Aberdeen Health and Rehab

In the surveyor’s words

From the most serious findings on record at Aberdeen Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 26, 2026

  Based 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). […]

• Actual harm, patternF684Dec 8, 2021

  Based on observation, interview, record review, policy review, and anonymous complaint report received by the South Dakota Department of Health (SD DOH), the provider failed to ensure residents received treatment and care in accordance with professional standards of practice for ensuring: *Six of Six residents (1, 2, 3, 4, 5, and 6) had received toileting, bathing, and services from staff in a timely manner. -There was a call system that would notify all direct care staff if any of the 57 residents in the building were in need of assistance. *One of one resident (7) had received toileting and services from staff in a timely manner, according to their representative interview. […]

• Actual harm, isolatedF689Jul 24, 2025

  Based 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.Findings include:1. Review of SD DOH FRI that was submitted on 7/15/25 revealed:*At approximately 11:15 a.m. […]

• Actual harm, isolatedF600Feb 6, 2025

  Based 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. Findings include: 1. Review of the 1/9/25 SD DOH complaint intake revealed: *The complainant had a concern regarding the quality of care and treatment for resident 51. […]

• Actual harm, isolatedF686Oct 19, 2023

  Based 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. Findings include: 1. Observation on 10/17/23 at 10:35 a.m. of resident 59 revealed: *He was seated in his wheelchair outside of the small dining room area near the rehabilitation unit. *He had gripper socks on his feet and both feet were placed on the foot-pedals of his wheelchair. […]