Rolling Hills Healthcare

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

55.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 57 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 43.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 51 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.38 therapist hours per resident per day in 2026Q1 — more than 65% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 83 beds and averages 58.1 residents a day — about 70% occupied, or roughly 25 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.47 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.90 on weekdays — 25% thinner on weekends — a notable drop. RN hours go from 0.66 to 0.37 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 65% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

34 citations, most serious first. The 15 most serious are shown; the remaining 19 are one tap away and print in full.

• Immediate jeopardy · Lcited before2024-09-04 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, job description review, and policy review, the provider failed to: *Maintain the temperature of the water in the three-compartment wash sink in the kitchen at a minimum of 110 degrees Fahrenheit (F). *Maintain the temperature of the water in the three-compartment sanitizer sink in the kitchen at a minimum of 75 degrees F. Those failures increased the potential risk of foodborne illnesses for the entire resident population who received meals that were prepared in the kitchen. Findings include: 1. Observation on 9/3/24 at 12:15 p.m. in the kitchen near the three-compartment sink revealed: *On the wall above the sink posted signage read: Dishwashing By Hand: The Basics. -Wash: 110 degrees F with detergent. -Sanitize: 75 degrees F with sanitizer. *A September 2024 Three-Compartment Sink Log that kitchen staff documented the temperature of the wash water used in the wash sink. -Wash Temp [temperature]: 110 degrees F was type-written at the bottom left corner of the log. -Five of five documented wash water temperatures were 90 degrees F or…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2026-02-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, interview, and policy review, the provider failed to identify, monitor, and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (3) who developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his buttocks. Findings include:1. Observation on 2/10/26 at 11:09 a.m. of resident 3 in his room revealed:*There was a cushion in his wheelchair seat.*He had an air mattress on his bed.*Resident 3 was sitting in his recliner.*There was no pressure relieving cushion in his recliner.2. Review of resident 3's electronic medical record (EMR) revealed:*He was admitted to the facility from the hospital on 8/14/25.*His 11/21/25 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated his cognition was moderately impaired.*His diagnoses included diabetes (a condition involving disruptions in how the body regulates blood sugar), stage four kidney disease (severe kidney damage) with dependence on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-09-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, interview, record review, and policy review, the provider failed to ensure staff implemented interventions for one of one sampled resident (1) identified with risk for burns from hot liquids, who subsequently sustained a burn from hot coffee. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: Her admission date was 4/15/25.The resident's Hot Liquid Safety Evaluation with an effective date of 9/8/25 indicated she required a cup with a lid or other adaptive cup and a clothing protector and/or lap protector when she drank hot liquids.Resident 1's 9/8/25 revised care plan revealed: I am at risk for hot liquid spills, please ensure I use a cup with a lid and am sittingupright for all hot beverages.Her 9/10/25 Brief Interview for Mental Status (BIMS) assessment score was 14. That indicated she had no cognitive deficits.2. Review of the provider's 9/10/25 FRI regarding resident 1 revealed:On 9/10/25, resident 1 had requested certified nurse aide (CNA) H to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-01-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, record review, interview, and personnel file review, the provider failed to protect the resident's right to be free from physical abuse by one of one registered nurse (RN) (B) while providing evening cares for one of one sampled resident (1). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 1/15/25 SD DOH FRI revealed the provider had determined physical abuse had occurred when RN B slapped resident 1 while providing evening cares on 1/14/25. Observation on 1/28/25 at 10:00 a.m. in resident 1's room revealed: *She was sleeping in her recliner with a blanket over her lap. *A gray call light was on the bedside table to her right. *She had a fall mat on the floor next to her bed. