Deficiencies (last 4 years)
Deficiencies (over 4 years)
6.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
106% worse than South Dakota average
South Dakota average: 3.3 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 28, 2025
Visit Reason
The inspection was conducted based on a complaint received on 2025-08-05 regarding resident-to-resident incidents of potential abuse and concerns about the facility's investigation and care planning related to these incidents.
Complaint Details
Complaint received on 2025-08-05 regarding resident 1's aggressive behaviors including walking into other residents' rooms, taking items, and choking another resident. The complaint alleged inadequate investigation and documentation by the provider.
Findings
The provider failed to thoroughly investigate incidents of resident-to-resident physical aggression, failed to update the care plan to address resident 1's aggressive behaviors and wandering, and did not follow professional nursing standards for pain assessment, medication administration documentation, and monitoring of mood-altering medication effectiveness.
Deficiencies (3)
Failure to thoroughly investigate resident-to-resident incidents of potential abuse by resident 1, including lack of documentation of staff and resident interviews and skin assessments after incidents.
Failure to develop and revise a complete care plan addressing resident 1's wandering into other resident rooms, verbal and physical aggression, and related interventions.
Failure to ensure nursing services met professional standards including lack of pain assessments in June 2025, inadequate documentation of reasons for as needed medication administration, and lack of documentation of effectiveness or adverse reactions to mood-altering medication (Depakote).
Report Facts
Medication administrations: 47
Falls: 5
Falls: 2
Pain assessment level: 6
Pain assessment level: 4
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to assess compliance with professional nursing standards regarding medication documentation and to ensure safety in the nursing home's transport vehicle following a reported incident.
Findings
The facility failed to ensure timely and accurate documentation of narcotic medication administration for two residents, and failed to secure a resident's wheelchair properly in the transport van, resulting in a spinal fracture to the resident due to equipment malfunction.
Deficiencies (2)
Failure to ensure professional nursing standards of practice regarding timely and accurate documentation of narcotic medications for two sampled residents.
Failure to ensure the nursing home area is free from accident hazards and provides adequate supervision to prevent accidents, resulting in a resident's wheelchair tipping backwards in the transport vehicle and causing a spinal fracture.
Report Facts
Date of incident: Jul 15, 2025
Date of survey completion: Jul 24, 2025
Medication doses not documented timely: 7
Fracture location: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in medication documentation deficiencies and narcotic sign-out issues |
| RN D | Registered Nurse | Named in medication documentation deficiencies |
| RN E | Registered Nurse | Named in medication documentation deficiencies |
| RN F | Registered Nurse | Interviewed regarding narcotic medication documentation practices |
| DON B | Director of Nursing | Interviewed regarding expectations for narcotic medication documentation and staff training |
| CNA G | Certified Nursing Assistant | Transport van driver involved in wheelchair tipping incident |
| CNA H | Certified Nursing Assistant | Accompanied resident during transport and assisted after wheelchair tipped |
| RN I | Registered Nurse | Assessed resident after wheelchair tipping incident |
| Administrator A | Administrator | Interviewed regarding transport van incident and staff training |
| BOA J | Business Office Assistant | Responsible for competency testing of van drivers |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 6, 2025
Visit Reason
The inspection was conducted based on complaints regarding the quality of care, environmental cleanliness, skin care neglect, and respiratory care issues at Aberdeen Health and Rehab.
Complaint Details
The complaint investigation was triggered by concerns about environmental cleanliness, neglect in skin care leading to necrosis and weight loss, failure to implement pressure ulcer prevention, inadequate restorative therapy, respiratory care deficiencies, and improper dishwasher sanitization monitoring.
Findings
The facility failed to maintain a clean and homelike environment, ensure proper skin care and monitoring leading to skin necrosis and significant weight loss in a resident, implement prescribed pressure ulcer prevention interventions, maintain a restorative walking program for a resident, ensure respiratory care needs including timely changing of oxygen and nebulizer tubing, and properly monitor dishwasher sanitization levels.
Deficiencies (6)
Failed to maintain a clean and homelike environment for residents, including buildup of dust, dirt, clutter, unmade beds, and peeling wallpaper.
Failed to protect a resident from neglect related to skin necrosis and significant weight loss, with delayed medical intervention and lack of family notification.
Failed to implement prescribed pressure ulcer prevention interventions, including failure to ensure heel lift boots were worn as ordered.
Failed to effectively implement, monitor, and document a walk to meals restorative program for a resident to maintain mobility.
Failed to ensure respiratory needs of a resident were met, including lack of physician order for oxygen, and failure to change oxygen and nebulizer tubing weekly as per policy.
Failed to monitor and record dishwasher temperatures and chemical sanitizer concentration for the mechanical dishwasher used for cleaning and sanitizing dishes.
