Aberdeen Heights

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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; [...]