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Actual harm · Gcited before2024-10-17 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation, record review, and policy review, revealed the provider failed to ensure one of one sampled resident's (3) pressure injuries had been identified, assessed, documented, and her physician was notified. Findings include: 1. Interview on 10/16/24 at 8:05 a.m. with director of nursing (DON) B regarding resident 3's Stage III pressure ulcer that was listed on the facility provided Matrix revealed that pressure ulcer was healed at the beginning of September 2024. Interview on 10/17/24 at 10:09 a.m. with certified nursing assistant (CNA) N regarding resident 3's skin concern revealed: *She had sores on her buttock and on her inner thigh, one [is the] size of [a] quarter [the] other's [the] size of [a] dime. -She had sores on her heels in the past, but currently did not. *She had notified licensed practical nurse (LPN) M of the sores. Interview on 10/17/24 11:05 AM with CNA I regarding resident 3's skin revealed: *She had a little tiny one [sore] in between her thighs. -She thought a nurse was aware. Interview on 10/17/24 at 11:29 a.m. with DON B regarding…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-02-12 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on Payroll Based Journal (PBJ) reports, interview, schedule review, and facility assessment review, the provider failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours of coverage for six days in quarter four (July 1 through September 30) of fiscal year 2025 and for two of fourteen days (1/29/26 and 1/31/26) between 1/28/26 and 2/10/26. Findings include:1. Review of the PBJ report for quarter 4 of fiscal year 2025 revealed the provider did not have RN coverage for eight consecutive hours on 7/4/25, 7/19/25, 7/26/25, 7/27/25, 8/30/25, and 8/31/25.2. Interview on 2/10/326 at 8:30 a.m. with administrator A during the entrance conference revealed the provider did not have any nurse staffing waivers.3. Interview on 2/12/26 at 8:37 a.m. with administrator A revealed there were not eight consecutive hours of RN coverage on 7/4/25, 7/19/25, 7/26/25, and 7/27/25.*An RN had not been scheduled to work on 7/4/25, 7/19/25, 7/26/25, and 7/27/25.4. Interview on 2/12/26 at 10:51 a.m. with assistant director of nursing (ADON) C revealed:*There were not eight…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
  Provide safe and appropriate respiratory care for a resident when needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding the storage of oxygen equipment for four of four sampled residents (1,18, 49, and 69) who required the use of oxygen. Findings included: Observation and interview on 2/10/26 at 10:02 a.m. with resident 1 in his room revealed: *He was lying in bed with his nasal cannula on which was connected to his oxygen concentrator (a device that filter room air into purified oxygen) beside him. *His wheelchair was positioned next to his bed and had a portable oxygen tank hanging on the back. There waws a nasal cannula connected to the oxygen tank that was laying on the floor underneath the wheel of the wheelchair. *The resident stated that the staff assisted him with removing and reapplying his nasal cannula. 2. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *His 12/15/25 Brief Interview of Mental Status (BIMS)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-12 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure the resident's medications were labeled and discarded for: Two of two sampled residents (7 and 18) who had opened boxes of nasal spray (Flonase) which that were not kept available for use after their use-by date. Two of two sampled residents (18 and 62) whose pain medications (hydrocodone and oxycodone) were not labeled according to their physician's order. One of one sampled resident's (15) inhaler that was expired and was not stored in a secure location. Findings include:1. Observation and interview on 2/10/26 at 10:15 a.m. of the 400 hall medication cart with certified medication aide (CMA) K revealed: *There were two opened boxes of residents' Flonase nasal sprays. *Resident 7's nasal spray had a use-by date of 6/25/25, and resident 18's nasal spray had a use-by date of 12/29/25. *CMA K stated that nasal sprays were labeled with use-by dates, and the staff were expected to review those dates before administering…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-02-12 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding:*Hand hygiene (handwashing) by two of two certified medication aides (CMA) (K and L) during medication administration for three of three sampled residents (46, 55 and 65).*An indwelling urinary catheter (flexible tubing inserted into the bladder to drain urine) being kept off the floor for one of one sampled residents (49).*The use of enhanced barrier precautions (EBP), glove and gown use when providing contact care, by the staff for three of three residents (3, 7, and 9) who were on enhanced barrier precautions (EBP), and one of one sampled resident (3) who was transferred by two of two staff members (certified nursing assistant (CNA) O and care assistant W) without using EBP.Findings include:1. Observation and interview on 2/10/26 at 1:45 p.m. with CMA K revealed: *She had prepared resident 55's nebulizer (a device that converts liquid…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0554 — isolated
  Allow residents to self-administer drugs if determined clinically appropriate.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, manufacturer's recommendations for use, and policy review, the provider failed to ensure residents were evaluated for the ability to safely administer their medications or had a physicians order for two of two sampled residents (55 and 65) who were observed self-administering their medications and for 0ne of one sampled resident (62) observed with a medication left at her bedside by one of one certified medication aide (CMA) (M). Findings include: 1.Observation and interview on 2/10/26 at 1:45 p.m. with CMA K in resident 55's room revealed CMA K administered resident 55's nebulizer (a device that converts liquid medication it an inhalable mist) treatment. After placing the nebulizer medication inside the medication cup, CMA K attached the face mask to the medication cup and secured the nebulizer mask over resident 55's nose and mouth. CMA K started the nebulizer machine, and turned the machine on to start the treatment. CMA K stated she would return to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0578 — failed to honor advance directives / code status — isolated
  Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure a resident's advance directives (a legal document that expresses a person's health care wishes if they become unable to speak for themselves)/code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) was accurately documented for staff to implement the resident's chosen wishes for one of one sampled resident (20) with documented code status discrepancies.Findings include: 1. Review of resident 20's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE].*Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 7, which indicated her cognition was severely impaired.*There was a banner displayed in her EMR, which indicated that she did not want CPR (cardiopulmonary resuscitation, an emergency procedure to provide chest compression and often rescue breathing to preserve brain function and maintain blood circulation).*Her care…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-12 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan was reviewed with the resident or the resident's representative within 48 hours of the resident's admission to the facility for three of six newly admitted sampled residents (3, 61, and 69). 1. Review of resident 3's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *His baseline care plan scanned into his EMR on 9/22/25 and was not dated or signed by the staff member who completed it. *There was no signature from resident 3 or their representative to indicate resident 3's baseline care plan was reviewed with them. 2. Review of resident 69's EMR revealed: *She was admitted to the facility on [DATE]. *Her 1/30/26 baseline care plan signed by LPN/wound care nurse G. *There was no signature from resident 69 or their resident representative to indicate resident 69's baseline care plan was reviewed with them. 3. Interview on 2/11/2026 at 3:00 p.m. with ADON C…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-12 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed nursing professional standards of practice for following physician's orders for insulin administration for one of one sampled resident's (67) who was administered according to the physician's order by one of one observed licensed practical nurse (LPN) (H). Findings include:1. Observation and interview on 2/11/26 at 8:20 a.m. with LPN H in resident 67's room revealed she was checking the resident's blood sugar level. The amount of Novolog (insulin) she would administer to the resident was contingent upon the resident's blood sugar level.Resident 67's blood sugar level was 232. LPN H was not surprised that the number was a little high because the resident had already eaten two breakfasts that morning.2. Interview and review of resident 67's medication administration record (MAR) on 2/11/26 with LPN H revealed there was a 5/24/25 Novolog insulin physician order that indicated, based on the resident's blood sugar level of 232, that she was to receive three units of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-29 · tag F0699 — isolated
  Provide care or services that was trauma informed and/or culturally competent.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, record review, interview, job description review, and policy review, the provider failed to implement comprehensive trauma-informed care for one of one sampled resident (1) with post-traumatic stress disorder (PTSD-a disorder in which an individual has difficulty recovering after experiencing or witnessing a traumatic event). Findings include: 1. Review of the provider's 9/10/25 FRI revealed resident 1 had requested certified nurse aide (CNA) H to fill her Thermos cup with coffee. Shortly after filling and returning that cup to the resident, the resident was heard calling out for help from her room. She stated that when the coffee reached her mouth, it was hot, and she expelled the coffee from her mouth onto her chest, resulting in a hot liquid burn.When director of nursing (DON) B spoke with resident 1 after the incident, the resident became upset. She told DON B that, as a child, her mother had burned her. The facility was aware that resident 1 had experienced childhood abuse, but did…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-29 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, summary of investigation review, record review, interview, and policy review, the provider failed to ensure a resident's medication needs were met, which included ensuring:A physician-ordered PRN (as needed) medication for the treatment of prolonged seizure activity was available for administration to one of one sampled resident (1).A physician-ordered PRN medication was accurately transcribed in one of one sampled resident's (1) electronic medical record (EMR).Findings include: 1. Review of the provider's 8/5/25 FRI revealed:On 8/4/25, resident 1 fell out of her bed and onto the floor. The fall was not witnessed. Staff heard the noise of the fall and responded by finding [resident 1] next to her bed. She continued to seize [a sudden burst of abnormal electrical activity in the brain that may include uncontrolled muscle movement and changes in a person's level of awareness] for many more seconds. [The] Nurse who discovered her [resident 1] called for support. [That nurse] Attempted to…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$80,634 in federal fines across 4 penalties.

• $25,490 — penalty dated 2025-09-29
• $7,008 — penalty dated 2025-01-28
• $16,656 — penalty dated 2024-10-17
• $31,480 — penalty dated 2024-09-04

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to EDURO HEALTHCARE — 34 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $369K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in SD