Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Avera Mother Joseph Manor Retirement Community during CMS and state inspections, most recent first.
Nursing staff posting did not include the actual hours worked by RN, LPN, and CNA staff per shift, and it was not posted daily. An RN health unit coordinator said she was responsible for the posting, was unaware of the requirement to include hours worked, and only posted it when she worked, leaving it incomplete on days she was absent, on weekends, and on holidays.
Dietary staff failed to perform proper hand hygiene during food prep and meal service, with multiple staff observed handling food, gloves, glasses, and clothing without washing hands between tasks. The facility also had repeated problems with food temperatures, including cold meals reported by residents and multiple foods observed or logged below required holding temperatures, along with missing temperature documentation. Dishwasher and sanitizer logs for several areas also showed frequent missing entries and out-of-range wash, rinse, and sanitizer results.
The facility failed to ensure an effective grievance process for resident complaints involving delayed call light response, nighttime noise, late meds, cold food, limited menu choices, and a lost hearing aid. Several residents said they were not told how to file a grievance or were not offered help, and staff responses were inconsistent, with some CNAs and an LPN unsure how to assist. The grievance officer and administrator described a process that was not consistently documented or clearly available to residents, despite policy requirements for prompt tracking, investigation, and resident notification.
A facility failed to answer resident call lights in a timely manner for multiple residents. Residents with intact cognition, severe cognitive impairment, hospice status, incontinence, mobility limits, and other medical needs reported waits of 20 minutes to more than 2 hours for help with toileting, incontinence care, meals, and activities. Call light alarm reports confirmed repeated prolonged delays, while staff stated call lights should be answered within about 5 to 10 minutes and the facility policy required prompt response.
Advance Directive and Code Status Not Honored: A resident with an intact BIMS score and a living will stating she did not want life-prolonging treatment was admitted as full code. Staff entered the full code order, placed a red dot on the door name plate, and documented the code status in the care plan, but there was no documentation that her wishes were reviewed with her on admission. Interviews showed staff expected code status to be discussed with the resident and/or family, yet the resident said no one had talked to her about it and she was upset that CPR was ordered.
Staff failed to properly clean and store respiratory equipment for multiple residents. Nasal cannulas were found draped over beds, on a concentrator, and on the floor instead of being stored in the plastic bag attached to the O2 concentrator. Nebulizer sets had visible liquid remaining after treatments and were not consistently disassembled, rinsed, and air dried. CPAP machines in two rooms had water reservoirs left filled with condensation present, and one resident said staff would not help fill the reservoir while another said she did not use the CPAP but the machine remained set up with an O2 connector.
Failure to Follow Hand Hygiene and Glove Use Practices: Staff did not follow standard infection prevention practices during resident care and while moving through the hallways. A CNA exited a room on EBP with a glove on, removed it in the hall, and did not perform hand hygiene before opening other resident room doors. In another room, a CNA caring for a resident with MRSA history repeatedly removed gloves without hand hygiene between tasks, used a phone with soiled gloves, and handled the resident's oxygen cannula, gown, and personal care items. An RN also wore gloves in the hall and medication room, performed a blood sugar check without proper hand hygiene between glove changes, and administered nebulizer care without hand hygiene before and after resident contact.
A resident with dysphagia, prior CVA, and a physician-ordered DNR/DNI: medical tx OK choked during lunch. Staff performed a finger sweep, back blows, and prolonged abdominal thrusts, and EMS removed meat from the airway. After the airway was cleared, the resident had no pulse or respirations, but the LPN told EMS the daughter would want CPR and CPR was started despite the resident’s code status. The daughter later stated she did not want CPR and questioned why it had been initiated.
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.
Nursing Staff Posting Missing Hours Worked
Penalty
Summary
The provider failed to ensure the posted nurse staffing information included the actual hours worked by RN, LPN, and CNA staff per shift, and the form was not posted daily. During observation on 10/2/25 at 10:00 a.m., the nursing services staff posting showed the number of nursing staff working, but did not include the number of hours worked. During interview on 10/2/25 at 11:12 a.m., the RN health unit coordinator stated she was responsible for posting the nursing services staff form, was not aware the posting had to include the number of hours worked by nursing services staff, and posted the form only when she worked, so it was not completed when she was gone, on weekends, or on holidays. The administrator stated the facility did not have a policy regarding the nursing staff posting.
