Dells Nursing and Rehab: Care Quality Deficiency - SD
The medication errors at Dells Nursing and Rehab Center went undetected until federal inspectors arrived in late October following a complaint. The facility's own blood pressure policy mandates physician notification when readings exceed 180/110 or drop below 85 systolic, but staff weren't consistently following the rules.
CMA C told inspectors on October 30 that she checks residents' blood pressure before administering medications with hold parameters. If the reading falls outside safe limits, she withholds the drug. But she had no idea she'd given medication twice to resident 1 when it should have been held.
"She was not aware she had administered medication twice in October 2025 to resident 1 when it should have been held," inspectors wrote.
The medication aide also didn't know about the facility's Blood Pressure Parameter Policy or when she should notify nurses about concerning readings. Her job description from August 2013 specifically required her to observe medication responses, report changes in residents' conditions, and notify charge nurses about medication errors.
Director of Nursing A confirmed the medication errors occurred and acknowledged the blood pressure policy hadn't been followed. She told inspectors she expected physicians to be notified each time medications were given inappropriately.
RN B explained the proper protocol during her October 30 interview. If she discovered a resident received medication that should have been held, she would check vital signs, follow the medication error policy, and notify the physician, director of nursing, and resident's family.
For blood pressure readings outside parameters, she would recheck after a few minutes and contact the physician if the reading remained abnormal. She referenced a parameter sheet at the nurses' station to determine safe ranges.
But the system broke down with resident 1. The medication aide administered blood pressure drugs twice when the resident's readings should have triggered holds instead.
The facility's August 2024 Blood Pressure Parameter Policy exists "to ensure adequate blood pressure parameters are reported and monitored by Physicians." It requires notification when blood pressure exceeds 180/110 or systolic drops below 85.
The provider's February 2025 medication policy sets clear expectations for professional standards during drug administration. Medications should only be given "upon written orders of a physician." When errors occur, staff must file occurrence reports and inform the physician, director of nursing, and power of attorney within 24 hours.
The policy also requires 24-hour monitoring following medication errors, with the director of nursing reviewing incidents and providing follow-up education. These cases get reported at quality assurance meetings.
Registered nurses carry responsibility for rendering professional nursing care, identifying quality resident care issues, and distributing medications "accurately and safely per physician order." They must maintain records reflecting resident conditions and medication administration while supervising nursing staff.
The inspection found medication aides are supposed to take and record vital signs, document observations about residents' conditions, and report changes to charge nurses. All chart entries require charge nurse co-signatures.
Despite these detailed policies and job descriptions, the October medication errors revealed gaps between written protocols and actual practice. The medication aide's unfamiliarity with blood pressure policies meant she couldn't properly assess when medications should be held or when concerning readings required physician notification.
The breakdown left resident 1 receiving blood pressure medication twice when facility policy demanded the opposite response. Federal inspectors classified the violation as minimal harm or potential for actual harm, affecting few residents.
But for resident 1, the difference between receiving medication and having it properly withheld could have meant the difference between stable blood pressure and a dangerous drop requiring emergency intervention.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Dells Nursing and Rehab Center Inc from 2025-11-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
DELLS NURSING AND REHAB CENTER INC in DELL RAPIDS, SD was cited for violations during a health inspection on November 24, 2025.
The medication errors at Dells Nursing and Rehab Center went undetected until federal inspectors arrived in late October following a complaint.
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.