Report Facts
Residents affected: 25
Weight loss: 30.4
Chemical sanitizer concentration: 200
Dishwasher wash temperature: 145
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse and Unit Manager | Informed resident's family about necrosis of toes and involved in skin care oversight. |
| DON B | Director of Nursing | Provided information on skin care policies, diabetic foot checks, and respiratory care. |
| DSM F | Dining Services Manager | Provided information on dishwasher use and sanitization monitoring. |
| RN E | Registered Nurse | Provided information on skin care assessments and wound care. |
| ADON C | Assistant Director of Nursing | Provided information on skin care, respiratory care, and resident care plans. |
| MDS Coordinator M | Minimum Data Set Coordinator | Responsible for care plan updates and restorative therapy program oversight. |
| COTA K | Certified Occupational Therapist Assistant | Discharged resident 54 from occupational therapy to restorative therapy. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 6, 2025
Visit Reason
The inspection was conducted based on a complaint intake by the South Dakota Department of Health regarding concerns about the quality of care and treatment for a resident (resident 51) who developed necrosis on both feet and significant weight loss, leading to hospitalization.
Complaint Details
The complaint was substantiated based on review of complaint intake, record review, interviews, and policy review. The complainant reported concerns about neglect, lack of family notification, and inadequate care leading to resident's foot necrosis and significant weight loss. The resident was hospitalized and later admitted to hospice care at a different facility.
Findings
The facility failed to protect the resident's right to be free from neglect by not adequately assessing and providing skin care to prevent skin necrosis and by not monitoring significant weight loss. The resident had untreated foot necrosis related to diabetes and was hospitalized, eventually requiring hospice care. Documentation and communication with family were inadequate, and regular diabetic skin checks were not performed.
Deficiencies (1)
Failure to protect resident from neglect related to assessing and providing skin care to prevent skin necrosis and monitoring significant weight loss.
Report Facts
Weight loss: 30.4
Weight loss: 23
BIMS score: 11
Dialysis frequency: 3
Dates of COVID-19 isolation: Resident 51 had COVID-19 from 12/16/24 to 1/1/25.
Date of survey completion: Survey completed on 02/06/2025.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse E | Registered Nurse | Called doctor and received orders to start antibiotic and make podiatry appointment; contacted resident's family about skin concern. |
| Wound Nurse N | Wound Nurse | Completed Non-ulcer Skin Assessment on 10/29/24; notified family of healed skin tear; participated in weekly wound rounds. |
| Assistant Director of Nursing C | Assistant Director of Nursing | Notified about resident's blackened toes on 1/1/25; arranged podiatry appointment; participated in weekly wound rounds. |
| Certified Medication Aid/CNA O | Certified Medication Aid / CNA | Performed residents' baths; reported skin concerns to nurse. |
| Director of Nursing B | Director of Nursing | Interviewed regarding skin assessments and COVID-19 isolation procedures. |
| Nurse Consultant P | Nurse Consultant | Provided assessment of resident's poor vascular circulation and frailty. |
Inspection Report
Routine
Deficiencies: 1
Date: Jan 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the cleanliness and safety of mechanical stand aid lifts used in the facility.
Findings
The provider failed to ensure that three mechanical stand aid lifts were cleaned after each resident's use, with dust, dirt, and unidentified solid particles observed on the footplates. Staff interviews confirmed inconsistent cleaning practices, and the facility's policy requires cleaning and disinfecting mechanical lifts between each resident use.
Deficiencies (1)
Failure to clean mechanical stand aid lifts after each resident's use, specifically the footplates and safety belts.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Assistant | Named in cleaning process and deficiency related to mechanical stand aid lifts. |
| UMA F | Unlicensed Medication Aide | Named in cleaning process and deficiency related to mechanical stand aid lifts. |
| Administrator A | Administrator | Interviewed regarding cleaning deficiencies and policy. |
| Director of Nursing B | Director of Nursing | Interviewed regarding cleaning deficiencies and policy. |
Inspection Report
Routine
Deficiencies: 4
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pressure ulcer prevention and treatment, pharmaceutical services, and infection control practices.
Findings
The facility failed to update and follow care plans reflecting residents' current needs, including grooming, oral care, and pressure ulcer prevention. Preventative interventions for pressure ulcers were inconsistently implemented, and there were discrepancies in care plans, pocket care plans, and Kardex interventions. Controlled substances awaiting destruction were not properly reconciled. Infection control practices, including hand hygiene and cleaning of equipment, were not consistently followed.
Deficiencies (4)
Failed to follow, revise, and update care plans for four sampled residents to reflect current needs, including grooming and oral care.
Failed to ensure preventative interventions and consistent implementation of pressure ulcer care for residents with pressure ulcers.
Failed to establish a system to accurately reconcile controlled substances awaiting destruction in medication rooms.
Failed to ensure proper infection prevention and control practices including hand hygiene, glove use, and cleaning of mechanical lifts between resident use.
