Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
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 Bethesda Home Of Aberdeen during CMS and state inspections, most recent first.
The facility failed to ensure food was at safe temperatures before serving it to residents. Chef H forgot to take and log food temperatures during a breakfast meal service, and a review of logs showed multiple instances of missing documentation for meals. CSM E was unaware of the issue and had not been monitoring the logs, contrary to the facility's policy requiring temperature checks and documentation before each meal.
A resident receiving hospice and oxygen services did not have a comprehensive care plan developed in collaboration with hospice. The care plan lacked details on oxygen delivery systems, equipment settings, and monitoring requirements. Staff interviews revealed the absence of a hospice care plan in the facility's EMR and hospice binder, and the director of nursing confirmed the care plan should have been updated upon the resident's admission to the facility.
A resident receiving oxygen therapy was left unattended during a nebulizer treatment, and the facility failed to maintain the cleanliness of the oxygen concentrator, tubing, and humidifier. The oxygen equipment was not labeled or dated, and the humidifier was found dry with debris. Staff interviews revealed inconsistencies in equipment maintenance and monitoring, contrary to facility policies.
A resident receiving hospice services did not have an integrated care plan accessible between the facility's nursing staff and the hospice agency. The hospice plan was not uploaded into the electronic medical record, and the hospice binder lacked documentation of the resident's oxygen needs. Interviews revealed that the care plan was not updated to reflect the resident's current needs, violating the facility's agreement with hospice services.
Failure to Ensure Safe Food Temperatures
Penalty
Summary
The provider failed to ensure that food was at safe temperatures prior to serving it to residents during a breakfast meal service. Chef H admitted to forgetting to take the food temperatures that morning, and the food temperature logs confirmed that temperatures had not been documented. Chef H sometimes took the temperatures without logging them and sometimes forgot to take them altogether. Culinary Services Manager (CSM) D instructed Chef H to take and log the temperatures for the next batch of food, which was completed. However, a review of the food temperature logs revealed multiple instances where temperatures were not documented for breakfast, lunch, and supper. CSM E was unaware that food temperatures had not been taken or logged that morning and acknowledged that the logs indicated temperatures were not being documented as required. She admitted to not monitoring the logs for a while, assuming the temperatures were being done. The facility's policy from 2021 required that food temperatures be taken and recorded prior to each meal service, but this was not consistently followed. Interviews with other staff, including Chef G and Chef M, confirmed that food temperatures should have been checked and logged with each meal. Administrator A was also unaware of the issue and expected that food temperatures would be taken with each meal.
Deficiency in Comprehensive Care Plan for Resident on Hospice
Penalty
Summary
The provider failed to develop a comprehensive care plan in collaboration with hospice for a resident receiving oxygen and hospice services. The resident, who was admitted from home with hospice services, had diagnoses including malignant neoplasm of the lung, chronic obstructive pulmonary disease, and chronic kidney disease. Observations revealed the resident was short of breath and using oxygen via nasal cannula, with an oxygen concentrator and a portable oxygen tank present. However, the care plan did not include specific details about the oxygen delivery systems, equipment settings, or monitoring requirements. Interviews with staff indicated a lack of a hospice care plan for the resident in the facility's electronic medical record (EMR) and hospice binder. The certified nursing assistant confirmed the resident was receiving hospice services but could not locate a hospice care plan. The director of nursing acknowledged that the hospice care plan should have been integrated into the resident's overall care plan and updated upon the resident's transition from home to the facility. The care plan was missing critical information such as the type of oxygen equipment used, frequency of equipment cleaning, and assistance required for nebulizer treatments. The facility's policies on oxygen administration and comprehensive care planning were not adhered to, as the care plan lacked measurable objectives and time frames to meet the resident's needs. The hospice plan of care was not uploaded into the EMR, and there was no documentation of the resident's oxygen needs or interventions in the hospice binder. This oversight resulted in a deficiency in providing a complete and coordinated care plan for the resident's medical and comfort needs.
Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The provider failed to maintain the cleanliness and proper administration of respiratory care equipment for a resident receiving oxygen therapy. During an observation, it was noted that a registered nurse (RN) initiated a nebulizer treatment for the resident and left the room, resulting in the resident being unattended with the nebulizer running for an extended period. The resident was unable to self-administer the treatment and was found holding the nebulizer mask in her hand, with the mask eventually ending up on the floor. This indicates a lack of supervision and proper administration of the nebulizer treatment. Further observations revealed that the oxygen concentrator, tubing, and humidifier were not maintained according to the facility's policies. The oxygen concentrator was covered in dust, and the filter contained visible lint and debris. The oxygen tubing and humidifier were not labeled or dated, and the humidifier was found to be dry with an unidentified white flaky substance at the bottom. Additionally, the nasal cannula connected to the portable oxygen tank was not labeled or dated, and the portable oxygen tank's tubing was observed resting on the floor. Interviews with facility staff, including RNs and the Director of Nursing, highlighted inconsistencies in the maintenance and monitoring of the oxygen equipment. The staff acknowledged that the oxygen tubing and humidifiers were supposed to be changed weekly, and distilled water should have been used for the humidifiers. However, there was no jug of distilled water in the resident's room, and the staff was unclear about the source of the water used. The facility's policies required weekly cleaning of the concentrator and filters, which was not adhered to, contributing to the deficiency in providing safe and appropriate respiratory care.
Failure to Integrate Hospice Care Plan for Resident
Penalty
Summary
The provider failed to ensure an integrated plan of care was developed and accessible between the nursing staff and hospice agency for a resident receiving hospice services. The resident, who had been admitted to the facility from home hospice, had a care plan that included diagnoses such as malignant neoplasm of unspecified bronchus or lung, chronic obstructive pulmonary disease, and chronic kidney disease. However, the hospice plan of care was not uploaded into the resident's electronic medical record, and the hospice binder at the nurse's station lacked documentation of the resident's oxygen needs or interventions. Interviews with facility staff revealed that the hospice care plan was not available, and the director of nursing confirmed that the care plan should have been updated to reflect the resident's current needs, including oxygen requirements and equipment usage. The facility's Hospice and Nursing Facility Services Agreement required collaboration with hospice staff and the maintenance of a joint plan of care, which was not adhered to in this case. The deficiency was identified through a review of records, interviews, and the facility's agreement with hospice services.
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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) |
|---|---|---|---|---|
| Avera Mother Joseph Manor Retirement Community | 1.3 mi | — | 9 | 0 |
| Prairie Heights Healthcare | 1.6 mi | — | 0 | 0 |
| Aberdeen Health And Rehab | 2.7 mi | — | 1 | 1 |
| Avantara Groton | 17.7 mi | — | 11 | 0 |
| Sun Dial Manor | 35.6 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.