Rolling Hills Healthcare: Accident Harm Cited - SD
Social Services Director G admitted during a September inspection that she never attempted to gather psychiatric information about Resident 1 from multiple sources identified in the patient's medical records. The resident had been discharged from a hospital on April 15, 2025, with a discharge summary that identified a psychiatrist. A June 16 psychiatry progress note referenced a therapist.
The director also failed to contact the resident's caseworker at a developmental disability program, who served as the patient's contact person and had access to an individual service plan used to manage the resident's PTSD and mental health concerns.
Most recently, the resident had seen a counselor on September 16, just two weeks before the inspection. That counselor had encouraged the resident to use specific exercises when feeling anxious. Director G acknowledged these exercises "may have been appropriate to have been carried over and implemented by the nursing home staff."
She never followed up with the counselor about those techniques.
When asked, Director G agreed the resident would have no problem signing a release of information to allow her to obtain records from the psychiatrist, therapist, and other mental health professionals. No such releases had been requested.
The facility's own policies required exactly the kind of coordination Director G had avoided. Rolling Hills Healthcare's revised Trauma Informed Care policy, dated June 16, 2025, mandated a "multi-pronged approach to identifying a resident's history of trauma" that included screening tools and assessments.
The policy specifically required staff to ask residents "about triggers that may be stressors or may prompt recall of a previous traumatic event." It demanded collaboration with "the resident's family, friends, the primary care physician, and any other health care professionals such as psychologists and mental health professionals to develop and implement individualized care plan interventions."
For residents reluctant to share trauma history, the policy instructed staff to "still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident."
None of this had happened for Resident 1.
The social services director's job description made clear her responsibility to ensure "the medically related emotional and social needs of the resident are met and maintained on an individual basis." The inspection found she had failed to meet this basic requirement.
The resident had an established network of mental health support before arriving at Rolling Hills Healthcare. A psychiatrist had been involved in hospital care. A therapist had provided ongoing treatment. A developmental disability agency had created an individual service plan specifically designed to address PTSD and mental health concerns. A counselor had recently worked with the resident on anxiety management techniques.
Director G had contacted none of them.
The failure occurred despite clear documentation in the resident's medical records identifying these professionals and their roles in the patient's care. The April hospital discharge summary named the psychiatrist. The June psychiatry progress note referenced the therapist. The developmental disability caseworker was listed as the resident's contact person.
The inspection revealed a pattern of missed opportunities to provide trauma-informed care for a vulnerable resident. Federal inspectors found the facility had violated requirements for comprehensive assessments and care planning for residents with mental health needs.
Rolling Hills Healthcare's policies promised individualized interventions developed through collaboration with mental health professionals. The reality was a social services director who never picked up the phone to call a single one of them.
Resident 1 remained at the facility without the benefit of psychiatric insights that could have informed daily care decisions, anxiety management strategies that had been proven effective, or care plan interventions based on professional mental health assessments conducted by specialists who knew the patient's trauma history.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rolling Hills Healthcare from 2025-09-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 1, 2026 · Our methodology
ROLLING HILLS HEALTHCARE in BELLE FOURCHE, SD was cited for violations during a health inspection on September 29, 2025.
The resident had been discharged from a hospital on April 15, 2025, with a discharge summary that identified a psychiatrist.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.