Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aberdeen Rehabilitation And Skilled Nursing Center during CMS and state inspections, most recent first.
A resident with CHF, COPD, type 2 DM, peripheral vascular disease, morbid obesity, moderate cognitive impairment, and documented dependence for transfers had active orders and a care plan requiring a mechanical lift with two-person assist due to muscle weakness and fall risk. On one occasion, a CNA used a mechanical lift alone to transfer the resident into a wheelchair, contrary to the physician order, care plan, and facility policy requiring at least two staff for Hoyer lift transfers. The resident subsequently slid from the wheelchair onto the floor in their room, reported low back pain, and was evaluated by nursing and a PA, with a lumbar x-ray ordered and pain management provided.
Kitchen food items were found improperly labeled or undated in the walk-in cooler and freezer, including feta cheese, bread, cheese pizzas, and sausage patties. The stove drip tray was soiled with dried and burnt food debris, no dish machine sanitizing log was available, and staff stated the dish machine was only tested weekly. In addition, about ten wall tiles were missing near the dish machine, leaving exposed surfaces that were not smooth or easily cleanable.
The facility failed to ensure proper use of the legally protected RD designation. A dietitian who had completed a dietetic program but had not earned RD status was listed as the facility RD, entered into the EHR as RD, and signed dietary notes using RD credentials. Interviews confirmed that another RD at a different building supervised her work, but the CDR stated that RD-EC is not a recognized credential and that only individuals who meet CDR requirements may use RD/RDN credentials.
The facility failed to keep the walk-in freezer in proper working order and failed to protect the commercial ice machine drain line from contamination. During a kitchen observation, the freezer temperature was 11 F despite a log entry of 5 F, and ice cream stored inside was soft rather than frozen solid. The DM reported a freon line leak had been refilled, and the ice machine drain line was observed without an airgap; the DM stated backed-up water from the floor drain could contaminate the ice machine.
Delayed MDS Submission: The facility failed to timely transmit MDS assessments for three residents. The RN/MDS Coordinator said she completed the quarterly MDSs but kept them in batch status pending a code from Corporate before submission, and the assessments had not been sent or accepted by CMS by the time of review. The Corporate Director of Operations stated the RN/MDS Coordinator could obtain her own code and confirmed the expectation that MDSs be submitted timely in accordance with CMS regulations.
Failure to transcribe a physician order onto the MAR resulted in a resident missing nine doses of MVI with minerals. During med pass, the resident did not receive the ordered supplement, and the DON confirmed the order had been entered under the wrong category and was not carried over to the MAR.
Medication administration errors exceeded the acceptable rate when surveyors observed missed doses during med passes and record review. An RN signed out medications as given even though a resident did not receive Ozempic and another resident did not receive Eliquis, and a separate review found a resident missed multiple doses of an MVI with minerals because the order was not transcribed onto the MAR.
A resident with severe cognitive impairment, mobility limitations, and multiple diagnoses was found unable to reach her call light while seated in a wheelchair. The call light was observed to be about three feet away, and both an activity aide and the DON confirmed it was not accessible. The resident's care plan and facility policy required the call light to be within reach at all times.
Surveyors observed that the Unit 300 shower room was left unclean, with used linens, gloves, and a patient gown on the floor after use. A CNA admitted to neglecting to clean the area at the end of her shift, and the DON confirmed that staff are required to clean the shower room and properly dispose of soiled items after each use, as outlined in facility policy.
The facility failed to address MRR recommendations timely for two residents, risking unnecessary medication use and poor communication between pharmacist and physician. One resident's sliding scale insulin use was not evaluated as recommended, and another resident's pharmacist recommendations were not initially located or signed off by a physician. The facility did not follow its policy for timely MRR actions.
The facility failed to maintain accurate medical records for two residents, leading to unclear pharmacy recommendations not being documented in their EHRs. For one resident, the pharmacist's recommendations were missing, and for another, the facility had to search for the pharmacy recommendations, which were not readily available.
