Rolling Hills Healthcare: Pharmacy Failures - SD
Social Services Director G admitted during a September inspection that she never attempted to get psychiatric information about the resident from either the psychiatrist identified in the patient's April hospital discharge summary or the therapist mentioned in a June psychiatry progress note.
The resident had been receiving services from a developmental disabilities agency that maintained an individual service plan specifically designed to manage her PTSD and mental health concerns. Director G never requested a copy of that plan from the resident's contact person, who also served as her caseworker at the DD program.
The resident had seen a counselor as recently as September 16, just weeks before the inspection. That counselor had recommended specific exercises for the resident to use when she felt anxious. Director G acknowledged those exercises "may have been appropriate to have been carried over and implemented by the nursing home staff," but she never followed up with the counselor to learn what they were.
When asked about obtaining these records, Director G said the resident "would have no problem signing a release of information" to allow her to get records from the mental health professionals.
The facility's own trauma-informed care policy, revised in June, required exactly the kind of coordination that never happened. The policy mandated that the facility "collaborate with resident trauma survivors, and as appropriate, 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."
The policy also required staff to use multiple approaches to identify a resident's trauma history, including "asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event." It specifically addressed situations where trauma survivors are reluctant to share their history, directing 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."
Director G's job description made her responsible for ensuring "that the medically related emotional and social needs of the resident are met and maintained on an individual basis."
The inspection found that none of this happened for the PTSD patient.
The resident had a documented history with multiple mental health professionals across different treatment settings. Her April hospital discharge summary specifically identified a psychiatrist. A June psychiatry progress note referenced a therapist. The DD agency that had been managing her care maintained detailed service plans addressing her trauma-related needs.
Yet the facility's social services director, whose job required coordinating exactly this type of care, made no effort to contact any of these providers or obtain any of their records.
The September counseling session occurred while the resident was living at Rolling Hills Healthcare. The counselor had given her specific coping strategies for managing anxiety. Staff never learned what those strategies were or how to help the resident use them.
Federal inspectors cited the facility for failing to meet social services standards, finding that the lack of coordination represented minimal harm or potential for actual harm to residents.
The violation highlighted a fundamental breakdown in the facility's trauma-informed care approach. Despite having detailed policies requiring collaboration with mental health professionals and individualized interventions for trauma survivors, the social services director operated in isolation from the very network of providers who knew the resident's specific needs and triggers.
The resident's caseworker at the DD program remained available as a resource. The psychiatrist and therapist who had treated her remained part of her care team outside the facility. The counselor who had just seen her in September had current insights into her mental state and coping strategies.
None of that expertise made it into the resident's care at Rolling Hills Healthcare, where staff remained unaware of the specific exercises she had been taught to manage her anxiety or the triggers that mental health professionals had identified as potentially re-traumatizing.
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 5, 2026 · Our methodology
ROLLING HILLS HEALTHCARE in BELLE FOURCHE, SD was cited for violations during a health inspection on September 29, 2025.
Director G never requested a copy of that plan from the resident's contact person, who also served as her caseworker at the DD program.
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.