, contrary to the facility's policy. The dietary manager noted that removing outdated food items was recently added to the staff's cleaning checklist.
The facility failed to maintain a clean and homelike environment, with strong urine odors and unclean conditions observed in public areas and resident rooms. A resident's room was cluttered with medical supplies and personal items, remaining unclean over several days. Interviews revealed dissatisfaction with the facility's upkeep, despite cleaning procedures and staff advocacy efforts.
A resident experienced an unresponsive episode and was later found to have an acute, displaced oblique fracture in the left leg. Despite complaints of pain and the fracture diagnosis, the facility did not investigate the cause of the injury or report it to any outside agency, violating their policy on reporting and investigating injuries of unknown origin.
The facility failed to ensure care plans for several residents were followed and updated. A resident with a compromised immune system did not have proper contact precautions followed, and another resident's care plan did not reflect the use of necessary Velcro straps for wheelchair safety. Additionally, a resident's care plan lacked information on seat belt use, and another resident's bed height was not properly marked, leading to inconsistencies in care delivery.
The facility failed to ensure proper physician orders for oxygen use for two residents, and therapeutic boots were not provided as ordered for another resident. Meal documentation was inaccurate for a resident with significant weight loss, and a resident using Velcro straps was not assessed for restraint use. Additionally, a resident self-administering medication lacked a complete evaluation of allowed medications.
The facility failed to maintain required water temperatures in the kitchen's three-compartment sink, increasing the risk of foodborne illnesses. Observations showed wash water temperatures were consistently below the required 110°F, and sanitizer water temperatures were not maintained at 75°F. Staff interviews revealed a lack of awareness of the correct temperature requirements, and log reviews showed discrepancies in recorded temperatures and PPMs.
The dietary supervisor, who also worked part-time as the HR director, had not completed the necessary dietary manager training or ServSafe certification. Additionally, she was unaware of relevant state and federal regulations. A registered dietician consulted at the facility but not full-time. The job description required certification as a dietary manager within four months and maintaining ServSafe certification.
A cook in an LTC facility failed to maintain proper infection control practices during meal service. Observations revealed the cook used the same gloves for multiple tasks, including handling food and kitchen items, without changing them, increasing the risk of cross-contamination. Additionally, a damaged food processor cover was used, further compromising food safety. The facility's policy on glove use was not followed, as confirmed by the dietary supervisor.
A resident fell from a tub chair because the lap belt, meant to secure them, was not properly placed. The resident was assessed and transferred to the ER, where no fractures were found, but low blood pressure was noted.
A resident with dementia and a history of wandering successfully eloped from the facility by disabling door alarms and walking two blocks away. Despite previous exit-seeking behaviors, the resident was assessed as low risk for elopement. The facility's interventions, including staff education and supervision, were not effectively implemented, leading to the deficiency.
Failure to identify and track buttock pressure ulcer care
Penalty
Summary
The provider failed to identify, monitor, and implement pressure ulcer healing and prevention interventions for a resident who developed a stage II pressure ulcer to the buttocks. The resident had diabetes, stage four kidney disease with dialysis dependence, reduced mobility, and moderately impaired cognition. Hospital discharge instructions from admission included wound care to the right buttock, barrier cream application, dressing coverage for open areas, offloading with repositioning every 2 hours and as needed, heel offloading, and use of a waffle cushion with frequent repositioning while in a chair. The resident’s care plan did not reflect the buttock wound or the discharge instructions for wound care and pressure relief. Although the resident was assessed as high risk for pressure injury on admission, the comprehensive care plan only addressed general skin integrity concerns and did not include the open area to the right buttock, the ordered barrier cream schedule, repositioning every 2 hours, or the use of a waffle cushion and frequent repositioning in the chair. Observation showed the resident sitting in a recliner without a pressure-relieving cushion, and the resident reported sleeping in the recliner for about the last month because the air mattress on the bed leaked and would deflate, leaving him on the bed frame. Skin assessments were incomplete and lacked required detail. The record showed missing weekly skin checks, and the documented assessments for the buttocks did not include measurements or wound descriptions, with several entries failing to state whether the wounds were improving, worsening, or stable. The wound care nurse stated she did not consider the buttock wounds pressure ulcers because the skin blanched, and she acknowledged the wounds were not measured or described on weekly assessments. Nursing staff also did not consistently apply the ordered dressing, and the resident’s buttock wounds were later observed as open areas on both buttocks, with the resident’s treatment order calling for triad paste and a sacral foam dressing.
