Care Center of Aberdeen

Inspectors wroteBased on record review, staff and family interviews, and facility policy review, the facility failed to ensure the Resident Representative (RR) was notified timely of a significant change in condition requiring the initiation of treatment for one (1) of four (4) sampled residents. Resident #1. This failure resulted in the resident representative not being informed that the resident developed three (3) new Stage II pressure injuries and that treatment had been initiated. Findings Include: Record review of facility policy titled Change In Resident Medical Status with review date of 3/26 revealed .A facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s), when there is - . [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure food items in the kitchen were properly labeled and dated after opening and failed to maintain a clean refrigerator to prevent cross-contamination of stored foods during one (1) of two (2) kitchen tours. Findings Include:Review of the facility policy titled Cleaning and Sanitizing Equipment, revised 5/18, revealed under Policy: All equipment is kept clean and food contact surfaces are cleaned and sanitized. Review of the facility policy titled Food Storage Labeling, revised 8/12, revealed under Policy: The facility will ensure the safety and quality of food by adhering to proper storage and labeling procedures. Also revealed under Procedure 1. Labelinga. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review the facility failed to accurately complete the Minimum Data Set (MDS) assessment, as evidenced by incorrectly coding during the 7-day observation look-back period for three (3) of nineteen sampled residents. Residents #3, Resident #7, and Resident #53 Findings Include: Record review of the facility policy titled, Minimum Data Set Charting Documentation Guidelines, dated 11/25, revealed, To have an accurate assessment of the residents, information must be gathered on the residents while in the observation period for the MDS. This information must come from resident assessment and documented information in the residents' chart within the time frames set forth on the MDS. To ensure that information is in the chart to validate information on the MDS the Charting Documentation guidelines should be utilized . [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to ensure the feeding tube care plan was implemented for Resident #5 and an Activities of Daily Living (ADL) care plan was implemented for Resident #17 for two (2) of nineteen care plans reviewed. Resident #5 and #17. Findings Include: Review of the facility policy titled Care Plan Process with a revision date of 12/24, revealed Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and needs, in relation to several specified areas (e.g., customary routine, vision, and continence). Resident #5 Record review of Resident #5's Care Plan Report revealed The resident requires tube feeding related to (r/t) resisting eating . Interventions . [...]

Inspectors wroteBased on staff interview and record review the facility failed to ensure blood sugar monitoring was provided in accordance with professional standards of practice for one (1) of five (5) residents who were reviewed for medication monitoring. Resident #94Findings Include: Review of a statement typed on facility letterhead dated 5/6/26 and signed by the Administrator revealed, The facility does not have a policy on insulin/glucose monitoring. Record review of Resident #94's Medication Administration Record (MAR) with order date of 04/28/2026, revealed Novolin 70/30 Flex Pen Subcutaneous Suspension Pen-Injector (70-30) 100 Unit/ml (milliliter) (Insulin NPH Isophane & Reg (Human) Inject eight (8) units subcutaneously two times a day. Record review of Resident #94's Medication Administration Record revealed no documentation of monitoring blood sugar. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care necessary to maintain personal hygiene for one (1) of 89 residents observed. Resident #17Findings include:Review of the facility policy titled Activities of Daily Living, with a review date of 9/2025, revealed, .ADLs shall include, but are not limited to personal hygiene, bathing, voiding, toileting, repositioning, and meals offered. On 5/4/2026 at 5:48 PM, 5/5/2026 at 8:47 AM, and again on 5/6/2026 at 8:26 AM, observations of Resident #17 revealed her fingernails were approximately one (1) inch in length with jagged edges and contained a dark brown/black substance underneath the nails. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure physician-ordered continuous enteral feedings were consistently administered for one (1) of two (2) residents reviewed for tube feeding management. Resident #5Findings Include:Review of the facility policy titled Tube Feedings with a revision date of 12/15 revealed, 1. All tube feedings will be administered in accordance with verified medical necessity, established infection control policies and procedures and physician's orders .Record review of the Order Summary revealed an order dated 02/23/2026 for Enteral Feed Order. Diabetasource at 59 ml (milliliters) /hr (hour) for 24 hours to include 1700 kcals (kilocalories), 88 grams of protein, and 1189 ml of fluid. An observation on 5/04/2026 at 5:36 PM revealed Resident #5's enteral feeding pump was paused and actively beeping. [...]

