Rolling Hills Healthcare

F-F600 occurred on 5/15/24 and based on the provider's implemented corrective actions for the deficient practice confirmed on 6/27/24, the non-compliance is considered past non-compliance.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 6 435035 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435035 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare 2200 13th Ave Belle Fourche, SD 57717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 43844 potential for actual harm Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, Residents Affected - Few 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.

Findings include:

1. Review of the provider's 6/24/24 (DATE) SD DOH FRI revealed:

*On 6/24/24 at 5:05 a.m. resident 1's walker was found by the courtyard door.

-At 5:27 a.m. resident 1 was found in walking in a field.

-He was returned to the facility, assessed, and was found with no injuries.

Review of resident 1's medical record revealed:

*His 5/28/24 SLUMS (a brief screening test for detecting mild cognitive impairment and dementia) score was

a 14 out of 30, which indicated he may have dementia.

*His 3/20/24 Brief Interview of Mental Status score was a 15, which indicated his cognition was intact.

*His 6/14/24 Elopement Risk Assessment revealed he had no wandering behaviors and was at low risk for elopement.

Review of resident 1's 6/27/24 care plan indicated:

*A 6/12/24 focus area that included:

-He had a diagnosis of dementia with agitation and anxiety.

-He wandered outside, into other resident's rooms, hallways, and urinated outside.

*Interventions for that focus area included staff were:

-To educate him when his behavior included going in and out of other resident rooms, was exit seeking and setting off alarms.

-To provide a 1:1 (one to one) visits when he is displaying depressive moods or feeling down, when highly agitated, exit seeking, angry or aggressive.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 6 435035 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435035 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare 2200 13th Ave Belle Fourche, SD 57717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 -To escort him outside, provide constant encouragement, and redirection.

Level of Harm - Minimal harm or *A 6/24/24 focus area that indicated he was an elopement risk due to a successful elopement. potential for actual harm -He had made statements of wanting to leave, intending to leave, and he had sufficient mobility to exit Residents Affected - Few unescorted.

-Staff were to notify his physician of any elopements and to follow the provider's elopement policy.

*Additional individualized interventions included staff were to:

--Observe him for his knowledge of alarm codes and notify administrator [ADM] A if resident knows codes. Provide constant supervision with 1:1 supervision when he is stated he planned to leave facility.

-Offer him to take walks through the courtyard with staff throughout the day.

Review of resident 1's progress notes revealed:

*On 5/11/24 a nurse's note that included:

-On 5/10/24 at 19:15 (7:15 p.m.) an unidentified certified nurse aide (CNA) had seen resident 1 walking along the street

-At that time she [CNA] was sitting with the wife, who was in their vehicle. Resident had at some point gotten out of the vehicle and refused to get back in because he refused to come back to the facility.

-At 19:45 (7:45 p.m.) the cop showed up at the facility with resident.

-Resident (1) agreed to come into facility, but stated that he intended to leave as soon as staff turned their back.

-Frequent checks have been made on resident.

*A 6/5/24 certified nurse practitioner note (CNP) that indicated:

He had intermittent periods of confusion.

-Has had some desire to exit building, enjoys spending time in the sun. Elopement in past.

*A 6/8/2024 nurse's behavior note that noted, Resident will not remain in the facility and he has now been going outside to urinate. Resident will not listen to staff redirection. Resident refuses any and all behavior interventions suggested by staff. Cont. [continue] to attempt and monitor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 6 435035 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435035 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare 2200 13th Ave Belle Fourche, SD 57717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 -A follow-up note to that behavior note that indicated Staff have tried: distraction, redirection, wii [Wii] games, 1:1, encouraging resident to relax in recliner with feet up, reading a book, conversing with staff, family phone Level of Harm - Minimal harm or calls. Resident will not accept any interventions and is noncompliant with education given regarding peeing potential for actual harm outside and or wandering.

Residents Affected - Few *A 6/9/24 note to redirect him from doors, and to walk with him when he is wandering.

-He was not easily redirected.

-He did allow staff to escort him outside to the patio.

-He was worked up and anxious, he has been wandering all shift.

Interview on 6/27/24 at 2:34 p.m. with CNA E regarding resident 1 revealed:

*Resident 1 often went outside to the courtyard and staff would assist him back in.

-There were two doors he would go out, one by the dining room and the other at the end of the hall where he resided.

Interview on 6/27/24 at 2:44 p.m. with licensed practical nurse C regarding resident 1 revealed:

*She thought he was at risk for elopement.

-Staff were monitoring him as he often went towards the courtyard doors.

*Elopement assessments were completed by a nurse when a resident was admitted for care.

-She thought other assessments were done on a quarterly basis.

Interview on 6/27/24 at 2:55 p.m. with CNA G regarding resident 1 revealed:

*On 6/24/24 at 5:00 she arrived at work.

-She heard a code pink announcement, which meant a resident was missing.

-The code was to search for resident 1.

*Resident 1 often wandered, and had a history, prior to 6/24/24, of going outside and not telling anyone.

*Resident 1 wore a call light pendant, and staff were to make sure he had it on.

-The call light pendant had been found in his trash can several times.

Interview on 6/27/24 at 3:09 p.m. with director of rehabilitation/speech therapist F regarding resident 1 revealed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 6 435035 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435035 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare 2200 13th Ave Belle Fourche, SD 57717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 *Resident 1 had an elopement on 6/24/24.

Level of Harm - Minimal harm or *He had slipped through the courtyard and crossed the field. potential for actual harm *He was exit seeking prior to that incident and he was normally easy to re-orientate. Residents Affected - Few *She stated, The fact that he was previously exit seeking and at home with [the] same behavior I believe is relevant to this specific investigation.

Interview on 6/27/24 at 3:30 p.m. with ADM A and director of nursing (DON) B regarding resident 1 revealed:

*ADM A said on 5/11/24 resident 1 had gone on an outing with his wife.

-He had walked away from her, knowing that she would follow him.

-She thought his wife had eyes on him at all times, therefore they had not considered it an elopement.

-He had told ADM A I just wanted to walk.

*DON B thought the 6/5/24 CNP statement documented in resident 1's medical record was a misstatement.

-They had stated that he had not eloped from the facility prior to 6/24/24 and was not at risk for elopement then.

*ADM A stated they had determined the root cause for his elopement was that he was angry at his wife for dropping him off [at the facility].

Interview on 6/27/24 at 3:54 p.m. with resident 1's spouse revealed:

*About a month ago he had walked away from her at the store.

-He walked several blocks.

-The police had to come pick him up and return him to the provider's facility.

*This was the first time that had happened.

Continued interview on 6/27/24 at 4:02 p.m. with ADM A and DON B regarding the accuracy of resident 1's assessments revealed:

*DON B indicated when a resident is admitted they have a safety care plan developed.

-They had been monitoring resident 1 for safety since his admission.

*ADM A stated he had made it outdoors to the courtyard by himself just the last few weeks.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 6 435035 Department of Health & Human Services Printed: 09/22/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 435035 B. Wing 06/27/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rolling Hills Healthcare 2200 13th Ave Belle Fourche, SD 57717

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 -He liked to walk through the courtyard.

Level of Harm - Minimal harm or *They both stated they thought his 6/14/24 Elopement Risk Assessment had been coded correctly. potential for actual harm

Review of the provider's 3/2019 Wandering and Elopements policy revealed, The facility will identify Residents Affected - Few residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

Review of the provider's 3/2022 Resident Assessments policy revealed, All members of the care team, including licensed and unlicensed staff members, are asked to participate in the resident assessment process.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 6 435035