Aberdeen Village

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to provide individualized care and services related to dementia care (a progressive mental disorder characterized by failing memory and confusion) for Resident (R)1, who displayed wandering behaviors into other resident's rooms. Findings Included:- R1's Electronic Medical Record (EMR) documented diagnoses of dementia, need for continuous supervision, adjustment disorder (a short-term, intense emotional or behavioral reaction to a stressful life change that is disproportionate to the event), muscle weakness, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), Post-Traumatic Stress Disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and cognitive communication deficient (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 54 residents. The sample included 19 residents, with five reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 20 remained free from chemical restraint related to the use her antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) without a Centers for Medicare and Medicaid Services (CMS) approved indication. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (difficulty sleeping), and major depressive disorder (major mood disorder). R20's Quarterly Minimum Data Set (MDS) dated 01/16/26 noted a Brief Interview for Mental Status (BIMS) score of four,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 54 residents. The sample included 19 residents, with five sampled reviewed for unnecessary medications. Based on observations, record review, and interviews, the facility failed to ensure the Consultant Pharmacist's (CP) recommended a Centers for Medicare and Medicaid Services (CMS) approved indication related to Resident (R) 20's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. Findings Included: - The Medical Diagnosis section within R20's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), insomnia (difficulty sleeping), and major depressive disorder (major mood disorder). R20's Quarterly Minimum Data Set (MDS) dated 01/16/26 noted a Brief Interview for Mental Status (BIMS) score of four, indicating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 56 residents, one kitchen, four serving areas, and dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Findings include: - On 05/13/24 at 08:09 AM during the initial tour, observation revealed the following: Bowls were stored upright on the rack by the delivery doors instead of inverted. Three refrigerator and four freezer temperature logs lacked evidence staff checked the temperature on Sunday, 05/12/24 in the main kitchen. The walk-in freezer had breaded chicken breasts that were uncovered and not dated. The commercial meat slicer was uncovered but not in use. The dishwasher temperature logbook lacked evidence staff checked the water temperature on 05/09/24 and 05/11/24. The cottage cheese and milk were open and not dated. On 05/15/24 at 11:40 AM Dietary Staff (DS) CC prepared…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 56 residents. The facility identified one medication room and four medication carts. Based on observations, record review, and interviews, the facility failed to store medications and biologicals appropriately when the facility failed to lock the medication room and additionally failed to appropriately label Resident (R)31's insulin (a hormone that lowers the level of glucose in the blood) medication once opened. This deficient practice placed the residents at risk for unnecessary medication and administration errors. Findings Included: -On 05/13/24 at 08:15 AM a walkthrough of the facility's second floor was completed. An inspection of the medication room revealed the entry door was not locked. The room contained a secured digital medication storage system for the facility's prescription medications, a locked medication refrigerator, and a shelf with unsecured stock (over-the-counter medications) medications. The room was secured by Licensed Nurse (LN) J upon completion of the medication room inspection. On 05/14/24 at 08:47 AM an inspection of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 56 residents. The facility identified six residents on enhanced barrier precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact care) and one resident on contact precautions (transmission-based precautions for infectious disease that may spread with direct or indirect contact). Based on record review, observations, and interviews, the facility failed to ensure adequate infection control standards related to following enhanced barrier precautions, wearing personal protective equipment (PPE), and indwelling catheter maintenance (tube placed in the bladder to drain urine into a collection bag). These deficient practices placed the residents at risk for infectious diseases. Findings Included: - On 05/13/24 at 08:11 AM an inspection of Resident (R)6's room revealed no enhanced barrier precaution signage or personal protective equipment was posted in or around his room for his wound care. On 05/13/24 at 08:13 AM an inspection of R14's room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 15 residents. Based on observation and interview, the facility failed to ensure residents' rights and dignity were respected by staff when staff failed to honor Resident (R) 37's request during dining. The facility further failed to ensure R46's dignity was maintained during care provided in the common area. This placed the residents at risk for decreased self-esteem and decreased self-worth. Findings included: - On 05/14/24 at 08:19 AM R37 sat in his wheelchair at the dining table with other residents and was a given chocolate shake. On 05/14/24 at 08:21 AM R37 sat in his wheelchair in the dining room. R37 asked staff if he could go into the TV room to eat. R37 asked staff repeatedly to take him to the TV room. Licensed Nurse (LN) H, Certified Nurse Aide (CNA) N, and Certified Medication Aide (CMA) R continued to stay seated assisting other residents. On 05/14/24 at 08:26 AM, CNA N gave R37 some apricots. R37 asked staff if he could go to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 15 residents with four residents reviewed for activities of daily living (ADL). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 46 received the necessary assistive services for transfers. This deficient practice placed R46 at risk for loss of independence, decreased self-esteem, and impaired dignity. Findings included: - R46's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), dementia (a progressive mental disorder characterized by failing memory, confusion), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 15 residents with four reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)47's pressure-reducing interventions were implemented correctly when the low air-loss mattress pump was set at an inaccurate weight for the resident. The facility additionally failed to complete weekly wound assessments on R37. This deficient practice placed all affected residents at risk for complications related to skin breakdown and pressure ulcers. Findings Included: - The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder), pressure ulcer,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 15 residents with three residents reviewed for catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 31 with an indwelling catheter (a tube inserted into the bladder to drain urine into a collection bag) when the facility failed to prevent the drainage bag from resting on the floor. This deficient practice placed R31 at risk for catheter complications including infection. Findings included: - R31's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of bladder cancer, dementia (a progressive mental disorder characterized by failing memory, and confusion), and urinary retention (lack of ability to urinate and empty the bladder). The Annual Minimum…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 56 residents. The sample included 15 residents with one resident reviewed for respiratory care. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 5's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask was stored in a sanitary manner. This placed R5 at an increased risk for respiratory infection and complications. Findings included: - R5's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (HTN-elevated blood pressure), kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), obstructive sleep apnea (an open airway during typical breathing during sleep…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility identified a census of 56 residents. The sample included 15 residents with four reviewed for siderails. Based on observations, record review, and interviews, the facility failed to identify Resident (R)47's low air-loss mattress and bolstered overlay as possible risks on R47's side rail assessment. This deficient practice placed R47 at risk for inadequate care due to unidentified care needs. Findings Included: - The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), major depressive disorder (major mood disorder), pressure ulcer, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and insomnia (difficulty sleeping). R47's Significant Change Minimum Data Set (MDS) completed 04/02/24 noted a Brief Interview for Mental Status (BIMS) score of four indicating severe cognitive impairment. The MDS noted she required substantial to maximal assistance for bed mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 49 residents. The sample included 15 residents. Based on observation, record review and interview the facility failed to secure chemicals in a safe, locked area, and out of reach of the 13 cognitively impaired independently mobile residents. This placed the affected residents at risk for accidents. Findings Included: - On 09/21/22 at 07:10AM an observation of the secured memory care unit revealed an unlocked sink cabinet in the kitchenette area accessible to the dementia care (progressive mental disorder characterized by failing memory, confusion) residents. Further investigation revealed two quart-size bottles which contained bleach disinfectant. The label stated, keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 09/22/22 at 07:30AM an inspection of the sink cabinet revealed the door to be secured. Licensed Nurse (LN) H stated that staff should be checking the cabinets and drawers daily before and after meal services to ensure they were locked. In an interview on 09/27/22 at 02:30PM Licensed Nurse (LN)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility identified a census of 49 residents. The sample included 15 residents with two residents reviewed for dementia care (progressive mental disorder characterized by failing memory, confusion). Based on observations, record reviews, and interviews, the facility failed to provide dementia care and services which included adequate supervision and activities to support Resident (R)43 and R49's highest practicable level of well-being. This deficient practice placed the residents at risk for decreased quality of life and impaired well-being due related to dementia. Findings Included: - The Medical Diagnosis section within R43's Electronic Medical Records (EMR) included diagnoses of dementia, major depressive disorder (major mood disorder), general anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), retention of urine (lack of ability to urinate and empty the bladder), benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.