Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aberdeen Health And Rehab during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, a history of wandering and elopement, and a documented elopement risk assessment score exited the building unsupervised through a bedroom window that lacked an effective safety stopper and had no functioning window alarm, despite the care plan indicating one was in place. Staff last saw the resident around midnight and discovered him missing several hours later, finding the window open with the screen pushed out and later locating the resident outside. Surveyors observed multiple unsecured sliding windows in resident rooms and common areas, including the TV lounge, restorative room, therapy room, chapel, and other rooms, many of which could be opened wide enough for a person to climb out, even near residents identified as elopement risks. Several exit doors were unlocked, unalarmed, or not routinely checked, and staff, including the DON and CNAs, were not fully aware of the resident’s exit-seeking behaviors or of required window alarm interventions, leading to a deficiency at F689 for accident hazards and inadequate supervision.
The facility did not complete the care plan within 7 days of the comprehensive assessment and failed to ensure it was prepared, reviewed, and revised by a team of health professionals as required.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk of accidents for residents.
Nursing staff failed to document the administration of narcotic medications in the eMAR at the time they were signed out for two residents, with several doses either not recorded or recorded late. In one case, a wasted narcotic was not verified by a second nurse as required. These actions did not meet professional standards or the facility's policy for controlled substance documentation.
A resident with dementia and multiple health conditions suffered severe neglect at a facility, resulting in skin necrosis and significant weight loss. The facility failed to monitor the resident's skin condition and did not inform the family of the deteriorating state until it was too late. The resident was hospitalized with necrotic tissue on both feet and had lost over 30 pounds. Staff interviews revealed inadequate skin assessments and poor communication, leading to the resident's eventual placement in hospice care.
The facility failed to monitor and document the dishwasher temperatures and chemical sanitizer concentration, leading to a deficiency in ensuring proper sanitization of dishes. The new low-temperature mechanical dishwasher, in use since November 2024, lacked logs to verify sanitization levels, contrary to the facility's policy and manufacturer's guidelines.
The facility failed to maintain a clean and homelike environment, with observations of cluttered rooms, unmade beds, and inadequate housekeeping. Residents reported dissatisfaction with cleaning services, inconsistent linen changes, and lost laundry. Despite previous feedback, these issues remained unresolved, highlighting deficiencies in the facility's housekeeping and maintenance practices.
A resident with a history of skin breakdown was observed multiple times without heel-lift boots, despite a care plan and doctor's orders requiring them. Staff interviews revealed a lack of awareness and adherence to these preventative measures, leading to a deficiency in care.
A resident with moderate cognitive impairment and limited mobility was not effectively participating in a restorative program to walk to meals, as required by her care plan. Instead, she used a wheelchair to move around the facility. Staff interviews revealed a lack of communication and follow-up, resulting in the resident's walking program being missed.
A resident with chronic respiratory conditions did not have her oxygen and nebulizer tubing changed weekly as required by facility policy. The resident expressed concern about the unchanged tubing since her hospitalization, and there was no physician's order for oxygen use documented. Facility staff were unaware of the need for an as-needed order, and the required documentation in the TAR was missing.
Failure to Secure Windows and Exits for Elopement-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision for a resident at known risk for elopement, who left the building unsupervised through his bedroom window. The resident had dementia with severe cognitive impairment, anxiety, a documented history of wandering and elopement, and an elopement risk assessment score indicating he was at risk for eloping. He had a physician’s order for a WanderGuard and was identified as a wander risk. On the night of the incident, staff last observed him around midnight; at 4:10 a.m. a CNA entered his room and found him missing, with his window open and the screen pushed out. Staff searched the building and then the grounds, ultimately finding him lying in the grass outside at approximately 4:38 a.m., wearing layered clothing, with no major injuries and normal vital signs. The facility’s own investigation determined that the resident’s bedroom window did not have a safety stopper in place at the time of the elopement, allowing it to be opened far enough for him to climb out. Although the care plan indicated that a window alarm had been placed on his window on the date of the incident, later observation by surveyors showed that there was no alarm on his window, only metal stoppers. The executive director stated that an alarm purchased after the incident did not fit the window and that another had not yet been ordered, and the maintenance director had not informed her of this. Staff interviews revealed that direct care staff were not aware that the resident was supposed to have a window alarm, and his Kardex and pocket care plan did not indicate a window alarm requirement, despite his exit-seeking and wandering behaviors, which included standing by exit doors with his coat and belongings and becoming more upset after family visits. Beyond this resident’s room, surveyor observations on multiple dates showed that numerous other windows and doors throughout the facility were not adequately secured, despite the presence of other residents identified as being at risk for elopement. Several sliding windows in common areas such as the TV room, restorative room, therapy room, chapel, and multiple resident rooms could be opened far enough for a person to climb out and lacked metal stoppers. Some rooms near these unsecured windows housed residents at risk for elopement. Certain windows had stoppers on only one side, allowing the other side to open widely. In addition, several exit doors, including doors in the activity room, near the laundry room and employee break room, and two black doors in the dining room to the courtyard, were found unlocked and/or not alarmed or not properly checked, even though the administrator had attested that all exit door alarms were in working order. The maintenance director acknowledged he had not checked all exit doors since starting employment and had only been oriented to some of the exit doors. The DON reported being unaware of the resident’s exit-seeking behaviors, and CNA behavior documentation was not being completed because nurses were documenting, even though nursing notes largely did not reflect exit-seeking behaviors prior to the incident. These combined inactions and environmental hazards led to the determination of noncompliance at F689 with Immediate Jeopardy. The facility’s policies required elopement risk assessments on admission and at set intervals, updating care plans based on risk, use of WanderGuards for moderate or high-risk residents, prompt response to exit alarms, and completion of missing resident drills on all shifts monthly. The resident’s record showed that elopement risk assessments had been completed and that he was identified as a wander risk with a WanderGuard order, but the environmental controls and care plan implementation did not prevent his unsupervised exit through the window. Staff interviews confirmed that residents had ongoing access to unsecured areas such as the television lounge, restorative therapy room, chapel, and therapy room, and that some of these areas contained windows that could be opened wide enough for egress. The combination of unsecured windows and doors, incomplete implementation of care plan interventions (including the missing window alarm), lack of full awareness of exit-seeking behaviors by key clinical staff, and incomplete maintenance checks on exit doors contributed directly to the resident’s elopement and the broader deficiency related to accident hazards and inadequate supervision.
