Aberdeen Health and Rehab: Care Plan Failures - SD
That was the finding from a complaint inspection completed August 28, 2025, at the facility located at 1700 North Highway 281. The inspection focused on a single resident, identified in records only as Resident 1, whose care plan lacked any interventions for her aggressive behaviors or her pattern of entering other residents' rooms uninvited.
Both Administrator A and Director of Nursing B confirmed it during the inspection. They did not dispute that the care plan had not been updated. They did not point to a staff miscommunication or a documentation error that had since been corrected. They confirmed it.
The facility's own April 2025 care planning policy required comprehensive, person-centered care plans for every resident, updated to reflect changes in a resident's condition and needs. The policy called specifically for "resident specific interventions" tied to each resident's assessed needs. Wandering into other residents' rooms is a documented safety concern, both for the resident doing the wandering and for the residents whose rooms she entered. Aggressive behaviors carry their own risks. Neither had triggered a care plan update.
The LPN and MDS coordinator identified in the inspection as Staff H carried primary responsibility for updating the nursing portions of residents' care plans. But the facility's own administrators told inspectors that anyone on the interdisciplinary team could make updates, and that care plans were expected to be revised with each quarterly and annual assessment as well as whenever a resident's needs changed.
The care plan for Resident 1 had not kept pace with what was happening to her or around her.
What that means in practice is that the staff members responsible for her daily care were operating without documented guidance on how to respond when she became aggressive or when she was found in a neighbor's room. Care plans exist precisely because facilities are staffed in shifts, with different aides and nurses cycling through. When a resident's behavior changes and the care plan doesn't reflect it, the next shift starts without that information in any formal, binding form. Someone might know. Someone might not.
The inspection classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. Those designations come from a federal scale that runs from no harm to immediate jeopardy, and this finding sat near the lower end. But minimal harm is not the same as no harm, and the residents whose rooms Resident 1 entered were affected by her wandering whether or not their experiences generated their own findings in this report.
The facility's care planning policy, quoted at length in the inspection report, described objectives that would be used to monitor a resident's progress and called for alternative interventions to be documented when needed. The policy was written in the language of individualized, responsive care. The care plan for Resident 1 did not reflect that language in any practical way when it came to the behaviors inspectors documented.
Aberdeen Health and Rehab had a policy that said the right things. The administrator and the director of nursing knew care plans were supposed to be updated when residents' needs changed. The MDS coordinator was identified as the person primarily responsible. And still, a resident was wandering into her neighbors' rooms, and the document meant to guide her care said nothing about it.
The inspection report does not say how long the behaviors had been occurring before the complaint was filed, or how many times Resident 1 entered another resident's room before anyone flagged the gap in her care plan. Those details were not included in the findings. What was included is that by the time inspectors arrived, the problem was not new, and the care plan still had not been touched.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aberdeen Health and Rehab from 2025-08-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
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: September 22, 2026 · Our methodology
ABERDEEN HEALTH AND REHAB in ABERDEEN, SD was cited for violations during a health inspection on August 28, 2025.
That was the finding from a complaint inspection completed August 28, 2025, at the facility located at 1700 North Highway 281.
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.