A facility failed to follow infection control protocols when a nurse and CNA provided care to a resident with a Stage II pressure ulcer without wearing gowns, despite signage indicating the need for enhanced barrier precautions. The resident had intact cognition, and the unit manager acknowledged the oversight.
Improper One-Person Mechanical Lift Transfer Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide proper transfer assistance and adequate supervision during a mechanical lift transfer, resulting in a fall. A resident with diagnoses including congestive heart failure, COPD, type 2 DM, peripheral vascular disease, and morbid obesity was admitted in mid-January and discharged in late February. An MDS assessment documented moderate cognitive impairment and dependence on staff for transfers. The resident’s physician order dated 1/19/26 specified transfers with a mechanical lift and two-person assist, and the care plan documented that the resident needed help with transfers due to muscle weakness, with an approach specifying two-person assist with a mechanical lift and assistance with all transfers due to fall risk. On the date of the incident, documentation shows that the resident reported sliding from their wheelchair onto their back in their room, with the fall witnessed and described as the resident sliding from the wheelchair onto the floor. Nursing notes recorded mild back pain initially, followed by complaints of low back pain related to the fall, and a PA ordered a lumbar x-ray and pain management. A fall assessment completed the same day documented the resident’s current transfer status as requiring a two-person assist. The DON later identified a CNA as the person who witnessed the fall and stated that the CNA had been alone when using a mechanical lift to transfer the resident into the wheelchair, despite the resident’s transfer order and facility policy requiring a minimum of two staff for Hoyer/mechanical lift transfers.
Kitchen Food Labeling, Cleaning, and Dish Machine Sanitation Deficiencies
Penalty
Summary
Food items in the kitchen were not consistently date-labeled and several food-contact and nonfood-contact areas were not maintained in a clean condition. During a kitchen tour, a plastic container of feta cheese in the walk-in cooler was dated 8/9/25, and the Dietary Manager stated opened cheese should be thrown out in seven days. An open bag of cinnamon raisin bread in the cooler and a bag containing four individual-size cheese pizzas and a bag of sausage patties in the walk-in freezer were all undated. The stove drip tray was observed soiled with dried and burnt food debris, and the Dietary Manager stated it was supposed to be cleaned on Sunday and doubted it had been cleaned the day before. The dish machine was not consistently verified for proper sanitization, and the surrounding wall surfaces were not cleanable. The Dietary Manager stated the dish machine used sodium hypochlorite for sanitizing and that a chlorine test strip was used once weekly to test the machine, but no sanitizing log was available when requested. The Certified Dietary Manager, who oversaw the kitchen operation, stated that if the dish machine was not tested prior to each use there was no guarantee it was properly sanitizing dishware. Sections of the walls around the dish machine were missing approximately ten 4 x 4 tiles, leaving exposed surfaces that were not smooth and not easily cleanable.
Misuse of RD Credential by Unlicensed Dietitian
Penalty
Summary
The facility failed to ensure proper use of the legally protected professional designation of Registered Dietitian. Survey review showed that dietitian H was listed in the survey prep book as the facility’s Registered Dietitian, but the credentials on file were for RD J. During interviews, the Regional Director of Operations acknowledged that dietitian H was not a Registered Dietitian and that RD J, who worked at another building, supervised dietitian H. Human Resources stated that dietitian H completed a Coordinated Undergraduate Program in September 2018 but had not obtained RD status, and RD J confirmed that dietitian H had completed a dietetic program but had not been certified as a Registered Dietitian. Dietitian H stated she had been using RD credentials for six years and had not considered whether that was a concern. The Regional Director of Operations also stated that dietitian H had been entered into the EHR as a RD, though that designation was being corrected. Review of dietary progress notes for multiple residents showed electronic signatures of RD H on notes written by dietitian H, and later the signature was changed to RD-EC. The Commission on Dietetic Registration representative stated that RD-EC is not a standard or recognized credential and that only individuals who meet the academic and professional requirements, complete supervised practice, and pass the national registration exam may use the RD/RDN credentials.