RN Coverage Not Scheduled for Required Eight Consecutive Hours
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours of coverage on multiple days identified in the Payroll Based Journal report for quarter 4 of fiscal year 2025 and again on two days during the schedule review period from 1/28/26 through 2/10/26. The PBJ review showed no RN coverage for eight consecutive hours on 7/4/25, 7/19/25, 7/26/25, 7/27/25, 8/30/25, and 8/31/25. During the entrance conference on 2/10/326, the administrator stated the facility did not have any nurse staffing waivers. During interviews on 2/12/26, the administrator confirmed there were not eight consecutive hours of RN coverage on 7/4/25, 7/19/25, 7/26/25, and 7/27/25, and stated an RN had not been scheduled to work on those dates. The assistant director of nursing confirmed there were not eight consecutive hours of RN coverage on 8/30/25 and 8/31/25 and stated an RN had not been scheduled to work on those dates. The schedule review also showed that on 1/29/26 RN U was scheduled from 8:30 a.m. to 11:30 a.m. and the DON from 2:00 p.m. to 7:00 p.m., and on 1/31/26 the DON was scheduled from 9:00 a.m. to 1:00 p.m.; these schedules did not provide eight consecutive hours of RN coverage. The DON was not in the facility or available for interview during the survey, and the facility assessment dated 9/22/25 stated 2-6 floor direct care RN/LPN per day, including at least 1 RN daily.
Improper Storage of Oxygen Cannulas
Penalty
Summary
The facility failed to follow infection control practices for oxygen equipment storage for four residents who required oxygen therapy. During observation, resident 1 was in bed with a nasal cannula connected to an oxygen concentrator, while a portable oxygen tank on the wheelchair beside the bed had a nasal cannula laying on the floor underneath the wheelchair wheel. Resident 18 was observed with a nasal cannula attached to the oxygen concentrator, while the portable oxygen tank on the wheelchair had a nasal cannula draped over the wheelchair back and lying on the seat. Resident 69 had a nasal cannula coiled under the handle of the oxygen concentrator when not in the room, and later the nasal cannula attached to the portable oxygen tank was hanging on the wheelchair handle with the portion placed in the nose touching the handle. Resident 49’s portable oxygen tank had a nasal cannula draped over the wheelchair back and resting on the wheelchair wheel. Record review showed resident 1 had diagnoses including COPD, acute respiratory failure with hypoxia, adult failure to thrive, hypotension, cachexia, and ischemic cardiomyopathy, and had an order for oxygen at 1-5 L via nasal cannula every shift. A CNA stated residents 18 and 69 needed staff help to switch between the oxygen concentrator and portable tank, and that nasal cannulas were to be stored in plastic bags and attached to the oxygen equipment when not in use; she acknowledged the cannulas were not stored in plastic bags because none were available. The ADON stated the admitting nurse was responsible for obtaining a storage bag for a resident’s nasal cannula and staff were expected to use the bag when the cannula was not in use. The facility’s oxygen administration policy stated oxygen tubing and mask/cannula were to be changed weekly and as needed if soiled or contaminated, and delivery devices were to be kept covered in a plastic bag when not in use.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to accepted practice. On the 400 hall medication cart, two opened boxes of Flonase nasal spray were observed for two residents, and both boxes had use-by dates that had passed. The CMA stated staff were expected to review the dates before administering the spray and that expired nasal sprays should have been discarded. Both residents had PRN Flonase orders on their MARs. Medication administration also revealed discrepancies between blister pack labels and MAR orders for pain medications. While preparing hydrocodone for one resident, the CMA observed that the blister pack label directed one tablet every four hours PRN, but the MAR showed one tablet four times daily, and the CMA administered the medication without comparing the two orders. For another resident, the oxycodone blister pack label directed one 5 mg tablet three times daily and another 5 mg tablet once daily PRN, while the MAR showed one 5 mg tablet four times daily plus a separate PRN order. The CMA recognized the discrepancy and stated she expected a change-order sticker to have been affixed to the blister pack after the MAR was updated. An expired albuterol inhaler was also found lying on a bedside table in a resident room that belonged to another resident. The resident in the room stated the inhaler had been brought in by a nurse and left there, and the roommate who actually had the inhaler order did not have an order for bedside medication storage. The resident with the inhaler order had moderately impaired cognition on BIMS, did not have an order for bedside storage, and staff interviews confirmed medications were not to be stored in a resident room without an order and self-administration assessment. Interviews also confirmed expired medications were not to be administered and that medication carts and the medication room were to be checked monthly for outdated medications.
