Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Health And Rehab during CMS and state inspections, most recent first.
Delayed Response to Resident Call Lights: Staff did not respond promptly to call lights for multiple residents, with logs showing repeated waits over 20, 30, and even 50 minutes, and some residents reporting waits up to 2 hours. Several residents said they became incontinent while waiting for bathroom help, and one resident was observed unable to reach her call light because it was disconnected from the extender. Residents also reported call lights left out of reach and concerns that staff were not available on the floor.
Expired hand sanitizer was found in many resident rooms, a linen cupboard lacked a covering to protect linens from airborne infectants, and a resident’s wheelchair had torn, dirty padding. Staff also failed to consistently follow EBP and hand hygiene during personal hygiene and wound care for residents with pressure ulcers, including not cleansing a wound before dressing it and bringing wound care supplies into multiple rooms without sanitizing equipment between residents.
Inaccurate MDS coding was found for two residents whose diabetes meds were non-insulin injectables. One resident with ESRD and diabetes had Ozempic ordered, and another resident with CKD and diabetes had Mounjaro ordered, but both MDS assessments incorrectly coded insulin use and hypoglycemic drug class use. The MDS coordinator acknowledged the coding error but did not update the assessments after learning of the inaccuracy.
Improper Storage and Dating of Oxygen and CPAP Equipment: Two residents had oxygen equipment and CPAP items observed out of proper storage, including nasal cannula tubing on the floor, undated or empty humidifiers, and a CPAP mask on the floor. One resident had OSA with an order for oxygen at bedtime and as needed, and the other had COPD with orders for nightly CPAP and continuous oxygen. Staff stated the tubing, humidifier, and CPAP mask should be stored and dated per facility practice, and the facility policy required weekly changes and dating of oxygen equipment.
Improper Hand Hygiene During Food Prep: A cook wore gloves while handling cucumbers, touched a garbage can lid, and then continued handling food without removing the gloves or washing her hands. She later changed gloves and resumed cutting cucumbers, then removed the gloves and washed her hands. The DM and the cook both stated hand hygiene was expected before gloving and after glove removal.
Nonfunctioning Resident Call Lights: A resident reported waiting a long time for staff to answer her call light and said it had been disconnected from the wall extender, while another resident said her call light had been unplugged and she had to get help by having a friend use his call light. Staff and residents also reported repeated call light problems for another resident, and the DON stated call lights were expected to always be in working order; the facility did not have a call light policy.
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.
Delayed Response to Resident Call Lights
Penalty
Summary
The provider failed to ensure staff responded promptly to resident call lights for 11 of 16 sampled residents, including residents 6, 22, 30, 34, 36, 40, 41, 62, 64, 68, and 73. Multiple residents reported waiting extended periods for assistance after activating their call lights, with some describing waits of 15 minutes to 2 hours. Several residents stated that delayed responses affected their ability to get help with bathroom needs, personal care, repositioning, and transfers, and some reported becoming incontinent while waiting for staff. Resident interviews and call light logs showed repeated long response times. Resident 6 reported waits of 15 minutes to 2 hours, and his call light log documented waits over 20, 30, and 40 minutes. Resident 30 reported sometimes waiting a long time, and her log showed multiple waits over 20 and 30 minutes. Resident 64 reported long waits, including a 2-hour delay during shift change, and stated she became incontinent of urine when staff did not respond promptly; her log showed multiple waits over 20 and 30 minutes. Resident 34 reported long waits that led to incontinence and said staff sometimes did not give her the call light device; her log showed repeated waits over 20, 30, and 40 minutes. Resident 36 reported waiting 20 to 45 minutes for help, and his log showed 29 response times over 20 minutes, including 11 over 30 minutes. Resident 40 and her family member reported that she sometimes lost bladder control while waiting for bathroom assistance, and her log showed multiple waits over 20, 30, and 50 minutes. Additional observations showed call lights were sometimes not within residents’ reach or were not functioning. Resident 34 was observed unable to reach her call light, and staff later found it disconnected from the extender. Staff interviews confirmed that call lights were sometimes found out of reach. During the resident council meeting, residents reported long waits, call lights left out of reach, and concerns that staff were not on the floor because they were in the breakroom or smoking. Staff interviews reflected differing expectations for response times, ranging from 2 minutes to 15 minutes, and the DON and executive director acknowledged that response times were sometimes delayed, including when staff had to locate a lift or when call lights were turned off before needs were addressed. The facility did not have a call light policy.
Infection Control Failures in Resident Care and Environmental Practices
Penalty
Summary
The provider failed to ensure infection prevention and control practices were followed in multiple areas of resident care and the environment. Surveyors observed expired hand sanitizer dispensers in 29 of 64 resident rooms, and the DON confirmed the facility did not have a specific policy for expired hand sanitizer products and was not sure who monitored expiration dates. The ED also confirmed the sanitizer was expired in those resident rooms and stated staff were not assigned to check expiration dates because it should not last that long in the rooms. Surveyors also observed a linen cupboard outside the TCU dining room that contained blankets, sheets, bath blankets, and gowns but had no doors or covering to protect the linens from airborne infectants. Staff interviewed stated they would not consider the linens in that cupboard to be clean. In addition, resident 26’s electric wheelchair had torn and partially missing padding on the right handle, with scotch tape wrapped around the damaged area. The resident stated the padding was not comfortable and that he had complained but staff did not address his concerns. Multiple observations showed staff did not consistently follow enhanced barrier precautions and hand hygiene during personal hygiene and wound care for residents with pressure ulcers. For resident 34, CNAs and a CMA provided hygiene care and wound care without consistent gown use, hand hygiene, or wound cleansing before dressing application. RN W applied a dressing without cleansing the wound first and stated the CNAs had already cleaned it, although she agreed that was not what was on the treatment plan. For residents 5, 6, 9, 10, and 34, the ADON/LPN/IP and RN U brought wound care supplies into multiple rooms, used the same bottles of soap, saline, betadine, and other items across residents, failed to sanitize wound care equipment between uses, and did not always perform hand hygiene appropriately. The report also noted that the facility’s infection surveillance report showed multiple healthcare-associated infections, and the facility policies required hand hygiene, EBP for residents with wounds, and routine surveillance of compliance with protective clothing and equipment.
