Aberdeen Health And Rehab
ABERDEEN HEALTH AND REHAB in ABERDEEN, SD — inspection on June 4, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of resident 4's electronic medical record (EMR) revealed he admitted to the facility on [DATE].
His 3/23/26 Brief Interview for Mental Status (BIMS) assessment score was 13 which indicated his cognition was intact. He had diagnoses of type 2 diabetes mellitus (a chronic condition that occurs when your body cannot properly produce or use insulin) without complications, end stage renal disease, and dependence on renal dialysis. He had a 1/24/26 physician's order for Ozempic (0.25 or 0.5 milligrams (mg)/dose) subcutaneous solution pen-injector 2 mg/1.5 milliliter (mL) (Semaglutide) (a GLP-1 receptor agonist that mimics gut hormones to suppress appetite, slow digestion, and regulate blood sugar), inject 0.25 mg subcutaneously one time a day every Saturday for diabetes. Resident 4's 3/24/26 annual MDS assessment section N0350 insulin injections in the last seven days was marked yes.
Section N0415 High-Risk Drug classes: use and indications section J Hypoglycemic (including insulin) was marked yes.
- Review of resident 59's EMR revealed she admitted to the facility on [DATE].
Her 6/1/26 BIMS assessment score was 15 which indicated her cognition was intact.
She had diagnoses of chronic kidney disease and type 2 diabetes mellitus without complications. Resident 59 had a 2/6/26 physician's order for Mounjaro subcutaneous solution auto-injector 2.6 mg/0.5 mL (Tirzepatide) (a dual GIP and GLP-1 receptor agonist that mimics gut hormones to stimulate insulin production when blood sugar rises and decreases the amount of sugar produced by the liver), inject 2.5 mg subcutaneously once weekly Friday for diabetes. Resident 59's 3/11/26 quarterly MDS assessment section N0350 insulin injections indicated she received one insulin injection during the last seven days.
Section N0415 high-risk drug classes: use and indications section J hypoglycemic (including insulin) was marked yes.
- Interview on 6/3/26 at 4:20 p.m. with Minimum Data Set (MDS) coordinator C revealed she was
aware that Ozempic and Mounjaro were coded inaccurately as insulin.
She learned about the inaccuracy on 4/24/26 but did not updated the MDS assessments for residents 4 and 59.
- Interview with executive director A on 6/4/26 at 1:22 p.m. revealed she expected MDS updates to
be completed within 24 to 48 hours, or a few business days.
Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed Section N, page 3, Coding Instructions for N0350A: Enter.the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received.
Section N, page N8 for N0415J1 and N0415J2, revealed, Hypoglycemic (including insulin): Check if a hypoglycemic medication was taken by the resident at any time during the 7-day observation period (or since admission/entry or reentry if less than 7 days).
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Aberdeen Health and Rehab 1700 North Highway 281 Aberdeen, SD 57401
frequencies, such as when a resident's call light was repeatedly activated within a 30- or 60-minute
provider did not have a call light policy.
435041 06/04/2026
Aberdeen Health and Rehab 1700 North Highway 281 Aberdeen, SD 57401
Observation on 6/3/26 at 1:29 p.m. in resident 6's room revealed his nasal cannula oxygen tubing was on the floor.
His nasal cannula oxygen tubing and the pre-filled humidifier were not dated. 3.
Review of resident 6's electronic medical record (EMR) revealed he admitted to the facility on [DATE] and had a diagnoses of obstructive sleep apnea (where your throat muscles relax too much and block your airway while you sleep). He had an 8/17/25 physician's order for oxygen to be administered at 3 liters (L) by a nasal cannula at bedtime while sleeping and as needed.
His June 2026 treatment administration record (TAR) did not indicate when the nurse was to change the oxygen tubing. 4.
Observation on 6/2/26 at 2:36 p.m. in resident 5's room revealed she had an oxygen concentrator in her room, the nasal cannula tubing was dated 6/1, and the pre-filled humidifier was empty and not dated.
Her continuous positive airway pressure (CPAP) machine (a bedside device used to pump a steady, gentle stream of pressurized air through a tube and a face mask) was on her nightstand, and the mask was on the floor between her bed and nightstand. 5.
Review of resident 5's EMR revealed she admitted to the facility on [DATE] and had a diagnoses of Chronic Obstructive Pulmonary Disease (COPD) (progressive lung disease that makes it hard to breathe).
She had a 7/16/24 physician's order to wear her CPAP nightly and when napping, and an 11/18/24 physician's order for continuous oxygen at 2 L.
Her June 2026 TAR indicated the nurse was to change the oxygen tubing and set it up weekly every Friday night, and to date it. 6.
Observation and interview on 6/3/26 at 3:51 p.m. with certified nursing assistant (CNA) S in resident 5's room revealed that resident 5's nasal cannula oxygen tubing was on the floor. He picked the tubing up off the floor and stated that the resident's oxygen tubing was supposed to be in the bedside table drawer or hung up so it did not touch the floor. He verified that resident 5's CPAP mask was on the floor between her bed and nightstand, picked it up, and stated it should not be on the floor, and he would clean it.
The nurse was responsible for changing and dating the oxygen tubing and pre-filled humidifier. 7.
Interview on 6/3/26 at 4:00 p.m. with registered nurse (RN P) revealed the CPAP masks should be stored on the CPAP machine, the nasal cannulas should be stored in a bag, and the nasal cannula and pre-filled humidifier should be dated when changed by the nurse weekly. 8.
