Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Bethesda Home Of Aberdeen during CMS and state inspections, most recent first.
A resident with MS, paraplegia, muscle wasting, and weakness developed a facility-acquired SDTI on the right heel after admission with an existing left heel pressure injury. Staff documented the wound and used foam dressings and boots, but the record showed no further Braden Scale assessments after the initial period, and the care plan did not include the resident’s inability to reposition her legs, heel floating, or use of Podus boots. The DON agreed the Braden scoring was incorrect and that the resident’s care plan lacked needed pressure injury prevention interventions.
Food service sanitation and storage practices were not followed in the kitchen and activity room kitchenette. Staff observed a dirty popcorn machine, buildup in the dishroom sink and beverage dispensers, debris in the freezer, raw meats stored with liquid pooling in the cooler, and bulk ingredients left undated with a spoon stored in sugar. The activity room dishwasher was used for resident cups and dishes even though it did not reach sanitizing temperatures and the detergent pods did not provide chemical sanitization. During meal service, a CNA touched resident wheelchair equipment and then poured water for three residents without performing hand hygiene.
Menu serving sizes and therapeutic diet menus were not followed. A chef served breakfast items using a scoop size that did not match the listed portion and used tongs for potatoes, making the amount served unverified. The facility also lacked dietitian-signed menus for NAS and heart healthy diets, and culinary managers stated residents on therapeutic diets received the same menu as the regular diet.
A facility failed to ensure residents and/or their representatives were informed of the risks versus benefits and alternative treatments before psychotropic medications were started or changed. One resident with Alzheimer’s disease, psychosis, hallucinations, and dementia was started on aripiprazole without documentation of POA notification or consent, and another resident with severe cognitive impairment had multiple psychotropic orders and dose changes, including mirtazapine, sertraline, aripiprazole, and lorazepam, without documented discussion of the medication purpose, risks, benefits, or alternatives. Interviews with the DON, LPN, and MDS RN confirmed the expected notification process and that written informed consent was not being obtained.
Failure to transmit discharge MDS assessments: Staff did not electronically submit discharge tracking MDS records for three discharged residents within the required timeframe. One resident’s discharge MDS was not completed, one discharge was missed from the paper tracking log, and one resident’s death was incorrectly documented as occurring in the facility rather than at the hospital.
A resident with Alzheimer's disease, psychosis, hallucinations, delusions, depression, and anxiety had documented episodes of seeing children and becoming agitated when staff did not acknowledge them. Staff said they validated the hallucinations to keep her calm, but the care plan only noted general paranoia and seeing things that were not there and did not include specific goals or interventions for those episodes. The social services director confirmed the care plan lacked interventions for staff to use when the resident was hallucinating.
A resident with DM and diabetic CKD had repeated low blood sugars, but staff did not notify the physician when readings fell below the ordered threshold, despite orders to report values under 70 mg/dL. Another resident with acute respiratory failure with hypoxia had an order for O2 at 2 L via nasal cannula to keep sats above 90%, but SpO2 monitoring was infrequent and not documented as ordered. Staff and the DON confirmed the expected monitoring and notification practices were not being followed.
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 identify and implement pressure injury prevention interventions for a resident with heel SDTI
Penalty
Summary
Pressure injury prevention interventions were not identified and implemented for a resident with multiple sclerosis, paraplegia, muscle wasting, and muscle weakness who developed a facility-acquired suspected deep tissue injury (SDTI) on the right heel. The resident was admitted with an existing left heel pressure injury and had Braden Scale scores of 19 on multiple assessments, with no further documented Braden Scale assessments after 2/11/26 until the wound was identified. The right heel SDTI was first documented on 2/5/26 and was measured at 22 mm by 32 mm, with foam dressing weekly and Multipodus boot treatment ordered. The resident stated that she wore a protective boot on the left foot and heel continuously, and that involuntary movement of her left leg while in bed caused friction between her heels, which she believed contributed to the right heel injury. She also stated that she could not independently reposition her lower body and that her legs occasionally had muscle spasms. During observation, she had protective boots on both lower legs and feet, and later reported that she was instructed to continue wearing both boots in bed and sometimes during the day. CNA and RN interviews confirmed that staff applied and removed the boots during care, repositioned residents, and attempted to offload the heels, but the resident sometimes refused offloading and had leg twitching when boots were applied. Review of the record showed that the right heel SDTI was monitored over time, with measurements decreasing from 22 mm by 32 mm to 20 mm by 30 mm and then to 15 mm by 25 mm, while the wound was described as pink, dry, and intact with a scab lifting at the edges. The DON reviewed the Braden Scale and agreed that the resident’s ability to respond to pressure-related discomfort and friction scores were coded incorrectly, noting that the resident was unable to move independently in bed and that her diagnoses should have reflected greater impairment. The DON also confirmed that the care plan did not include the resident’s inability to reposition her legs, the use of Podus boots, or that her heels were floated, despite the facility’s pressure injury prevention policy and guidelines addressing risk assessment, care plan revision, heel offloading, and prevention of rubbing between body surfaces.
