Aberdeen Heights

Based on observation and interview, the facility failed to ensure staff followed their abuse and neglect policy when a resident (Resident #3) told a Certified Nursing Assistant (CNA) and a Registered Nurse (RN) a black fellow beat him/her up. Neither the CNA or the RN reported the resident's allegation to the facility Administrator and/or Director of Nursing (DON). Six residents were sampled. The census was 34.Review of the facility Prohibition of Any Form of Abuse policy, last revised on 8/7/25, showed:-Any report of potential abuse, neglect or misappropriation of resident property must be reported to the Executive Director (Administrator)/DON or health care administrator immediately;-Policy: Residents have the right to be free from verbal, sexual, and physical and mental abuse;-It is the responsibility of employees to promptly report to community management any occurrence of neglect or resident abuse from other residents, staff, family or visitors, including injuries of unknown source and theft or misappropriation of resident property;-Staff are mandated reporters and must comply…

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.

Based on observation, interview and record review, the facility failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were in reach or a call light pendant was worn for one resident (Resident #31). The sample was 13. The census was 35. Review of the facility's Resident Call System policy, revised 5/3/19, showed: -Policy: The community strives to provide an environment to promote resident safety, dignity, and a sense of well-being; The community will be equipped and maintained to protect the health and safety of the residents; -Procedure: The community shall have a call button or pull cord located next to each bed and in each resident bathroom. Review of Resident #31's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/23/25, showed: -Cognitively intact; -Dependent on staff for toileting, bathing, upper and lower body dressing; -Required maximum assist from staff for personal hygiene; -Frequently incontinent or bowel and bladder. Review of the resident's medical…

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.

Based on observation, interview and record review, the facility failed to ensure residents who required activities of daily living (ADLs, bathing, dressing and toileting) assistance received necessary services to maintain adequate personal hygiene when staff left one resident soiled for an extended period (Resident #2). The sample size was 13. The census was 35. Review of the facility's Standards of Practice-Clinical Services policy, revised 2/3/25, showed: -Clinical Services policy and procedure preface: -The Clinical Services policies and procedures described in the manual should be used as guidelines for the nursing staff of the facility; Individual resident care decisions should be based on scientific principals in accordance with the skill an training of the caregiver; Additional clinical resources available from other sources or created in collaboration with the facility; -Philosophy: -Nursing is a process that includes assessment of the resident's state of being, determining a nursing diagnosis, planning and developing short and long-term goals; Implementing appropriate…

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.

Based on observation, interview, and record review, the facility failed to ensure physician orders for oxygen usage were revised and current, which resulted in contradictory orders, with staff documenting both as completed for one resident(Resident #30). The facility also listed outdated information in the resident's care plan regarding the oxygen settings. The sample was 13. The census was 35. Review of the facility's oxygen therapy policy, dated 2/3/25, showed: -Policy: Oxygen is treated as a medication ordered by the physician. The order includes the amount per minute to be delivered, the device used for delivery, and during what times to deliver oxygen therapy; -Procedure: These delivery devices will be maintained in a sanitary manner. Change disposable prefilled humidifier bottle every 30 days. Non-disposable refillable humidifier bottles are changed every seven days. Change tubing once a week or when soiled. Label with resident name, date, time, staff initial tubing when changed. Document on the treatment administration record (TAR). When device is not in use, store in plastic…

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.

Based on observation, interview and record review, the facility failed to follow acceptable infection control standards by not implementing Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce the transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities) as recommended by the Centers for Disease Control and Prevention (CDC) and required by the Centers for Medicare and Medicaid Services (CMS) for residents with wounds requiring treatments and the facility failed to ensure staff used good infection control practices for one resident when providing perineum care (peri-care, cleansing of the genitals and anal area) (Resident #4). The sample was 13. The census was 35. Review of the facility's EBP policy, revised 1/9/24, showed: -EBP, refer to an infection control intervention designed to reduce transmission or MDRO that employs targeted gown and glove use during high contact resident care activities; -EBP are used in conjunction with standard precautions and expand 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 Based on observation, interview and record review, the facility failed to follow their policies by failing to ensure glucometers (a machine that obtains a resident's blood glucose level by placing a drop of blood onto a strip inserted into the glucometer) were cleaned and disinfected with an approved germicidal agent. In addition, staff failed to ensure a barrier (such as a clean paper towel) was placed between the glucometer and any surface on which it was placed. The facility identified four residents who required blood glucose monitoring, two were observed and infection control problems were identified with both (Resident #31 and #30) The census was 34. Review of the facility's Preventing Reuse of Devices Used for Blood Glucose Monitoring policy, dated 11/2017, included the following: -Issue: Glucometers designed for use by a single resident should never be used for more than one resident. Many health care providers are under the mistaken belief that changing the lancet needle (used to pierce the fingertip to…

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.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5%. Out of 28 opportunities observed, two errors occurred resulting in a 7.14% error rate (Resident #9). The census was 34. Review of the facility's Medication Administration policy, revised on 3/15/22, included the following: -Policy: Medications are administered as prescribed in accordance with the good nursing principles and practices and only by persons legally authorized to do so; -It is the responsibility of the nursing professional to be aware of the clinical rationale for the medication, classification, action, correct dosage and side effects of medication before administration and to monitor to determine if there is progress toward goals and/or emergencies of adverse consequences; -A primary care provider order that includes dosage, route, frequency, duration and other required considerations is required for administration of medication; -Procedure: -Prior to administration, the medication and dosage schedule on the electronic Medication Administration…

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.

Based on observation, interview and record review, facility staff failed to follow the facility's Injectable Medication/Storage and Stability policy by failing to record the dates insulin pens had been opened so they could be discarded if necessary if not completely used by the discard dates. Four residents had been identified by the facility as having orders for insulin, and problems were identified with all four (Residents #15, #21, #30 and #31). In addition, staff failed to consistently check/document the temperature of the medication refrigerator in the medication room. The census was 34. Review of the facility's Medications: Vials and Ampules (small sealed vial) of Injectable Meds policy, last revised on 10/8/21, included the following: -Policy: Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use and disposal; -Procedure: -The date opened is recorded on multidose vials (on the vial label or an accessory label affixed for that purpose); -Refer to insulin storage and…

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.

Based on observation and interview, the facility failed to ensure food in the walk-in freezer was dated properly and ensure staff wore hair restraints while serving food. This deficient practice had the potential to affect all residents who ate at the facility. The census was 36. Observations of the walk-in freezer, on 6/2/21 at 8:42 A.M., 6/3/21 at 7:00 A.M. and 6/4/21 at 6:37 A.M., showed: -One opened box, which included four, three pound boxes of breaded cream cheese stuffed jalapeno, dated 11/28/18; -One opened box, which included six, one pound boxes of bone-in chicken thighs, dated 2/28/18; -One sealed ten pound box, of wavy lasagna sheets, dated 5/26/20; -One sealed one pound box, of blue water shrimp, dated 1/14/21; -One sealed box, which included 16, one pound beef patties, dated 1/30/20; -Three sealed six pound trays, of peach cobbler, dated 3/25/21; -One sealed six pound tray, of peach cobbler, dated 3/19/21. During an interview on 6/4/21 at 6:45 A.M., Sous-Chef (SC) A said the dates on the food were the manufacturer's date, not the expiration date. The dates were when…

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.