Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Avera Mother Joseph Manor Retirement Community during CMS and state inspections, most recent first.
A resident with a history of stroke and peripheral artery disease developed a new wound on the left foot, which was identified by a CNA and assessed by an LPN. The LPN failed to document the wound in the EMR or notify the physician, contrary to facility policy, resulting in a delay in wound evaluation and treatment.
A resident was injured after falling from a wheelchair while being transported by an OTA without foot pedals attached. The resident's feet dropped to the floor during transport, leading to a forward fall, a head laceration, and multiple rib fractures. The absence of wheelchair foot pedals contributed to the incident.
The provider failed to reconcile and account for home narcotic medications for two residents and administered expired medications to three residents. Medications were improperly stored without proper documentation, and expired medications were not removed from the medication cart, contrary to the provider's policy.
Failure to Document and Communicate New Wound Resulting in Delayed Treatment
Penalty
Summary
A deficiency occurred when an LPN failed to document and communicate a newly observed wound on a resident's left foot. The wound was first identified by a CNA during bathing, who immediately notified the LPN. The LPN assessed the wound and recorded the measurements on her personal report sheet but did not enter the information into the resident's electronic medical record (EMR) or the designated wound/incision complex flowsheet. Additionally, the LPN did not notify the physician or ensure the wound was communicated in the shift-to-shift nursing report, as required by facility policy. The resident involved had a history of a right-sided middle cerebral artery stroke resulting in left-sided weakness and peripheral artery disease, placing her at increased risk for skin wounds. She required significant assistance with mobility, dressing, and bathing, and was dependent on staff for footwear management. A prior skin risk assessment had identified her as being at risk for skin wounds, and staff were instructed to observe and report any skin changes daily. Despite these risk factors and protocols, the new wound was not properly documented or communicated, resulting in a delay in physician notification and wound treatment. Interviews with other nursing staff revealed that the expected practice was to document new wounds in both the EMR and a paper communication sheet, notify the physician and family, and include the information in shift reports. The LPN involved was unaware of the requirement to document new wounds in the wound/incision complex flowsheet and believed she had communicated the information, though this was not confirmed by other staff. The lack of documentation and communication led to a delay in the evaluation and treatment of the resident's wound.
Failure to Use Wheelchair Foot Pedals During Transport Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident was being transported in a wheelchair by an occupational therapy assistant without the wheelchair foot pedals attached. The resident was holding his feet off the floor during the transport, but his feet eventually dropped to the floor, causing him to fall forward out of the wheelchair. As a result of the fall, the resident sustained a head laceration with bleeding and was subsequently evaluated in the emergency department. Further evaluation revealed that the resident had multiple rib fractures on the left side, as confirmed by a chest X-ray. The lack of wheelchair foot pedals during transport was identified as a contributing factor to the fall and resulting injuries. The incident was documented in the facility-reported incident review and confirmed through interviews, record review, and policy review.
Failure to Reconcile Narcotic Medications and Administer Non-Expired Medications
Penalty
Summary
The provider failed to ensure proper reconciliation and accounting for home narcotic medications for two residents. Specifically, medications belonging to residents 38 and 68 were found in the medication cart without a controlled substance record form to confirm the count. The medications were supposed to be sent home with family but were instead stored improperly. Interviews with the DON revealed that controlled substance sheets should have been started when the medications were found, and the medications should have been counted each shift, sent home, or destroyed as per policy. The provider's policy mandates accurate accounting and reconciliation of controlled substances to promptly identify loss or potential diversion. Additionally, the provider failed to ensure that expired medications were not administered to residents. Three residents (8, 29, and 55) received medications that had expired. Observations and MAR reviews revealed that these expired medications were still in use, and the DON was unaware of this issue. The provider's policy requires that medications with an expiration date be checked periodically, properly disposed of if expired, and replaced as needed. The DON acknowledged that expired medications should have been removed from the medication cart, sent back to the pharmacy, and an incident report should have been completed with notifications to the residents, their family members, and their physicians.
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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 | 0.5 mi | — | 0 | 0 |
| Bethesda Home Of Aberdeen | 1.3 mi | — | 7 | 0 |
| Aberdeen Health And Rehab | 1.4 mi | — | 1 | 1 |
| Avantara Groton | 18.7 mi | — | 11 | 0 |
| Sun Dial Manor | 36.7 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.