Infection Prevention and Control Failures During Hand Hygiene, Catheter Care, and EBP Use
Penalty
Summary
The provider failed to ensure infection prevention and control practices were followed during medication administration, catheter care, and use of enhanced barrier precautions. During observation, one CMA entered a resident’s room, assembled nebulizer equipment, and administered the treatment without first performing hand hygiene, then returned to the medication cart and prepared another resident’s medications without performing hand hygiene. A second CMA prepared another resident’s medications without first performing hand hygiene, and only performed hand hygiene after the medications were administered. The ADON confirmed hand hygiene was expected before and after resident care transitions and acknowledged the CMAs did not demonstrate that practice. The provider also failed to keep an indwelling urinary catheter drainage bag off the floor for a resident who was unable to transfer without staff assistance. The resident’s drainage bag was observed lying directly on the floor in the room on two separate observations, without a dignity bag or other protective barrier. The resident stated he did not place the bag on the floor and indicated staff likely did when assisting him into the chair. Staff later observed the bag hanging on the recliner footrest, and CNAs stated the drainage bag should not be directly on the floor and that there should be a barrier to prevent contamination. The ADON stated catheter drainage bags were to be placed in a dignity bag and not directly on the floor. The provider further failed to use enhanced barrier precautions for residents who were ordered to have EBP. One resident with a dialysis port, one resident with a history of ESBL, and one resident with an MDRO history were observed without PPE or EBP signs on their doors, and residents stated staff did not wear gowns or gloves during toileting, dressing, bathing, or transfers. One resident with EBP orders was transferred from a wheelchair to the toilet by two staff members without PPE. The EMR and care plans for these residents documented EBP orders and gown-and-glove use during high-contact care, and the ADON stated residents were to be on EBP for conditions including urinary catheters, feeding tubes, wounds, MDRO history, or dialysis access ports.
Failure to Verify Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were evaluated for the ability to safely self-administer medications or had a physician’s order supporting self-administration for three sampled residents. One resident with a BIMS score of 6 and severe cognitive impairment was observed receiving a nebulizer treatment that a CMA set up and started, with the expectation that staff would return in 10 to 15 minutes to monitor and shut off the machine; the CMA did not return at that time. The resident had a medication self-administration assessment stating she was safe for nebulizer self-administration after staff set up the treatment, but there was no physician’s order indicating she was safe to self-administer the nebulizer. A second resident with a BIMS score of 15 was observed self-administering an inhaler after a CMA handed it to her, but the resident did not properly use the inhaler and the medication drifted out of her mouth. The CMA stated she knew the resident did not properly self-administer the inhaler and believed verbal instruction might have helped, but no instruction was provided during the observation. The resident had not been assessed for her ability to safely self-administer the inhaler, and there was no physician’s order indicating she was safe to self-administer it. Manufacturer instructions for the inhaler required exhaling fully away from the inhaler, sealing lips around the mouthpiece, and inhaling slowly while pressing the dose-release button. A third resident with a BIMS score of 11 and moderate cognitive impairment had a clear plastic cup with amber liquid left on her over-the-bed table, which she identified as a “get well soon” medication. The CMA later removed the cup and believed it was Prostat, a physician-ordered nutritional supplement that had already been administered that morning. The resident had no medication self-administration assessment, and the physician’s order for Prostat did not indicate it could be left at the bedside. The ADON stated the self-administration assessments were not current for the resident who received the nebulizer, that there was no assessment or order supporting the inhaler self-administration, and that there was no assessment or order supporting the Prostat being left at the bedside.
Advance Directive and Code Status Not Matched
Penalty
Summary
The facility failed to ensure that one resident's advance directive and code status were accurately documented and aligned for staff implementation. Resident 20 was admitted with a BIMS score of 7, indicating severely impaired cognition. Her EMR displayed a banner showing she did not want CPR, her care plan included an advance directive focus area stating she had a DNR order, and there was a physician's order for DNR. However, her signed advance directive stated that she wanted CPR/full resuscitative measures. During interview, the social services director acknowledged that Resident 20's code status did not match her advance directive and stated that the resident had a physician's DNR order that did not match her advance directive for over four years, without explanation for how this occurred. Observation and interview with a CNA showed that staff references also reflected DNR status: the resident was listed as DNR on the hall cheat sheet, and a flower icon indicating DNR was posted next to her room nameplate. The facility policy stated that advance directives should be obtained on admission, copied to the chart, communicated to staff, reviewed during care planning, and documented in the medical record and communicated to the interdisciplinary team.