Hand Hygiene, Food Temperature, and Dishwashing Sanitation Failures
Penalty
Summary
Dietary staff failed to perform appropriate hand hygiene during food preparation and service, and the facility failed to maintain dishwashers and sanitation solution containers in accordance with food service sanitation standards. During kitchen observations, multiple staff members were seen handling food, utensils, gloves, glasses, and clothing without washing their hands between tasks or after glove removal. One cook dried his hands on his pants after washing, another staff member cut strawberries after putting on gloves without washing hands, and the hospitality services manager handled prepared food and utensils with bare, unwashed hands while plating and wrapping food. A cook also touched his glasses repeatedly while plating meals and did not wash his hands, and another staff member wiped her nose on her forearm before putting away clean dishes. Resident interviews showed ongoing concerns about food quality and temperature. One resident who preferred to eat in her room said her meals were often cold when delivered and that she had told kitchen staff, but no one followed up. Another resident said food was sometimes cold when served in the dining room, that it sat in the window before service, and that noodles were sometimes hard and meat difficult to eat. A resident council record also documented concerns that scalloped potatoes were never done and that food temperatures needed to be hotter. Kitchen observations and temperature log reviews showed food was repeatedly held or served below required temperatures and that temperatures were often not documented. Surveyors observed milk at 50.6 degrees F and chicken noodle soup at 96.9 degrees F before service, and other foods such as pureed meat, pureed broccoli, pork chops, and soups were found below safe serving temperatures during meal preparation. Logs for the dining rooms and main kitchen showed numerous missing cooking and holding temperature entries, as well as multiple low holding temperatures without documented corrective action. Reviews of dishwasher and sanitizer logs for the Cedar wing, Dakota wing, and main kitchen showed many missing temperature and sanitizer checks, several wash and rinse temperatures outside required ranges, and no documentation of corrective action for out-of-range results.
Ineffective grievance process for resident complaints
Penalty
Summary
The facility failed to implement an effective grievance process for residents who voiced concerns about care and services, including long call light response times, nighttime noise, late medication administration, cold food, limited menu choices, and a lost hearing aid. Multiple residents stated they were not aware of how to file a grievance, were not offered assistance to do so, or did not know what actions the facility was taking after they voiced concerns. The grievance policy required residents to be informed orally and in writing of their right to file grievances, including anonymously, and required prompt investigation, tracking, and communication through resolution. Resident 89 reported that a nurse aide responded to her call light after she requested help to use the bathroom and made comments that she felt were rude. She also stated that her morning Zofran was consistently given late, after she was already nauseated and unable to eat noon meals. She told another nurse aide about the interaction but was not offered or asked if she wanted to file a grievance. Resident 55 reported long waits for call light response, episodes of urine incontinence while waiting, unsafe self-transfer to the bathroom, and nighttime noise from staff and her roommate. She said she notified the prior DON and the RN/quality and infection prevention supervisor, but the concerns continued. Resident 76 reported waiting a long time for staff to answer her call light, especially in the morning, and being kept awake by a loud resident across the hall; she said she complained to staff but was unsure how to file a grievance. Resident 67 stated that meals delivered to her room were often cold and that she preferred milk with meals, but she was only given water and did not know who completed her menu choices. She told kitchen staff her food was cold, but no one followed up and the issue continued. Resident 90 reported that her hearing aid was lost and said staff looked in the trash and recliner, but she was not aware of how to file a grievance and did not know what the facility was doing about the loss. Staff interviews showed inconsistent understanding of the grievance process, with several CNAs and an LPN unsure how to help residents file grievances or who the grievance officer was. The social worker stated she was the grievance officer, but she was not aware of any posted grievance materials and did not know whether grievance forms were available without asking staff. The administrator stated only four grievances had been documented in the past year, while the grievance logs available covered only the first quarter of 2025.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to provide prompt response to resident call lights for seven residents who reported long waits for assistance. Interviews with residents and family members, along with call light alarm report reviews, showed repeated delays ranging from 20 minutes to more than 2 hours. The provider’s own staff stated that call lights were expected to be answered within about 5 to 10 minutes, and the administrator confirmed that anyone who could help a resident should answer the call light. The facility’s call light policy required prompt response to resident requests. Resident 71’s husband reported that when his wife, who had severe cognitive impairment, urinary incontinence, Alzheimer’s disease, and a history of UTIs, needed incontinence care, staff took over 45 minutes to respond. Resident 76, who had intact cognition and diagnoses including depression, anxiety, spinal