Rolling Hills Healthcare

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

9/29/25 at 2:00 with director of nursing (DON) B revealed that after resident 1's 9/10/25 burn, she had observed the resident between 9/11/25 and 9/16/25 to ensure her coffee was being served in a lidded mug.

Those audits ended after 9/16/25.DON B had not seen resident 1 use anything other than her lidded Thermos cup to drink hot beverages.6. Observation on 9/29/25 at 2:05 p.m. of resident 1 in her room with DON B and interview with resident 1 revealed the resident was lying in her bed. The resident's Thermos was not seen. Resident 1 did not know where her Thermos was or when she last saw it.Resident 1 stated that she sometimes used an unlidded coffee mug from the kitchen to drink her coffee from.Interview on 9/29/25 at 2:10 p.m. with DON B confirmed that neither the recommendations from resident 1's above Hot Liquid Safety Evaluation nor the intervention on her above care plan to ensure she used a cup with a lid for hot beverages were followed to mitigate resident 1's risk for burns from hot liquids.Review of the provider's Quarter 3, 2018 Safety of Hot Liquids policy revealed:4. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include b. Serving hot beverages in a cup with a lid;Review of the providers' revised 5/16/25 Incidents and Accidents policy revealed:Policy Explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

did not attempt to obtain psychiatric information regarding resident 1 from either the psychiatrist identified

in the resident's 4/15/25 hospital discharge summary or the therapist referred to in the 6/16/25 psychiatry progress note.She did not request a copy of the resident's individual service plan that the DD agency had followed to manage the resident's PTSD and mental health concerns from resident 1's contact person, who was also the resident's caseworker at the DD program. SSD G had not followed up with the counselor referred to above, whom the resident 1 saw on 9/16/25, regarding the exercises the resident was encouraged to use when she was anxious. She agreed that those exercises may have been appropriate to have been carried over and implemented by the nursing home staff. SSD G felt that resident 1 would have no problem signing a release of information to allow SSD G to obtain records from the above individuals.

Review of the provider's revised 6/16/25 Trauma Informed Care policy revealed:2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, an others.4. The facility will 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.10. In situations where a trauma survivor is reluctant to share their history, the facility will 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.Review of the provider's undated Social Services Director (SSD) job description revealed it was the responsibility of that SSD to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/29/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

in mid-August 2025 to resident 1's medical provider. An order for an alternative seizure medication for resident 1 and the discontinuation of the PRN Diazepam nasal spray. She had not received any response to that request.DON B confirmed that resident 1's primary medical provider or other medical providers within that medical practice group were in the facility for resident visits no less than three times weekly. DON B did not speak face-to-face with any of those providers regarding an alternate seizure medication option for resident 1 and the discontinuation of the PRN Diazepam nasal spray.Review of the provider's revised 6/15/25 Medication Orders policy revealed:3. Elements of the Medication Order: [included] j. Diagnosis or indication for use.4. Documentation of Medication Orders: [included] b. Clarify the order.Review of the provider's revised 6/15/25 Medication Reordering policy revealed:2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner.5. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician.

Event ID:

Facility ID:

If continuation sheet