Failure to Document Review of Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure that the baseline care plan was reviewed with the resident or the resident's representative within 48 hours of admission for three newly admitted residents. For resident 3, the EMR showed admission to the facility and a baseline care plan scanned into the record on 9/22/25, but it was not dated or signed by the staff member who completed it, and there was no resident or representative signature showing the plan had been reviewed. For resident 69, the EMR showed admission to the facility and a 1/30/26 baseline care plan signed by an LPN/wound care nurse, but there was no signature from the resident or representative to show review of the plan. For resident 61, the EMR showed admission to the facility and a 1/16/26 BIMS score of 10, indicating moderately cognitively impaired status, but there was no documentation that the baseline care plan was reviewed with the resident or representative, or that a copy was provided. Interview with the ADON on 2/11/2026 and 2/12/26 confirmed there was no documentation that the baseline care plans for residents 3 and 69 were reviewed with the resident or representative or that a copy was offered within 48 hours of admission, and the ADON stated she was not aware that such documentation was required. The ADON also described the facility process for completing the baseline care plan, including placement in a binder at the nurse's station and presentation to the physician during the initial assessment.
Insulin Not Given Before Meals as Ordered
Penalty
Summary
The nursing facility failed to ensure staff followed professional standards of practice for administering insulin according to a physician's order for one resident. During observation, an LPN checked the resident's blood sugar level in the resident's room and found it was 232. The LPN stated the resident had already eaten two breakfasts that morning, and the amount of Novolog to be given depended on the blood sugar result. Review of the resident's MAR and interview with the LPN showed a 5/24/25 physician order for Novolog required three units when the blood sugar was 232 and directed that the insulin be given before meals. The LPN acknowledged she did not administer the Novolog before the resident ate breakfast. She stated she knew Novolog was a rapid-acting insulin used to improve blood sugar control and was ordered before meals, but said it was difficult to ensure morning blood sugar testing and insulin administration occurred at scheduled times because of the number of residents needing those services. The ADON stated she expected the LPN to administer the Novolog according to the physician's order, but that did not occur.
Failure to Implement Hot Liquid Safety Interventions Results in Resident Burn
Penalty
Summary
Staff failed to implement required safety interventions for a resident identified as being at risk for burns from hot liquids. The resident's care plan and Hot Liquid Safety Evaluation specified the need for a cup with a lid and a clothing or lap protector when consuming hot beverages. Despite these documented interventions, the resident was served hot coffee in her personal Thermos cup without verification of the coffee's temperature, and she was not provided with a clothing protector at the time. The coffee, obtained from the employee breakroom where temperatures were not monitored, was too hot, resulting in the resident expelling it onto her chest and sustaining small blisters. Further review and interviews revealed that the kitchen did not maintain a list of residents requiring specific accommodations for hot beverages, and there were no lidded mugs available for general resident use. The resident sometimes used unlidded mugs from the kitchen, contrary to her care plan. Staff, including the CNA and kitchen staff, were unaware of the temperature differences between coffee sources and did not consistently follow the interventions outlined in the resident's care plan to mitigate the risk of burns from hot liquids.
Failure to Implement Comprehensive Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to implement comprehensive trauma-informed care for a resident diagnosed with post-traumatic stress disorder (PTSD), developmental disabilities, anxiety, major depressive disorder, and a seizure disorder. The resident, who had a history of childhood abuse, experienced a triggering event when a certified nurse aide provided her with hot coffee, resulting in a burn to her chest. This incident caused the resident to recall past trauma and led to thoughts of self-harm, necessitating her transfer to a hospital for evaluation. Prior to this incident, the resident's trauma history and mental health needs were not adequately identified or addressed in her care plan. Trauma assessments conducted after admission did not capture her trauma history, developmental and functional background, support network, or coping mechanisms. The social services designee acknowledged that she had limited information about the resident's trauma and had not proactively sought additional psychiatric or therapeutic records, nor had she requested the resident's individual service plan from her previous community-based program. The facility's policy required a multi-pronged approach to identifying trauma history and collaboration with relevant professionals to develop individualized care plans. However, these steps were not followed, and a trauma-informed care plan was not initiated until after the burn incident. The social services designee also did not follow up with the resident's counselor regarding recommended anxiety management exercises, missing opportunities to integrate effective interventions into the resident's care.