Freezer Not Maintaining Frozen Food and Ice Machine Drain Lacked Airgap
Penalty
Summary
The facility failed to ensure the walk-in freezer remained in proper working order and failed to protect the drain line from the commercial ice machine against contamination. During the kitchen tour, the internal temperature of the walk-in freezer was observed at 11 F, while the temperature recorded on the freezer log earlier that day was 5 F, and a four-ounce cup of ice cream stored in the freezer was soft and not frozen solid. The Dietary Manager stated the freezer should be zero or below and reported there was a leak in the freon line that had been refilled. The drain line from the commercial ice machine was also observed without an airgap between the end of the drain line and the flood rim of the floor drain. The Dietary Manager stated that if water backed up from the floor drain, it could contaminate the ice machine. The Regional Director of Operations later acknowledged the deficiency with the air gap and stated kitchen staff should have notified maintenance if the freezer was not operating correctly.
Delayed MDS Submission
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessments to the State within 7 days of assessment for three of six residents reviewed for resident assessments. During interview and record review on 9/10/25, the RN/MDS Coordinator stated that she completes MDS assessments and places them in a "batch" for submission, but she must obtain a code from the Corporate Director of Operations before sending them. She reported that the quarterly MDS assessments for R15, R17, and R29 were completed but remained in batch status and had not been sent or accepted by CMS. The assessments were due for submission on 8/21/25 for R15 and R29 and on 8/23/25 for R17, but none had been submitted at the time of review. On 9/11/25, the Corporate Director of Operations stated that the RN/MDS Coordinator could obtain her own code to submit MDS assessments to CMS and was unsure why that had not been done, and confirmed that the facility expected MDS assessments to be submitted timely and in accordance with CMS regulations.
Failure to Transcribe Physician Order Resulted in Missed Multivitamin Doses
Penalty
Summary
The facility failed to follow the standard of practice for transcribing physician orders for one resident, resulting in missed doses of a multivitamin with minerals. During medication administration observation, the resident did not receive the ordered MVI with minerals. Review of the electronic health record showed the physician ordered MVI with minerals once daily, but the order was not transcribed onto the September 2025 MAR. The DON confirmed the resident was supposed to receive the supplement and stated the order had been placed under the wrong category and therefore did not appear on the MAR. The DON also confirmed the resident missed nine days of the MVI with minerals because the order was not transcribed.
Medication administration errors exceeded the acceptable rate
Penalty
Summary
The facility failed to keep the medication error rate below 5%, with surveyors observing 3 medication errors during 28 opportunities for a 10.4% error rate. During one medication pass, RN C administered medications at the bedside for R28 and signed out all medications as given, but R28 did not receive Ozempic 2 mg/3 ml, 0.5 ml subcutaneous injection. When questioned, RN C confirmed all medications had been given, then acknowledged the Ozempic should have been administered that day because it was ordered every Wednesday, and the MAR accurately reflected that order. During another medication pass, RN B administered medications for R47 and signed out all medications as given, but R47 did not receive Eliquis 5 mg. RN B confirmed all medications had been given, then stated the Eliquis should have been administered but was not in the medication cart at the time. In addition, reconciliation of R47's medication administration showed the resident had not received a multivitamin with minerals since 8/31/25 because the order was not transcribed onto the September 2025 MAR. The DON confirmed the order had been placed under the wrong category and that R47 missed 9 doses of the multivitamin with minerals from 9/1/2025 through 9/9/2025.
Call Light Not Kept Within Reach for Resident with Mobility and Cognitive Impairments
Penalty
Summary
The facility failed to ensure that a call button was within reach for a resident who required assistance, as observed during a survey. The resident, who was seated in her wheelchair in her room, was heard calling for help and expressing pain, stating she needed to get in bed. Upon observation, the call light was found to be approximately three feet away from the resident, making it inaccessible. An activity aide confirmed that the resident was unable to reach the call light. The Director of Nursing also acknowledged that the call light was not within the resident's reach during a subsequent observation. The resident's clinical record indicated diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis, muscle weakness, and difficulty walking, with documentation of severe cognitive impairment and wheelchair use for mobility. The resident's care plan specifically required that the call light be kept within reach at all times while in the room. Facility policy also mandated that the call light be within easy reach for residents in bed or confined to a chair. No additional documentation or information was provided by facility leadership during the exit conference.