stenosis, spondylolisthesis, and oxygen dependence, reported waiting a while for staff to answer her call light, especially in the morning, and said she missed going for a walk because of the delay. Resident 30, who was on hospice and cognitively intact, reported waiting 45 minutes in the middle of the night after bowel incontinence and said staff sometimes took a while during the day as well. Resident 34, who was cognitively intact, reported waiting 30 to 40 minutes at dinner and supper for call light response and said staff told her they did not have enough help. She also reported long waits at night for a bedpan and having to turn her call light back on after staff said they would return. Resident 55, who was cognitively intact and had a healing left lower leg fracture, left ankle sprain, wound vacuum, CAM boot, overactive bladder, and mobility limitations, reported waiting up to 30 minutes at night and becoming incontinent while waiting for bathroom assistance. Resident 45, who was cognitively intact and total assist for transfers, reported long waits for help to get to activities and meals. Resident 73, who was cognitively intact and needed one-person assist for transfers, reported waiting long periods for help, especially during meals. Call light reports documented multiple prolonged waits for each of these residents, including numerous instances over 20 minutes and several lasting up to 1 hour 33 minutes, 2 hours 5 minutes, 52 minutes, 35 minutes, 1 hour 5 minutes, 50 minutes, and 52 minutes.
Advance Directive and Code Status Not Honored
Penalty
Summary
The provider failed to protect a resident’s right to have her advance directive and code status wishes identified accurately on physician orders and in the care plan. Resident 55 had a living will stating that if death was imminent or she was permanently unconscious, she chose not to prolong her life and wanted life-sustaining treatment stopped while remaining comfortable. Her BIMS score was 15, indicating intact cognition, and she told staff that no one had discussed her code status wishes with her after admission and that she did not want CPR if her heart or breathing stopped. On admission, the resident was entered as full code based on physician orders, including hospital discharge orders, and the red dot on her door name plate indicated full code status. LPN/resident care supervisor J entered the full code order, completed the admission assessments and care plan, and stated she was supposed to verify the resident’s code status wishes at admission. However, she did not have documentation showing that resident 55’s wishes were reviewed with her to ensure they would be followed. The resident’s printed baseline care plan also listed her code status as full code, and it was signed by the LPN and the resident. Interviews with staff showed that code status was expected to be reviewed with the resident and/or family representative and then matched to a physician order, but the resident did not sign code status forms. The RN/quality and infection prevention supervisor stated the designated staff member was to discuss code status with residents, and the interim DON stated admitting staff needed to review both physician orders and advance directives to determine that the resident’s wishes were followed. The facility’s advance care planning policy stated that advance directives are intended to ensure patient wishes are honored, and the admission handbook stated the resident or representative must sign the form designating desired code status, with physician agreement before an order is written.
Improper respiratory equipment cleaning and storage
Penalty
Summary
Staff failed to follow respiratory equipment care practices for nasal cannulas, nebulizer administration sets, and CPAP machines for multiple residents. The report identified that nasal cannulas for residents 5, 50, and 90 were not stored in the plastic bags attached to their oxygen concentrators when not in use. Instead, one cannula was draped over the top of an oxygen concentrator, another was draped over an unmade bed, and another was found lying on the floor behind the concentrator. Staff interviews confirmed that nasal cannulas were expected to be rolled up and stored in the plastic bag on the oxygen concentrator, and that resident 50 required staff assistance to turn the concentrator on and off and to manage the cannula. Nebulizer equipment was also observed to be improperly cleaned and stored for residents 5, 42, and 63. Resident 63 had a nebulizer machine on the bedside table with liquid remaining in the medicine chamber, and resident 42 repeatedly had clear liquid drops visible inside the nebulizer administration set after treatments. Resident 42 stated that after he completed treatments, he placed the nebulizer set on the side of the machine and that some nurses rinsed it while others did not. The RN/quality and infection prevention supervisor stated that nebulizer administration sets were to be disassembled, rinsed with sterile or distilled water, and placed on a towel to air dry after each use, and washed with soap and water every night at bedtime. CPAP machines in the rooms of residents 5 and 90 were observed with water reservoirs that were about three-fourths full of clear liquid, with condensation visible in the reservoirs. Resident 5 stated she did not use the CPAP because she needed water in the reservoir to prevent her mouth and throat from becoming too dry, and she said night staff would not assist her with filling it. Resident 90 stated she did not use her CPAP and used oxygen at night instead, but the CPAP machine in her room had a blue connector for oxygen and was observed with the reservoir filled with water. The provider’s respiratory equipment care policy stated that nebulizers were to be rinsed after every treatment and stored to air dry, nasal cannulas were to be stored in the plastic bag attached to the oxygen concentrator when not in use, and cannulas and tubing were to be changed weekly.