Failure to Provide Ordered PRN Seizure Medication
Penalty
Summary
The facility failed to ensure that a resident's medication needs were met by not having a physician-ordered PRN Diazepam nasal spray available for administration in the event of prolonged seizure activity. The medication was not present in the medication cart when needed because the pharmacy was waiting for the resident's medical provider to complete and return pre-authorization paperwork. Despite the order being active in the resident's electronic medical record, the medication was never received by the facility. Additionally, the resident's PRN Ativan order, which previously included seizure disorder as an indication, was discontinued and replaced with an order for anxiety only, leaving the resident without an appropriate PRN medication for seizures. Interviews with staff confirmed that the PRN Diazepam nasal spray was not available and that the Ativan order was incorrectly transcribed, omitting seizure disorder as an indication. The Director of Nursing acknowledged that since the change in the Ativan order, the resident had no medication available to treat a prolonged seizure. The facility's policies required timely acquisition and clarification of medication orders, but these were not followed, resulting in the resident being left without necessary seizure medication.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
RN Slaps Resident During Evening Care
Penalty
Summary
The deficiency involved a registered nurse (RN) who physically abused a resident during evening care. The incident occurred when the RN slapped the resident while providing care, as reported by a certified nursing assistant (CNA) who witnessed the event. The resident, who had a history of hemiplegia, dementia, and moderate cognitive impairment, was subjected to forceful handling by the RN, which led to the resident hitting the RN, prompting the RN to retaliate by slapping the resident. The resident's medical record indicated she had existing conditions such as hemiplegia, dementia, and moderate cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 8. Observations noted bruising and scratches on the resident, which were documented in skin assessments following the incident. The resident's care plan was updated to monitor for changes in mental state and behavior, although no new behaviors or fear were observed in the resident following the incident. Interviews with the CNAs present during the incident revealed that the RN was agitated and forceful, disregarding the resident's refusal to go to bed. The CNAs reported feeling uncomfortable with the RN's actions and were instructed by the RN not to report the incident. Despite the RN's actions, the resident did not exhibit any new behaviors or fear in subsequent interactions with the CNAs. The RN was terminated following the incident, and the matter was reported to the South Dakota Board of Nursing and local law enforcement.
Failure to Identify and Document Pressure Injuries
Penalty
Summary
The facility failed to properly identify, assess, document, and notify the physician regarding a resident's pressure injuries. Interviews with the Director of Nursing (DON), Certified Nursing Assistants (CNAs), and Registered Nurses (RNs) revealed inconsistencies in the awareness and documentation of the resident's pressure injuries. The DON initially stated that the resident's Stage III pressure ulcer had healed, but CNAs reported sores on the resident's buttock, inner thigh, and heels. Despite these reports, the DON and other nursing staff were not aware of the current pressure injuries, and no documentation or physician notification had been completed. The resident's electronic medical record indicated previous pressure injuries on the heels, which were noted to have healed. However, new observations revealed an open area on the resident's upper leg and a suspected deep tissue pressure injury on the heel. The Assistant Director of Nursing (ADON) and other nursing staff confirmed they were not previously aware of these issues. The facility's policies required thorough assessment, documentation, and physician notification for pressure injuries, which were not followed in this case.
Deficiency in Food Service Delivery and Temperature Maintenance
Penalty
Summary
The deficiency report highlights several issues related to the food service delivery at the facility, particularly concerning the temperature and timeliness of meal trays delivered to residents' rooms. During an observation of the evening meal service, it was noted that food was plated in a sequence that resulted in late trays being served at unappetizing temperatures. The steam table used to keep food warm was left uncovered, and the temperature was lowered to prevent gravy from burning, which affected the overall temperature of the food. Additionally, the plate warmer was not functioning properly, contributing to the cold food complaints from residents. Resident 43, who preferred to eat in his room due to a pressure ulcer, experienced significant delays in receiving his meals. On one occasion, his meal was delivered over forty-five minutes past the normal delivery time, and the food was cold upon arrival. Despite his requests for specific meal preferences, he often did not receive what he ordered, leading to dissatisfaction and refusal to fill out meal preference sheets. His request for an alternative meal of chicken noodle soup was also delayed, and when it was finally delivered, it was not hot enough for his liking. The facility's policies on food temperatures and in-room dining were not adhered to, as evidenced by the failure to maintain hot food at the required temperature of at least 135 degrees Fahrenheit. The nursing staff did not promptly serve meals upon arrival on the unit, and there was a lack of communication and coordination between the dietary and nursing staff, resulting in delayed and unsatisfactory meal service for residents like Resident 43.