Inaccurate MDS Coding for Diabetes Medications
Penalty
Summary
The facility failed to ensure accurate MDS coding for dialysis-related medications for two residents. Resident 4 had diagnoses including type 2 diabetes mellitus without complications, end stage renal disease, and dependence on renal dialysis. His EMR showed an order for Ozempic (semaglutide) 0.25 mg subcutaneously once weekly for diabetes, but his annual MDS coded section N0350 as insulin injections in the last seven days as yes and section N0415J hypoglycemic (including insulin) as yes. Resident 59 had diagnoses of chronic kidney disease and type 2 diabetes mellitus without complications. Her EMR showed an order for Mounjaro (tirzepatide) 2.5 mg subcutaneously once weekly for diabetes, but her quarterly MDS coded section N0350 as one insulin injection in the last seven days and section N0415J hypoglycemic (including insulin) as yes. The MDS coordinator stated she knew Ozempic and Mounjaro were coded inaccurately as insulin and learned of the inaccuracy on 4/24/26, but did not update the MDS assessments for residents 4 and 59.
Improper Storage and Dating of Oxygen and CPAP Equipment
Penalty
Summary
The provider failed to ensure infection control practices were followed for oxygen equipment for two residents. One resident had obstructive sleep apnea and an order for oxygen at 3 L by nasal cannula at bedtime and as needed; observations showed the nasal cannula tubing on the floor and not dated, and the pre-filled humidifier was not dated. The resident’s June 2026 TAR did not indicate when the nurse was to change the oxygen tubing. Another resident had COPD and orders for nightly CPAP use and continuous oxygen at 2 L. Observations showed the oxygen concentrator in the room, the nasal cannula tubing dated but later found on the floor, the pre-filled humidifier empty and not dated, and the CPAP mask on the floor between the bed and nightstand. Staff interviews stated the oxygen tubing should be stored in a bag or in the bedside table drawer when not in use, the CPAP mask should be stored on the CPAP machine, and the tubing and humidifier should be dated when changed. The facility policies stated oxygen tubing and nasal cannula/mask were to be changed weekly, the tubing should be changed when found lying on the floor, and the humidifier bottle should be replaced weekly and as needed with date and initials.
Improper Hand Hygiene During Food Preparation
Penalty
Summary
Food was not handled in accordance with standard food safety practices during kitchen food preparation. During observation, cook Y wore gloves while peeling cucumbers, then walked to the garbage can, lifted the lid, and discarded the peelings. With the same gloved hands, she placed the peeled cucumbers in a bowl and rinsed them with water. She then removed her gloves and did not wash her hands before continuing food handling tasks. Cook Y later placed a bag of shredded cheese in the walk-in cooler, used pot holders to remove a peach cobbler pan from the oven, and then changed tasks by taking a dirty knife to the dirty dish area and obtaining a clean knife. She put on a new pair of gloves and cut the cucumbers on a cutting board, then picked up the cut cucumbers and placed them in a bowl. She brought the dirty knife and cutting board to the dirty dish area, wiped the counter with a sanitizer cloth, removed her gloves, discarded them in the trash can, and washed her hands with soap and water. In interview, cook Y stated she should wash her hands with soap and water when entering the kitchen, before putting on gloves, and after removing gloves, and the dietary manager stated she expected cook Y to remove her gloves after touching the garbage can lid and wash her hands after glove removal.
Nonfunctioning Resident Call Lights
Penalty
Summary
The provider failed to ensure that resident call lights were functioning for three sampled residents whose call lights were not working. Resident 34 was observed in bed and stated she had waited a long time for staff to answer her call light and then would be incontinent of urine. She said she had turned her call light on a while ago and no one had come. When RN P checked, resident 34’s call light was found disconnected from the call light extender that plugged into the wall, so it did not turn on when pushed. Resident 34’s EMR showed a BIMS score of 14, indicating intact cognition. Resident 73 stated she had problems with her call light being unplugged from the wall and had to yell to a friend across the hall to turn on his call light to get staff help. Her EMR showed a BIMS score of 15, indicating intact cognition. During the Resident Council Meeting, staff and residents reported that resident 41’s call light had not worked numerous times and that resident 73 had issues with her call light not working. On another observation, resident 34’s call light turned back off on its own, and the ADON/LPN/IP stated that it did that sometimes. RN P also stated that call lights sometimes get hooked under the bed and pulled out of the connector, causing them not to work. The DON stated she expected call lights to always be in working order, and the facility did not have a call light policy.
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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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 6 | 0 |
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