Dells Nursing and Rehab Center: Care Plan Failures SD
DELL RAPIDS, SD - A January 2025 inspection of Dells Nursing and Rehab Center revealed significant failures in maintaining current care plans for vulnerable residents, including those who experienced multiple falls, developed pressure ulcers, and had recurring infections, according to a state survey report.
Multiple Residents With Falls Lacked Updated Care Plans
The inspection found that three residents who experienced repeated falls had care plans that were never updated to reflect new safety interventions or changing needs. The most concerning case involved a resident who fell three times between August and December 2024, including a serious incident on December 28 that required emergency room treatment for a laceration above her left eye.
Despite this pattern of falls and the significant injury, the resident's care plan remained unchanged from August 14, 2024, when it was first identified that she was at risk for falls. The original plan included only basic interventions: a physical therapy evaluation and following the facility's fall protocol.
Another resident with Parkinson's disease and chronic obstructive pulmonary disease experienced seven falls between October and December 2024. During the inspection, surveyors observed this resident in a wheelchair with a full body mechanical lift sling underneath her, indicating she now required two-person assistance for transfers. However, her care plan contained no documentation of fall prevention interventions since her admission in February 2024.
A third resident was observed during the inspection wearing an electronic monitoring device on her wrist that would alarm to alert staff of position changes. Records showed she had fallen ten times between August and December 2024. Despite the electronic monitoring and multiple falls, no fall prevention interventions were documented in her care plan since her admission in May 2024.
The Director of Nursing acknowledged during interviews that care plans should be updated when new interventions are added for residents and confirmed that these residents' plans should have been revised to reflect their changing needs and safety requirements.
Care Plan Deficiencies Extended Beyond Fall Prevention
The failure to maintain current care plans affected residents with various medical conditions. One resident with chronic kidney disease and type 2 diabetes had experienced seven episodes requiring antibiotic treatment for urinary tract infections between August and December 2024. Despite this pattern of recurring infections, her care plan had not been updated since March 27, 2024, when monitoring for infection signs was first initiated.
A nursing assistant interviewed about this resident's care revealed that staff were instructed to watch for behavioral changes that might indicate a urinary tract infection and would collect urine samples when infections were suspected. However, the assistant noted that she did not have access to residents' care plans, highlighting potential communication gaps between care planning and direct care staff.
Pressure Ulcer Treatment Plans Incomplete
A resident who developed a stage II pressure ulcer in November 2024 had equipment and interventions in place that were not reflected in her care plan. During the inspection, surveyors observed that she had two specialized cushions in her wheelchair - a waffle cushion for comfort and a Roho air cushion designed to distribute weight evenly and prevent pressure ulcers. However, the Roho cushion was not properly inflated, and neither cushion was documented in her care plan.
The resident's care plan did reference her pressure ulcer in a nutrition-focused section, noting the need for extra protein to aid wound healing, but failed to document the pressure-reduction equipment that had been provided. When the resident transferred to her recliner, no specialized cushioning was available there despite her history of pressure ulcers.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 18, 2026 · Our methodology
DELLS NURSING AND REHAB CENTER INC in DELL RAPIDS, SD was cited for violations during a health inspection on January 16, 2025.
The original plan included only basic interventions: a physical therapy evaluation and following the facility's fall protocol.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.