Deficiencies in Resident Dignity and Care
Penalty
Summary
The provider failed to ensure that residents maintained a sense of dignity by not providing adequate assistance with bathing, clothing changes, and meal assistance. Three residents did not receive their preferred weekly baths, as documented in their care plans. Interviews with CNAs revealed inconsistencies in the bathing schedule and documentation, with some residents refusing baths without proper follow-up. The facility's policy did not specify the frequency of baths, leading to gaps in care. One resident was observed with soiled clothing and food residue on her face and teeth after a meal, and staff did not address her appearance promptly. This lack of attention to personal hygiene and appearance compromised the resident's dignity. Additionally, during meal services, staff were observed standing over residents while assisting them with eating, contrary to the facility's policy that required staff to sit next to residents to provide a more dignified dining experience. Furthermore, two residents were observed in the dining room with exposed stomachs due to improperly fitting clothing. Staff failed to assist these residents in adjusting their clothing to maintain their dignity. The facility's dignity policy emphasized the importance of caring for residents in a manner that promotes their well-being and self-esteem, but these observations indicated a failure to uphold these standards.
Improper Food Labeling and Storage in Facility Refrigerators
Penalty
Summary
The provider failed to ensure that food items in the Bistro refrigerator/freezer and the walk-in refrigerator in the kitchen were properly labeled, dated, and covered. During an observation in the Bistro kitchenette, several food items were found without proper labeling or dating, including two pieces of pizza, multiple pieces of sliced pepperoni, half of a chocolate cream pie, a piece of cherry pie, and two ham sandwiches. Additionally, some items were past their best by dates, such as a container of Yoplait peach yogurt and a carton of vanilla ice cream. In the freezer, a Lean Cuisine dinner and an uncovered Dairy Queen Blizzard cup were also noted. Similarly, the walk-in refrigerator contained undated sandwiches and a container labeled with a date that was not compliant with the facility's policy. The dietary manager confirmed that the task of removing outdated food items was recently added to the kitchen staff's weekly cleaning checklist. The facility's policy requires all food items to be properly covered, dated, and labeled before being placed in any refrigerator or freezer. The 2019 Food and Nutrition Services in Healthcare Policy and Procedure Manual specifies that leftovers must be dated, labeled, covered, cooled, and stored in a refrigerator, which was not adhered to in this instance.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by observations of strong urine odors and unclean conditions in both public areas and resident rooms. Specifically, the 300 wing's public area had lounge chairs with urine odor and stained carpets. Resident rooms, particularly those of residents 12 and 18, were found to be in disarray, with strong urine odors, clutter, and unclean surfaces. Resident 18's room contained various items scattered on the floor, including medical supplies and personal belongings, and was observed in the same condition over multiple days. Interviews with staff and family members highlighted ongoing concerns about cleanliness and maintenance. Resident 12's daughter expressed dissatisfaction with the facility's upkeep, noting persistent urine odors and inadequate room conditions. The facility's cleaning procedures, as described by a housekeeper, included daily tasks such as trash removal and surface cleaning, but did not address dusting if residents were present. Despite having a system where staff members acted as advocates to review room cleanliness and address resident concerns, the issues persisted, indicating a failure to ensure a clean and homelike environment.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The provider failed to investigate an injury of unknown origin for a resident who was sent to the emergency department due to an unresponsive episode. Upon returning to the facility, the resident was transferred using a sit-to-stand lift, during which the resident's daughter noticed instability in the resident's left leg. Despite complaints of pain and a subsequent X-ray revealing an acute, displaced oblique fracture, the facility did not investigate the cause of the injury. The director of nursing was aware of the resident's pain and had notified the primary care provider and family, but did not reach out to the emergency department for further information or report the fracture to any outside agency. The facility's policy requires all reports of resident abuse, including injuries of unknown origin, to be reported and thoroughly investigated. However, there was no documentation to support that an investigation was completed for the resident's fracture. The director of nursing confirmed that no investigation was conducted and that the fracture was not reported to the South Dakota Department of Health. The resident had a history of pathological fractures, but the lack of investigation and reporting was a violation of the facility's policy.