Shower Room Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain the Unit 300 shower room in a clean and sanitary condition. During an observation, surveyors found a wet, used face cloth and gloves on the floor of one shower stall, and a used patient gown along with two wet, used face cloths on the floor of another stall. A CNA acknowledged that she neglected to clean the shower at the end of her shift, and stated that the shower rooms should not have been left in that condition. The DON confirmed that approximately 18 residents use the shower room and that staff are required to clean the shower room after each use for infection control, with used linens to be bagged and placed in the soiled utility room. Facility policy also requires all towels, bath cloths, and soiled clothing to be discarded in the soiled laundry container and equipment to be cleaned with disinfectant after use. No additional documentation or information was provided by facility leadership during the exit conference.
Failure to Address Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to obtain and address Medication Regimen Review (MRR) recommendations in a timely manner for two residents, resulting in the potential for the continuance of unnecessary medications and lack of communication between the pharmacist and physician. For one resident, identified as R12, the pharmacist recommended evaluating the use of sliding scale insulin due to the risk of hypoglycemia, as per the AGS Beers Criteria. However, there was no documented response from the physician or the facility to this recommendation, and the Director of Nursing (DON) later admitted that the recommendation had been missed. For another resident, identified as R3, the facility could not initially locate the pharmacist's recommendations from two separate reviews. The Director of Nursing reported that these recommendations were not part of the clinical record and were stored in an office. Eventually, the recommendations were retrieved, but there was no indication that the physician had been notified or had signed off on them. The Regional Director of Operations confirmed that the pharmacist's reports and recommendations should be part of the resident's medical record and communicated to the physician. The facility's policy on Pharmacy Medication Review outlines that the MRR should be conducted monthly, and recommendations should be submitted to the DON and Medical Records Designee within 48-72 hours. The physician is required to sign off on all recommendations and provide a rationale if they disagree. However, in these cases, the facility did not adhere to its policy, leading to a lack of timely action on the pharmacist's recommendations.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R3 and R12, which resulted in unclear pharmacy recommendations not being maintained in the residents' Electronic Health Records (EHR). For resident R3, the pharmacist's drug reviews indicated recommendations on two occasions, but there was no further documentation to describe these recommendations. The Director of Nursing (DON) was unable to locate the pharmacist's recommendations, and the Regional Director of Operations (RDO) confirmed that the facility could not find the actual recommendations, which should have been part of the resident's medical record. For resident R12, the clinical record showed that the resident was admitted with multiple diagnoses, including diabetes mellitus, acute respiratory failure, congestive heart failure, dementia, and asthma. The pharmacy recommendations for R12 were not readily available in the electronic medical record, and the facility had to search for them. An email from the pharmacist was submitted by the DON, indicating an attempt was made to update the electronic medical record with the pharmacy recommendation from several months prior.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to adhere to proper infection control techniques for a resident who required enhanced barrier precautions. During an observation, a registered nurse and a certified nursing assistant were seen providing care to a resident without wearing a gown, despite the resident having a pertinent diagnosis of Stage II pressure ulcer to the buttocks. The resident's electronic medical record indicated intact cognition with a Brief Interview of Mental Status score of 14/15. The unit manager confirmed that there was a sign on the door indicating the need for gown usage during care, which was not followed by the staff.
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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 Trenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Applewood Nursing Center, Inc | 0.8 mi | ★★★★★ | 0 | 0 |
| Aerius Health Center | 3 mi | ★★★★★ | 0 | 0 |
| Rivergate Terrace | 4.8 mi | ★★★★★ | 13 | 0 |
| Rivergate Health Care Center | 4.8 mi | ★★★★★ | 4 | 0 |
| Belle Fountain Nursing & Rehabilitation Center | 4.9 mi | ★★★★★ | 0 | 0 |
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