Interview on 6/4/26 at 11:24 a.m. with assistant director of nursing (ADON)/licensed practical nurse (LPN)/infection preventionist (IP) N revealed that she expected oxygen tubing to not to be on the floor, and to be in a bag on the resident's concentrator when not in use.
The oxygen tubing and the pre-filled humidifier were to be changed weekly, and the tubing and the pre-filled humidifier should be dated when they were opened to be used. 9.
Interview on 6/4/26 at 3:05 p.m. with DON B revealed she expected oxygen tubing to not be on the floor but to be stored in a bag when not in use, and the oxygen tubing and the pre-filled humidifier should be dated when they were opened to be used. 10.
Review of the provider's 4/20/26 Respiratory Equipment Cleaning Procedure policy revealed O2 [oxygen] tubing, nasal cannula/mask will be changed weekly. O2 tubing will, also, be changed when tubing (nasal prong area) is noted lying on the floor.
The pre-filled Humidifier bottle needs to be replaced weekly & [and] prn [as needed] (date and initial).
This policy did not include information regarding cleaning or storage of the CPAP mask. 11.
The provider's 11/18/25 CPAP and BiPAP policy did not include information regarding cleaning or storing the CPAP mask.
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Aberdeen Health and Rehab 1700 North Highway 281 Aberdeen, SD 57401
Observation on 6/2/26 at 10:32 a.m. of cook Y in the kitchen revealed she was wearing a pair of gloves and was peeling cucumbers on a cutting board with a knife.
She walked over to the garbage can, lifted the garbage can lid, and discarded the cucumber peelings in the garbage can.
With those same gloved hands, she put the peeled cucumbers in a bowl, rinsed them with water, removed her gloves, and did not wash her hands.
She put a bag of shredded cheese in the walk-in cooler, used pot holders to take a peach cobbler pan out of the oven, and placed it on a metal tray.
She took off the pot holders, took a dirty knife to the dirty dish area, obtained a clean knife, put on a pair of gloves, and cut the cucumbers on a cutting board.
With those gloved hands, she picked up the cut cucumbers and put them in a bowl, brought the dirty knife and cutting board to the dirty dish area, obtained a washcloth with sanitizer on it, and wiped the counter where she cut the cucumbers.
She removed her gloves, discarded her gloves in the trash can, and washed her hands with soap and water. 2.
Interview on 6/3/26 at 2:31 p.m. with cook Y revealed she was to wash her hands with soap and water when she came into the kitchen, before putting on gloves, and after taking gloves off.
She should have removed her gloves and washed her hands after touching the garbage can lid. 3.
Interview on 6/3/26 at 4:15 p.m. with dietary manager (DM) X revealed she expected cook Y to remove her gloves after touching the garbage can lid and wash her hands after removing her gloves. 4.
Review of the provider's 4/20/26 Hand Hygiene policy revealed, proper hand washing techniques should be used to protect against the spread of infection. It indicated that hand hygiene with hand sanitizer should be completed immediately before putting on gloves and after glove removal. 5. A policy regarding hand hygiene in the kitchen was requested, and the provider did not have a policy regarding hand hygiene specifically for the kitchen.
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Aberdeen Health and Rehab 1700 North Highway 281 Aberdeen, SD 57401
Review of the provider's 4/20/26 Hand Hygiene policy revealed proper hand washing techniques should be used to protect against the spread of infection.
Cleaning your hands reduces the spread of potentially deadly germs to the residents.
Handwashing should be performed by all employees, as necessary, between tasks and procedures.
Alcohol based hand sanitizer should be used before touching a resident, before performing aseptic techniques, immediately before putting gloves on, when gloves are removed, and after touching a resident's environment.
Hand washing with soap and water should be done before moving from a soiled body site to a clean body site on [the] same resident.
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Aberdeen Health and Rehab 1700 North Highway 281 Aberdeen, SD 57401
The surveyor reported to them that resident 34 stated that her call light was on for a while. RN P went to check on resident 34's call light and stated that the call light was disconnected from the call light extender that plugged into the wall, so that is why it did not turn on when she pushed her call light.
- Review of resident 34's electronic medical record (EMR) revealed her 5/4/26 Brief Interview for
- Interview on 6/2/26 at 4:44 p.m. with resident 73 in the dining room revealed she had issues with
- Review of resident 73's EMR revealed her 4/29/26 BIMS assessment score was 15, which
- Observation on 6/3/26 at 10:31 a.m. in resident 34's rooms revealed ADON/LPN/IP N turned on
- Interview on 6/3/26 at 4:00 p.m. with RN P revealed that the call lights sometimes get hooked
- Interview on 6/4/26 at 1:09 p.m. with DON B revealed she expected call lights to always be in
Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.
her call light being unplugged from the wall, and she had to yell to her friend who lived across the hall to turn on his call light to get the staff's help.
indicated her cognition was intact.
resident 34's call light, and it turned back off on its own. ADON/LPN/IP N stated that resident 34's call light does that sometimes, and she would notify maintenance.
under the resident's bed and get pulled out of the connector, then the call light does not work.
working order.
She stated that most days, maintenance staff or Minimum Data Set (MDS) coordinator C have already repaired or replaced any non-working resident call lights before leadership staff arrived at 8 a.m.
- Interview during the Resident Council Meeting on 6/4/26 at 1:30 p.m. revealed that resident 41's
- Review of resident 41's EMR revealed her 4/30/26 BIMS assessment score was 14, which
- The provider's call light policy was requested, and they did not have a call light policy.
call light has not worked numerous times, and resident 73 had issues with her call light not working.
indicated her cognition was intact.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.