Care Plan Deficiencies in LTC Facility
Penalty
Summary
The provider failed to ensure that care plans for five of eight sampled residents were followed, updated, and revised promptly to reflect their current status and care needs. For Resident 18, there was a lack of adherence to contact precautions as the CNA was unaware of the specific precautions required, despite the resident having a compromised immune system and a history of ESBL in urine. Additionally, the care plan for Resident 18 included the use of an AFO for transfers and ambulation, which was not being utilized as the resident was dependent on a sit-to-stand lift and did not ambulate. Resident 29's care plan did not reflect the use of a Velcro strap for his left foot, which was necessary to prevent it from sliding off the wheelchair pedal. The resident was paralyzed on the left side and required assistance with the placement of Velcro straps on his hand and foot. Similarly, Resident 26's care plan did not include information regarding the use of a seat belt on his wheelchair, despite a physician's order for its use. The resident was able to remove the seat belt himself, but staff members continued to place and latch it around him. Resident 46's care plan included the use of a full-body mechanical lift for transfers, but the interventions for his risk of falls and injuries were not adequately addressed. The care plan for Resident 6 included a specific bed height marked by blue tape, which was missing from the wall, leading to staff estimating the bed height. The interdisciplinary team was responsible for updating care plans, but there was a failure to ensure that care plans were revised as residents' conditions changed, leading to inconsistencies in care delivery.
Deficiencies in Oxygen Orders, Therapeutic Boots, and Documentation
Penalty
Summary
The facility failed to ensure that two residents using oxygen concentrators had the necessary physician orders for oxygen administration. Observations revealed that an oxygen concentrator was present in the room of one resident, who had been using it since returning from the emergency department, yet there was no physician order or care plan documentation for its use. The Director of Nursing confirmed the absence of an order and was unaware of the resident's oxygen use, noting that the concentrator was intended for another resident, who also lacked an order for oxygen. Another deficiency involved a resident who was supposed to use therapeutic boots as per physician orders. Observations showed that the only brace found in the resident's room was an AFO, not the prescribed Multipodus or Thera-boots. Interviews with staff, including the Director of Nursing and the Director of Rehab, confirmed the absence of the required boots and highlighted a misunderstanding regarding the types of braces ordered. The resident's care plan did not reflect the physician's orders for the therapeutic boots. Additional issues included inaccurate meal documentation for a resident who had significant weight loss and required assistance with meal setup. The documentation inaccurately reflected meal consumption, as the CNA responsible for the documentation had not observed the meal intake. Furthermore, a resident using Velcro straps for stabilization had not been assessed for restraint use, contrary to the facility's policy. Lastly, a resident self-administering medication did not have a complete evaluation listing the medications he was allowed to self-administer, as required by the facility's procedures.
Failure to Maintain Proper Water Temperatures in Kitchen
Penalty
Summary
The provider failed to maintain the required water temperatures in the three-compartment sink in the kitchen, which increased the potential risk of foodborne illnesses for the residents. Observations revealed that the wash water temperature was consistently documented as 90 degrees Fahrenheit or lower, contrary to the required 110 degrees Fahrenheit. Additionally, the sanitizer water temperature was not maintained at the required 75 degrees Fahrenheit. Interviews with kitchen staff, including a cook and the dietary supervisor, indicated a lack of awareness and understanding of the correct temperature requirements. The dietary supervisor admitted to not knowing the expected wash water temperature and only reviewed logs to ensure documentation was completed, not to verify if the data was within expected parameters. A review of the August 2024 Three-Compartment Sink Log showed discrepancies, with wash water temperatures either exceedingly high or low, and no wash water temperatures documented for the entire month. The sanitizer water temperature was often recorded in the wrong column, and many recorded PPMs were below the expected range. The deficiency was identified as an immediate jeopardy situation, requiring immediate corrective action. The provider's failure to adhere to the Food and Drug Administration's recommendations and their own policy for maintaining proper water temperatures in the kitchen's three-compartment sink posed a significant risk to the health and safety of the residents receiving meals prepared in the facility.
Removal Plan
- DM educated all dietary staff on the 3 sink method, 3 compartment sink order, 3 compartment sink steps, water temperature in a 3 compartment sink, sanitizer temp, and when it is essential to clean and sanitize a utensil, sanitizer per manufacturer recommendations that include submerging for at least 1 minute.
- Education to dietary staff on compartment sink log requirements of testing temps and sanitizer ppm, including action required if temps are not within the requirements.
- DM, primary dayshift cook, primary evening cook, are enrolled in ServSafe Certification.
- All new dietary staff will receive ServSafe certification.
- A new log was created by DM to record wash, rinse, sanitizer water temperatures, and sanitizer ppm with each use, including what to do if temps or ppm are outside of parameters.
- LNHA provided education to DM on the policy and procedure manual, including 3 compartment sink method regulations, job description of the dietary manager including adherence to policies and ensure that sanitary regulations are followed by the entire department.