Food Safety, Dishwashing, and Hand Hygiene Failures
Penalty
Summary
Food service sanitation and storage practices were not followed in the main kitchen and activity room kitchenette. During observations, the popcorn machine in the dining room bar area had leftover kernels in the basin and a kettle with black burnt-on oily residue. The dishroom handwashing sink had stains and food debris in the basin and drain. The walk-in freezer floor had black buildup, empty food packaging, crumbs, and dirt. The beverage station in the dining room had limescale on the coffee dispenser spouts, an unidentified black substance near the juice dispenser spouts, and dust on the refrigeration vents. The kitchen also had a missing ventilation hood panel above the cooking equipment. Raw meat was not stored in a manner that prevented cross-contamination in the walk-in cooler. Observations showed raw ground beef, beef stew meat, and raw pork loin chops stored on different shelves, and later the cooler contained raw ground beef sitting in a reddish puddle of liquid with thawing raw turkey roast, additional turkey roast, beef stew meat on a sheet pan with a large puddle of red liquid, and raw pork loin chops below. Staff interviews showed the culinary managers were not aware that raw poultry should be stored on the bottom shelf and that whole cuts should be stored above ground meats. The cleaning checklists reviewed did not include the freezer, beverage dispensers, or dishwasher, and the freezer cleaning task was not listed on the checklist. In the activity room kitchenette, bulk sugar and flour containers were not dated when filled, and a spoon was stored inside the sugar container. The microwave had crusted food splatters inside. The household dishwasher in that kitchenette was used for residents’ coffee cups, happy-hour dishes, and baking items, but the detergent pods used did not contain chemicals for sanitizing dishes, and the dishwasher owner’s manual showed maximum temperatures below the level identified for sanitizing. Staff and management stated they did not know whether the dishwasher could sanitize dishes, yet it was being used for resident dishware. During meal service in the dining room, a CNA touched resident wheelchair foot pedals and other resident equipment, then poured water for three residents without performing hand hygiene before or after the contact. The DON acknowledged hand hygiene should have been performed before and after resident contact and after contact with resident equipment.
Menu Serving Sizes and Therapeutic Diet Menus Not Followed
Penalty
Summary
The facility failed to ensure that menu serving sizes were followed and that therapeutic diet menus were created and followed. During breakfast service, a chef served ham and cheese egg scramble with a green-handled #12 scoop and served breakfast potatoes with tongs. The menu and recipe binder listed the ham and cheese egg scramble serving size as four ounces, but the facility did not have a chart identifying scoop sizes, and culinary managers confirmed the green #12 scoop was three ounces, not four ounces. They also stated that using tongs for the breakfast potatoes was not the best choice because the quantity served could not be verified. Record review and interview also showed that the facility did not have complete therapeutic diet menus for residents prescribed NAS and heart healthy diets. The dietitian-signed menu available at the facility included pureed, mechanically altered, gluten free, renal, and carbohydrate controlled diets, but did not include heart healthy or no added sodium menus. The culinary managers stated that residents on therapeutic diets, including diabetic, heart healthy, and low sodium diets, all received the same menu as the regular diet. The diet type report identified nine residents prescribed NAS diets and eighteen residents prescribed heart healthy diets.
Failure to Inform Residents and Representatives Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure residents and/or their representatives were fully informed of the risks versus benefits of psychotropic medications and alternative treatments before those medications were started or changed. The deficiency involved two sampled residents, including one resident with Alzheimer’s disease, psychosis, hallucinations, delusional disorder, dementia, depression, and anxiety who lacked decision-making capacity and whose son served as POA. That resident was started on aripiprazole 5 mg at bedtime for hallucinations, but the record did not show that the POA was notified, that risks versus benefits were discussed, or that consent was obtained before the first dose was given. A second resident with severely impaired cognition, anxiety disorder, delusional disorder, and dementia with behavioral disturbance had multiple psychotropic medication orders and dose changes without documentation that the resident’s representative was informed of the indication, risks versus benefits, or alternative treatments. The record showed orders for mirtazapine for anxiety, sertraline for anxiety, aripiprazole for mood and delusions, lorazepam for anxiety and restlessness, and several dose increases and decreases of these medications. Some progress notes documented that the representative was notified of certain medication changes, but the chart did not show that the required discussion of the reason for the medication, risks versus benefits, or alternative treatments occurred. In some instances, staff documented an attempted call or a notification, but there was no documentation of a completed discussion or of repeated attempts when the representative could not be reached. Interviews with the DON, LPN, and MDS RN confirmed that the facility expected nurses to notify residents’ representatives when new medications were ordered or doses changed, and to document those notifications in progress notes. The DON stated that written informed consents were not obtained before starting psychotropic medications, that the medication list signed at admission did not address psychotropic risks versus benefits, and that the facility did not have a system in place to ensure staff were educating and obtaining informed consents regarding changes in care. The facility’s psychotropic medication policy stated that residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments and non-pharmacological interventions.
