Aberdeen Village

Inspectors wroteBased 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. [...]

Inspectors wroteThe 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: [...]

Inspectors wroteThe 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: [...]

Inspectors wroteThe facility identified a census of 55 residents. The sample included three residents. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired Resident (R)1, who required staff assistance for activities of daily living (ADL) including safe ambulation with her walker and was at risk for falls. On 10/17/24 between 04:00 AM and 04:30 AM, Certified Nurse Aide (CNA) M heard R1's toilet flush, entered R1's bathroom, and asked R1 if she needed anything. R1 responded No and CNA M left to assist another resident without assisting R1 back to bed as CNA M assumed the resident would go back to bed. [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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. [...]

Inspectors wroteThe 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: [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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: [...]

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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). [...]

Inspectors wroteThe 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. [...]

Inspectors wroteThe 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: [...]