Report Facts
Deficiencies cited: 4
Pressure ulcer measurements: 0.8
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 1
Discrepancy in morphine sulfate solution: 13.75
Remaining morphine sulfate solution: 14.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse manager O | Nurse Manager | Received undated pocket care plan for resident 52 and provided interview regarding care plan updates. |
| CNA P | Certified Nursing Assistant | Interviewed regarding resident 59's pressure ulcer care and resident 52's grooming and personal hygiene. |
| CNA Q | Certified Nursing Assistant | Interviewed regarding resident 59's pressure ulcer care and resident 52's grooming and personal hygiene. |
| RN K | Registered Nurse | Provided wound care and interviewed regarding pressure ulcer interventions and documentation. |
| MDS coordinator L | Minimum Data Set Coordinator | Responsible for updating resident care plans and pocket care plans; interviewed regarding care plan discrepancies. |
| DON C | Director of Nursing | Interviewed regarding care plan updates, pressure ulcer prevention, infection control expectations, and controlled substance reconciliation. |
| Nurse manager D | Nurse Manager | Interviewed regarding controlled substance lock box and pressure ulcer care. |
| CMA N | Certified Medication Aide | Observed and interviewed regarding improper hand hygiene and glove use during blood glucose testing. |
| CNA F | Certified Nursing Assistant | Observed not wearing gloves and not performing hand hygiene during personal care. |
| CNA G | Certified Nursing Assistant | Observed moving mechanical lift without disinfecting; interviewed regarding cleaning practices. |
| ED A | Executive Director | Interviewed regarding controlled substance lock box and medication disposal procedures. |
| COO B | Chief Operations Officer | Interviewed regarding pharmacy service changes and medication disposal procedures. |
Inspection Report
Routine
Deficiencies: 10
Date: Oct 27, 2022
Visit Reason
The inspection was a routine survey of Aberdeen Health and Rehab to assess compliance with regulatory requirements related to resident care, medication management, infection control, dining services, and quality assurance.
Findings
The survey identified multiple deficiencies including failure to ensure proper medication self-administration protocols, inadequate documentation and response to resident grievances, failure to timely report bruises of unknown origin, lack of assistive devices for resident independence, inadequate pressure ulcer prevention and care, improper medication storage and monitoring, insufficient kitchen cleanliness, failure to provide substantial bedtime snacks, incomplete infection control practices, and gaps in quality assurance performance improvement projects.
Deficiencies (10)
Failed to ensure one resident had a physician's order and assessment to self-administer medications.
Failed to follow policy for documenting and responding to resident and family grievances.
Failed to timely report bruises of unknown origin for one resident.
Failed to ensure assistive devices (grab bars) were available for one resident while showering.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for one resident.
Failed to maintain medication room to professional standards including storage, monitoring outdated medications, and securing resident brought-in medications.
Failed to maintain cleanliness of kitchen including grease trap drawer, ice machine, and floors.
Failed to ensure a substantial bedtime snack was offered to all residents when mealtimes were more than 14 hours apart.
Failed to implement infection prevention and control program ensuring sanitary personal care and hand hygiene.
Failed to set up and follow an ongoing quality assessment and assurance program to review quality deficiencies and develop corrective plans.
Report Facts
Instances of call light on for more than 20 minutes: 28
Instances of call light on for more than 20 minutes: 33
Instances of call light on for more than 20 minutes: 3
Instances of call light on for more than 20 minutes: 17
Instances of call light on for more than 20 minutes: 32
Braden skin risk assessment score: 14
Date of survey completion: Oct 27, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA D | Certified Medication Aide | Named in medication self-administration deficiency |
| Clinical Coordinator C | Interviewed regarding medication self-administration and quality assurance | |
| Administrator A | Administrator | Named as grievance official and involved in QAPI and call light PIP |
| CLM K | Community Life Manager / Activity Director | Named in resident council grievance documentation deficiency |
| CNA E | Certified Nursing Assistant | Named in infection control and reporting bruises deficiency |
| CNA F | Certified Nursing Assistant | Named in infection control and reporting bruises deficiency |
| RN G | Registered Nurse | Named in reporting bruises deficiency |
| DON A | Director of Nursing | Named in reporting bruises and medication self-administration deficiencies |
| DON B | Director of Nursing | Named in bruises investigation and infection control |
| Registered Nurse I | Registered Nurse | Interviewed regarding assistive devices for showering |
| Maintenance Manager L | Maintenance Manager | Interviewed regarding shower room grab bars |
| Assistant Director of Nursing H | Assistant Director of Nursing | Interviewed regarding medication room and infection control |
| Dietary Manager M | Dietary Manager | Interviewed regarding snacks and kitchen cleanliness |
| Cook N | Cook | Interviewed regarding mealtimes and snacks |
| Cook O | Cook | Interviewed regarding mealtimes and snacks |
| Clinical Coordinator C | Received call light audit information from leadership team |
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