Failure to Timely Develop and Review Care Plan by Interdisciplinary Team
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. Additionally, the care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified through review of facility records and documentation, which showed that the care planning process did not meet the specified regulatory timelines and team involvement.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Ensure Timely and Accurate Documentation of Narcotic Medications
Penalty
Summary
The provider failed to ensure professional nursing standards of practice regarding the timely and accurate documentation of narcotic medications for two residents. Multiple instances were identified where Hydrocodone-Acetaminophen tablets were signed out on the narcotic sign-out sheet by registered nurses but were not documented as administered in the medication administration record (MAR) at the same time, or in some cases, not documented at all. There were also discrepancies in the timing of documentation, with one dose not recorded in the MAR until several hours after it was signed out. Additionally, one instance was noted where a narcotic tablet was removed without a time of removal, and the administration was documented by a different nurse at an earlier time than the removal. For another resident, a narcotic tablet that was dropped was not properly documented as wasted, as it lacked a second nurse's signature to verify the destruction of the medication. Interviews with nursing staff and the director of nursing confirmed that the facility's expectation and policy require that narcotic medications be documented in the MAR at the same time they are signed out on the narcotic sign-out sheet, and that any wasted narcotics must be verified by two nurses. Review of the facility's Controlled Substances policy further supported these requirements, stating that the controlled substance sheet and eMAR must match and that proper record keeping is essential. The observed failures in documentation and verification did not align with these established standards and policies.
Neglect Leads to Severe Skin Necrosis and Weight Loss
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in severe skin necrosis and significant weight loss. The resident, who had dementia and multiple health conditions including diabetes and chronic kidney disease, was admitted to the hospital with necrotic tissue on both feet. The facility did not adequately monitor or assess the resident's skin condition, despite a previous hospitalization where no skin issues were noted. The first communication with a doctor regarding the necrosis occurred only after the condition had significantly worsened. The resident's family was not informed of the deteriorating condition until it was too late, and they were not included in care plan meetings. The facility's staff failed to perform regular diabetic foot checks and did not document any skin assessments or wound care for the resident's feet between the discovery of the necrosis and the subsequent hospitalization. Additionally, the resident experienced a significant weight loss of over 30 pounds, which was not communicated to the family or addressed in the care plan. Interviews with facility staff revealed a lack of consistent skin assessments and inadequate communication regarding the resident's condition. The facility's policies on skin assessments and care planning were not followed, contributing to the neglect. The resident's condition ultimately required hospitalization, and the family had to make the difficult decision to place the resident in hospice care due to the severity of the neglect.
Failure to Monitor Dishwasher Sanitization Levels
Penalty
Summary
The provider failed to ensure proper monitoring and documentation of the dishwasher temperatures and chemical sanitizer concentration in the facility's main kitchen. During an initial observation, it was noted that the mechanical dishwasher used for cleaning and sanitizing dishes did not have any logs or documentation to verify that the temperature and sanitizing solution were at appropriate levels. The dining services manager (DSM), who had been working at the facility for several years, confirmed that the new low-temperature mechanical dishwasher, which used chemical sanitization, had been in use since November 2024. However, no records were maintained to ensure the sanitization process was effective. Further interviews and record reviews revealed that the previous dishwasher used heat sanitization, and logs were maintained to record temperatures at each meal. These logs indicated that the wash and rinse cycle temperatures met the required standards. However, after switching to the new dishwasher, the facility did not continue logging the wash temperature and sanitization levels. The DSM acknowledged that the dietary staff were not using a form to document these parameters, which could pose a risk of improper sanitization. The facility's policy, as per the 2013 Dish Machine Temperature Log, required dishwashing staff to monitor and record dish machine temperatures to ensure proper sanitization. The administrator confirmed that this policy was still in effect and should have been followed. The manufacturer's manual for the new dishwasher also specified the required temperature and sanitizer levels, which were not being documented. The lack of adherence to these procedures led to the deficiency in ensuring the dishwasher's effectiveness in sanitizing dishes.