- Education provided on supervisory roles including ensuring the department adheres to State and Federal regulations, and assuming the authority, responsibility and accountability to carry out the duties of the dietary department, monitor use of equipment and chemicals, and ensuring required documentation is completed and appropriate per regulations.
- Education included reporting to LNHA any areas of concern within the dietary department, equipment, and chemicals.
- Dietary manager will complete ServSafe certification.
Dietary Supervisor Lacks Required Training and Certification
Penalty
Summary
The provider failed to ensure that the dietary supervisor met the necessary requirements to manage the food and nutrition services effectively. The dietary supervisor, who assumed the position on a part-time basis in February 2024, was also working part-time as the human resources director. At the time of the interview, the dietary supervisor had not completed the required dietary manager training program and was not aware of the state and federal regulations related to her position. Additionally, the dietary supervisor had not completed the required ServSafe training program. Although a registered dietician consulted at the facility, it was not on a full-time basis. The job description for the dietary supervisor position required certification as a dietary manager or a commitment to become certified within four months of employment, as well as maintaining current ServSafe certification.
Infection Control Breach During Meal Service
Penalty
Summary
The provider failed to maintain proper infection control and prevention practices during a meal service, as observed with one cook, identified as cook C. During the preparation of the noon meal, cook C was seen using gloved hands to cover metal containers with aluminum foil, then reaching into her pocket to retrieve a permanent marker, which she used to write on the foil before returning it to her pocket. She continued to use the same gloves to handle various kitchen items, including oven mitts, pans, cabinet doors, drawer handles, and meal service utensils, without changing gloves. Cook C eventually removed the gloves, citing sweaty hands, and performed hand hygiene before donning a new pair of gloves. Further observations revealed that cook C used a damaged food processor cover, which was cracked and missing a piece of plastic, to puree pasta. After use, she washed the cover in a three-compartment sink and left it to dry. Additionally, while plating food items, cook C used the same gloves to touch the food service cart, retrieve clean cups, operate the microwave, and handle food items without changing gloves between tasks. The dietary supervisor confirmed that gloves were not used properly, increasing the risk of cross-contamination. The facility's policy on glove use emphasized the need for glove changes to prevent contamination, which was not adhered to in this instance.
Resident Safety Compromised Due to Improper Use of Tub Chair Belt
Penalty
Summary
The provider failed to ensure the safety of a resident who fell from a tub chair due to the improper placement of a lap belt intended to secure the resident. The incident occurred when the lap belt was not placed around the resident, leading to the fall. Following the fall, the resident was assessed at the facility and found to have no apparent injuries. However, the resident was transferred to the emergency room for further evaluation, where X-rays showed no bone fractures, but low blood pressure was identified.
Failure to Accurately Assess Elopement Risk
Penalty
Summary
The provider failed to ensure an accurate assessment of elopement risk for a resident who successfully eloped from the facility. The resident, who had a diagnosis of dementia with agitation and anxiety, was able to enter the code to turn off the alarms on the door to the enclosed patio and courtyard, exit the courtyard, and walk approximately two blocks from the facility before being found. The resident's medical records indicated a SLUMS score suggesting possible dementia and a Brief Interview of Mental Status score indicating intact cognition. However, the resident's Elopement Risk Assessment conducted on 6/14/24 classified him as low risk for elopement, despite previous behaviors of wandering and exit-seeking. The resident's care plan included interventions for his wandering and exit-seeking behaviors, such as staff education, 1:1 visits, and constant supervision. However, these interventions were not effectively implemented, as evidenced by the resident's ability to elope. Interviews with staff revealed that the resident often wandered and had a history of going outside without informing anyone. Despite these behaviors, the staff did not consider the resident at risk for elopement until after the incident on 6/24/24. The facility's policies on wandering and elopements and resident assessments were reviewed, indicating that the facility aimed to identify residents at risk for unsafe wandering and involve all care team members in the assessment process. However, the facility's failure to accurately assess and address the resident's elopement risk led to the deficiency. Interviews with the facility's administration and staff highlighted a lack of recognition of the resident's elopement risk and insufficient monitoring and intervention to prevent the elopement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Belle Fourche
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spearfish Canyon Healthcare | 10.8 mi | ★★★★★ | 13 | 0 |
| Monument Health Sturgis Care Center | 23.6 mi | ★★★★★ | 4 | 0 |
| Crook County Medical Services District Long Term C | 31.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.