Failure to Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to ensure staff electronically submitted MDS discharge tracking assessments to CMS within the required 14-day time frame for three discharged residents. Review of the EMR showed that one resident was discharged to the hospital, another was discharged to her daughter’s home, and a third resident died while at the hospital. The discharge tracking MDS assessments for all three residents were not transmitted to CMS, and one resident’s discharge tracking MDS was not completed at all. During interview and record review, the MDS RN stated she was responsible for ensuring MDS assessments were transmitted within the required time frames and that she used the RAI Manual Version 1.20.1 October 2025 as reference. She acknowledged awareness of the transmission timelines and confirmed the discharge tracking MDS assessments for the three residents were not transmitted. She also reported using an electronic MDS system with a paper cheat sheet tracking form, noted one resident’s discharge was not added to the paper tracking form, and identified that one resident’s discharge MDS incorrectly indicated the resident died in the facility rather than at the hospital.
Care plan lacked person-centered interventions for hallucinations
Penalty
Summary
The facility failed to ensure that a complete, person-centered care plan was developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by an interdisciplinary team for a resident with dementia, hallucinations, behaviors, and agitation. Resident 2 had diagnoses including Alzheimer's disease, unspecified psychosis, unspecified hallucinations, delusional disorder, dementia, depression, and anxiety disorder. Her BIMS score was 3, indicating severe cognitive impairment, and her MDS assessments documented hallucinations and delusions. On observation, Resident 2 was sitting in a recliner in the Morning Dove Lounge with her left leg pulled up toward her torso, appearing to adjust her gripper sock or pant cuff while talking about a “bum” on or near her left foot. Her walker was in front of her, and she was not wearing shoes. A CNA stated that the resident often wandered the facility without shoes, was assisted with gripper socks in the morning, and frequently experienced hallucinations about a lost dog or children. The CNA said staff did not try to bring her out of the hallucinations and instead validated what she was seeing to help her remain calm. Review of the EMR showed progress notes documenting hallucinations, including a behavior note stating the resident was actively hallucinating, seeing children, and becoming agitated when staff did not acknowledge them. Although the care plan included general background information about paranoia and seeing or talking to someone not there, it did not include focus areas, goals, or interventions related to her usual hallucinations or staff approaches to address them. The social services director confirmed that the care plan did not include interventions for staff to consider when the resident was experiencing hallucinations, even though staff were expected to use the care plan, EMR, and experienced staff knowledge when providing care.
Failure to Follow Orders for Blood Glucose and Oxygen Saturation Monitoring
Penalty
Summary
The facility failed to follow physician orders and professional standards related to blood glucose monitoring and physician notification for a resident with Type 2 Diabetes Mellitus and diabetic chronic kidney disease. The resident reported receiving insulin and having a history of low morning blood sugars, sometimes as low as 50 to 57 mg/dL, and said staff usually gave him juice when his blood sugar was low. The EMR showed physician orders for Accuchecks twice daily with notification to the physician if blood sugars were less than 70 or greater than 400, but low readings of 55 mg/dL, 59 mg/dL, and 65 mg/dL were documented without physician notification. Staff interviews confirmed that the physician was to be notified when blood sugars were outside ordered parameters, and the nurse who had cared for the resident stated she did not notify the physician on two occasions because she did not think the physician would change the interventions. The facility also failed to monitor oxygen saturation as ordered for a resident with acute respiratory failure with hypoxia. The resident had a physician order for oxygen at 2 L via nasal cannula to keep oxygen saturation above 90% every morning and at bedtime, but the record showed oxygen saturation was last documented on 3/1/26 and was documented only six times from 1/1/26 through 3/11/26. Observation found an oxygen concentrator turned on at the foot of the resident's bed while no one was in the room using it. The care plan included oxygen use at night and when sleeping, and staff interviews indicated the resident usually received oxygen at night. Interviews with nursing staff and the DON confirmed that blood glucose values outside ordered ranges were expected to be reported to the physician and that oxygen saturation should be monitored according to physician orders. The facility policies reviewed stated that critical high and low glucose tests were to be managed according to physician orders and that physicians must be promptly notified of changes in resident condition outside the normal range. The oxygen administration policy also stated that the care plan should identify interventions such as monitoring SpO2 levels and/or vital signs as ordered.
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 | ★★★★★ | 13 | 1 |
| Avantara Groton | 17.7 mi | ★★★★★ | 11 | 0 |
| Sun Dial Manor | 35.6 mi | ★★★★★ | 1 | 0 |
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