Failure to Follow Hand Hygiene and Glove Use Practices
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff did not follow standard infection prevention practices during resident care and while moving through the facility. On 9/30/25, a CNA exited a resident room with a glove on, removed the glove in the hallway, did not perform hand hygiene, and then opened the doors to three other resident rooms. The resident room had PPE posted on the door and the resident in that room was on enhanced barrier precautions (EBP). During direct observation in resident 51's room, CNA R provided multiple hands-on care tasks for a resident who was on EBP due to a history of MRSA infection. The resident was lying in bed, the lights were dimmed, and relaxing music was playing. CNA R washed her hands and put on a gown and gloves before care, but repeatedly removed gloves and did not perform hand hygiene before putting on new gloves for subsequent tasks. She assisted with bedding and clothing, cleaned the resident's bottom, washed the perineal area, brushed the resident's teeth, and later washed the resident's face while using a phone with soiled gloves. With those same gloved hands, she removed the resident's nasal cannula, applied lotion and deodorant, changed the gown, reapplied the nasal cannula, cleaned the resident's nails, brushed the resident's hair, and later handled the garbage bag and fall mat before performing hand hygiene and leaving the room. RN Z was also observed not following hand hygiene and glove practices. While in the medication room, she put on gloves without washing her hands, walked to resident 83's room with those gloves on, completed a blood sugar check, removed the gloves, and did not perform hand hygiene before returning to the medication room and putting on another pair of gloves. She then cleaned the glucometer and only afterward performed hand hygiene. RN Z was also observed administering a nebulizer treatment to resident 49 without hand hygiene before preparing the medication and placing the mask, and later, after leaving the room, she put on gloves at the nurse's station, walked back to the resident's room, removed the nebulizer mask, rinsed it in the resident's sink, removed her gloves, and then performed hand hygiene.
CPR Provided Despite DNR/DNI Status After Choking Episode
Penalty
Summary
The facility failed to withhold CPR for a resident with a physician-ordered DNR/DNI status after she choked during lunch and later had no pulse or respirations after her airway was cleared. The resident had a history of dysphagia, a prior stroke, and had recently been hospitalized for aspiration pneumonia. Her record showed a DNR/DNI: Medical Tx OK order, and her daughter was her POA and had previously signed a no code directive. On the day of the incident, the resident choked while eating lunch in the dining room. The nurse performed a finger sweep, back blows, and prolonged abdominal thrusts while staff assisted the resident to stand. 911 was called, and when EMTs arrived they removed a piece of meat from the resident’s throat using a camera and forceps. After the airway was cleared, the resident was unresponsive and had no radial or carotid pulse. The paramedic confirmed the resident was DNR/DNI and contacted the emergency medical doctor, who instructed continued ventilation and monitoring. Facility staff told the paramedics that the resident’s daughter would want CPR in this situation, and the LPN stated she believed the daughter would want CPR started. CPR was initiated and two rounds were completed before a pulse returned and the resident was transported to the hospital. The resident’s daughter later stated she did not want CPR and questioned why it had been started when staff knew the resident’s code status was DNR/DNI. The facility administrator and quality/infection prevention RN confirmed that the resident’s code status was DNR/DNI with medical treatment allowed and that the LPN had not followed the physician-ordered code status.
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 | ★★★★★ | 13 | 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 July 2026) and official state health department websites.