Aberdeen Health and Rehab

Inspectors wroteBased on the observation, interview, and record review, the provider failed to ensure the staff responded promptly to 11 of 16 sampled residents (6, 22, 30, 34, 36, 40, 41, 62, 64, 68, and 73) call lights.

Inspectors wroteBased on observation, interview, record review, and policy review the provider failed to ensure the staff followed standard infection control and prevention practices regarding:*Hand sanitizer dispensers that were past their expiration dates in 27 of 64 resident rooms. *One of one linen cupboard had a covering to protect against airborne infectants.*One of one resident wheelchair (26) was kept in good repair and had a cleanable surface on it.*Two of two observed residents (9 and 63) wheelchairs were clean and free from odor.*Three of three observed certified nursing assistants (CNA) (R, S, V,), one of one observed certified medication aide (CMA) (T), and one of one registered nurse (RN) (W) followed enhanced barrier precautions (EBP) (gown and glove use) when assisting one of one observed resident (34) with personal hygiene care and wound care. [...]

Inspectors wroteBased on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual version 1.20.1 October 2025 review, the provider failed to ensure accurate MDS (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment coding for two of three sampled residents (4 and 59) dialysis (a medical treatment that performs the essential functions of the kidneys when they fail) medications.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure infection control practices were followed regarding the storage of oxygen equipment for two of two sampled residents (5 and 6).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to follow standard food safety practices for one of one observed cook (Y) who did not remove her gloves and washed her hands after touching a garbage can lid before handling resident food, and when she changed her gloves.

Inspectors wroteBased on observation, interview, and record review, the provider failed to ensure call lights (a communication tool that enabled residents to alert staff for assistance) were functioning for three of three sampled residents (34, 41 and 73) whose call lights were not functioning.

Inspectors wroteBased on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, document review, record review, and policy review, the facility failed to ensure the safety for one of one sampled resident (1) who was identified at risk for elopement (leaving the facility without staff knowledge) and left the building unsupervised on 2/13/26. Immediate Jeopardy (IJ) at F 689, severity K, began on 2/13/26 at 4:10 a.m. when the provider failed to ensure the safety of resident 1 who eloped through his bedroom window and was found at 4:38 a.m. outside when outdoor temperatures were approximately 25 degrees Fahrenheit (F), for an unknown amount of time, and the safety of any other residents identified at risk for elopement (total of 11). [...]

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to thoroughly investigate resident-to-resident incidents of potential abuse by one of one sampled resident (1) who used acts of physical aggression toward two of two sampled residents (2 and 3) on separate occasions. Failure to thoroughly investigate those incidents may have placed all residents at risk for potential resident-to-resident abuse.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to have reviewed and revised the care plan for one of one sampled resident (1) needs and how to manage those needs.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint, record review, interview, and policy review, the provider failed to follow professional nursing standards to ensure:*One of one sampled resident's (1) pain was assessed according to the provider's policy.*The indication for administration of an as needed anxiety medication administered to one of one sampled resident (1) was documented.*The effectiveness and any adverse reactions were documented for the use of a newly ordered mood-altering medication (Depakote) for one of one sampled resident (1).

Inspectors wroteBased on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, and policy review, the provider failed to ensure one of one sampled resident's (1) wheelchair was secure in the facilities transport vehicle according to manufacturer's guidelines resulting in the resident's wheelchair tipping backwards and the resident sustained a spinal fracture.

Inspectors wroteBased on record review, interview, and policy review, the provider failed to ensure professional nursing standards of practice regarding timely and accurate documentation of narcotic medications for two of two sampled residents (1 and 2) to ensure accountability of high risk medications.

Inspectors wroteBased on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect related to assessing and providing skin care to prevent skin necrosis (death of cells or tissue through disease or injury) of both the residents feet and implementing monitoring to potentially prevent a significant weight loss for one of one sampled discharged resident (51) who required hospitalization related to those conditions.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure the dishwasher temperatures and chemical sanitizer concentration were monitored and recorded for one of one mechanical dishwasher used for the cleaning and sanitization of dishes and items used to prepare and serve residents' food.

Inspectors wroteBased on observation, interview, resident council meeting, and policy review, the provider failed to ensure a clean and homelike environment had been maintained for 25 of 25 residents (2, 6, 8, 11, 12,14, 15, 16, 19, 21, 23, 24, 26, 33, 36, 38, 41, 44, 45,52, 53, 55, 59, 60, 61) of the C wings.

Inspectors wroteBased on observation, record review, interview, and policy review the provider failed to implement prescribed, and care-planned preventative pressure injury interventions for one of one (50) sampled resident with a history of skin breakdown on his feet.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to effectively implement, monitor, and document a walk to meals restorative program for one of one sampled resident (54) to help maintain her mobility.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to ensure respiratory needs of one of one sampled resident (15) had been met for changing of oxygen tubing and nebulizer tubing weekly according to the provider's policy.

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure three of three mechanical stand aid lifts were cleaned after each resident's use.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to ensure:*Preventative interventions and approaches were implemented prior to the development of pressure ulcers for two of two sampled residents (59 and 60). *Interventions and approaches were consistently implemented for three of three sampled residents (25, 59, and 60) who currently had pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and policy review, the provider failed to establish a system to accurately reconcile controlled substances that were waiting for destruction in one of two medication rooms.

Inspectors wroteBased on observation, record review, interview, and policy review, the provider failed to follow, revise, and update care plans for four of nineteen sampled residents (52, 59, 60, and 48) to reflect their current needs.

Inspectors wroteBased on observation, record review, interview, resident handbook review, and resident bill of rights review, the provider failed to ensure grooming and oral care were consistently provided and accurately documented for 1 of 19 sampled residents (52).

Inspectors wroteBased on observation, interview, and policy review, the provider failed to ensure the following: *Gloves had been used during incontinence care of resident (60). *A sit to stand mechanical lift had been cleaned in between resident use. *Hand hygiene and glove use had been used during personal care for one of one sampled resident (45). *Proper hand hygiene and glove use was performed by one of one certified medication aide (CMA) N for one of one sampled resident (27) during blood sugar testing.