Deficiencies in Housekeeping and Maintenance
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment for its residents, as evidenced by multiple observations and interviews. The C wing hallways were observed to have a buildup of gray dust and debris along the edges where the carpet met the wall. Several resident rooms were cluttered with personal items, leaving no space for additional belongings, and many beds were unmade. Bathrooms shared by residents had visible dirt, unpleasant odors, and maintenance issues such as peeling wallpaper and missing toilet paper dowels. Additionally, a piece of linoleum flooring was missing in one room, and the flooring had been in disrepair since March 2024. Interviews with residents revealed dissatisfaction with housekeeping services, as rooms were not cleaned thoroughly or regularly. Residents reported that bed linens were not changed on bath days or when soiled, and garbage was not removed regularly. Some residents had to request clean towels and washcloths, which were not provided consistently. The facility's process for managing residents' personal laundry was also inadequate, with frequent reports of lost or misplaced items that were not replaced by the facility. The resident council meetings highlighted ongoing issues with housekeeping and laundry services, despite previous feedback and action plans. Residents expressed that their grievances regarding insufficient cleaning, lack of clean linens, and lost laundry had not been resolved. The facility's policies for routine care by CNAs, including making beds and ensuring rooms were tidy, were not consistently followed, contributing to the deficiencies observed during the survey.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The provider failed to implement prescribed and care-planned preventative pressure injury interventions for a resident with a history of skin breakdown on his feet. Observations on multiple occasions revealed that the resident was lying in bed without heel-lift boots, which were part of his care plan and doctor's orders to prevent further skin breakdown. Despite the treatment administration record indicating that the boots were in place, the resident was observed without them, and staff interviews confirmed a lack of awareness and adherence to the care plan. The resident's electronic medical record showed a care plan intervention to offload heels with heel-lift boots initiated months prior, and a doctor's order for heel protection boots was in place. Interviews with staff, including a CNA, RN, and the ADON, revealed a lack of compliance with these orders, as the CNA was unaware of the requirement, and the ADON confirmed the absence of the boots in the resident's room. The DON expressed an expectation for adherence to the care plan and doctor's orders, which was not met, leading to the deficiency.
Failure to Implement and Monitor Restorative Program for Resident
Penalty
Summary
The provider failed to effectively implement, monitor, and document a restorative program for a resident to maintain her mobility. The resident, who had moderate cognitive impairment and limited physical mobility, was supposed to participate in a restorative therapy program of walking to meals every day. However, observations and interviews revealed that the resident had not walked to meals for a long time and instead used her wheelchair to move around the facility. The certified nursing assistant confirmed that it had been months since the resident last walked to meals. Interviews with staff, including the certified occupational therapist assistant, assistant director of nursing, and MDS coordinator, indicated a lack of communication and follow-up regarding the resident's restorative program. The MDS coordinator acknowledged that the resident's walking program had been missed and expressed a desire for therapy to reassess the resident's current mobility and needs. The facility's restorative program process and person-centered care plan policies were not effectively followed, leading to the deficiency in maintaining the resident's mobility.
Failure to Change Oxygen and Nebulizer Tubing Weekly
Penalty
Summary
The provider failed to meet the respiratory needs of a resident by not changing the oxygen tubing and nebulizer tubing weekly as per the facility's policy. During an observation, it was noted that the oxygen tubing and nasal cannula used by the resident were not dated or tagged, and the resident expressed concern that the tubing had not been changed since her hospitalization in January 2025. The resident, who had intact cognition and diagnoses of Chronic Obstructive Pulmonary Disease, Coronary Artery Disease, and Chronic Respiratory Disease, used oxygen when short of breath and during sleep. However, there was no physician's order for oxygen use, and the resident's care plan and medical records did not document the changing of the oxygen concentrator tubing. Interviews with facility staff, including the ADON, LPN, RN, and DON, revealed a lack of awareness and documentation regarding the resident's oxygen use and the necessary changes to the tubing. The ADON acknowledged that the nursing staff needed to obtain an as-needed order for the resident's oxygen, and the DON was unable to locate an order for oxygen in the electronic medical record. The facility's policy required oxygen tubing and nasal cannula to be changed weekly, with documentation in the TAR, but this was not done. The facility's standing orders indicated the use of oxygen at 4 liters per nasal cannula as needed for oxygen saturation levels below 92%, but the physician was not notified when oxygen was started for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aberdeen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Prairie Heights Healthcare | 1.1 mi | — | 0 | 0 |
| Avera Mother Joseph Manor Retirement Community | 1.4 mi | — | 9 | 0 |
| Bethesda Home Of Aberdeen | 2.7 mi | — | 7 | 0 |
| Avantara Groton | 20 mi | — | 11 | 0 |
| Prince Of Peace Care Center | 36.3 mi | — | 1 | 0 |
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