Inspectors wroteBased on observation, record review, staff and representative interviews, and facility policy review, the facility failed to ensure residents were free from the use of chemical restraints for one (1) of three (3) residents reviewed for chemical restraints (Resident #5), when the facility administered psychotropic medications without obtaining the required consent to inform the resident or representative of the risks, benefits, and alternatives of the medication prior to use.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to honor the resident's right to receive written notification, including the reason for the change, before the resident's room in the facility was changed for one (1) of three (3) residents reviewed. Resident #1Findings include:Record review of facility policy titled, Room Changes dated 11/17, revealed, The Social Service Designee/Social Worker, in conjunction with the DON (Director of Nursing), will facilitate that each resident is assigned a room suited to his/her needs.4. The resident or resident representative, when applicable, will receive written notice to include the reason for the change before the resident's room or roommate in the facility is changed. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to protect a resident's safety and prevent an accident when staff failed to use a wheelchair lift safety belt to secure a resident's wheelchair on the lift gate during the lift procedure to place the resident into the back of the van. This resulted in the resident rolling backwards in the wheelchair and flipping off the lift gate when it was lifted around four (4) feet high in the air and the resident hit backwards onto the concrete injuring her head and received a three (3) centimeter (cm) laceration to the back of her head. This was for one (1) of two (2) residents incidents reviewed. Resident #37 Findings Include: Review of the facility policy titled Policies for Company Owned Vehicle with a revision date of 5/18 revealed under, 3. Seatbelts: [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to label and store food properly and maintain the kitchen and the equipment in a clean and sanitary condition for two (2) of three (3) kitchen tours.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review, the facility failed to ensure cognitive residents' right to determine their end-of-life care for three (3) of 24 residents reviewed. Resident #37, #73, and #75 Findings Include: Review of the facility policy titled Advance Directives with a revision date of 6/15, revealed under, Policy: The facility recognizes that all adults have a fundamental right to make decisions relating to their own medical treatment, including the right to accept or refuse medical care. It is the policy of the facility to encourage residents and their family/caregivers to participate in decisions regarding care and treatment . Resident #37 During an interview with Resident #37 on [DATE] at 3:26 PM, the resident stated she wanted to make her own healthcare decisions while she was able. [...]

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to address and resolve a resident grievance related to timely Activities of Daily Living (ADL) care for one (1) of 20 sampled residents.

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to submit a change in status referral for a Level II PASRR (Pre-admission Screening and Resident Review) for a resident with a new mental diagnosis for one (1) of four (4) PASRR's reviewed. Resident #5. Findings Include: Review of the Facility Policy Pre-admission Screening (PAS)/PASRR with latest revision date of 08/24 documented A change in status referral for Level II Resident Review Evaluations Is Also Required for Individuals Who May Not Have Previously Been Identified by PASRR to Have Mental Illness, Intellectual Disability/Developmental Disability, or a Related Condition in the Following Circumstances: [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for Activity of Daily Living (ADL) related to nail care for two (2) of 20 sampled residents.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for two (2) of 20 sampled residents. Resident #63 and #75.

Inspectors wroteBased on observation, staff, resident and resident family interviews, record review, and facility policy review, the facility failed to ensure a clean environment as evidenced by dirty wheelchairs and strong, offensive odors for three (3) of seven (7) sampled residents reviewed. Resident #6, Resident #7, and Resident #8. Findings Include: Record review of the facility policy titled, Policy for General Cleaning and Maintenance of Equipment with latest review date of 08/21 revealed, It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident .Equipment is first cleaned of surface soil with soap and water or facility disinfectant . [...]

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review, the facility failed to honor a resident's choice to smoke cigarettes for one (1) of 17 smokers residing in the facility. Resident #45. Findings Include: Record review of the facility policy titled Resident's Rights Policy with a revision date of 11/23 revealed, Every resident in this facility has the right to: . 22. Use tobacco in accordance with applicable policies, rules, and laws . An observation with interview on 11/13/23 at 3:30 PM, with Resident # 45, revealed him standing in the day room waiting to go outdoors to smoke. The resident revealed that the facility was punishing him because he was caught smoking in his bathroom. He stated they took his cigarettes away as punishment, and he was only allowed to use a vape pen. [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to submit a change in status referral for a level 2 PASRR (Pre-admission Screening and Resident Review) on a resident with a new mental diagnosis, new antipsychotic medication, and an inpatient psychiatric stay for one (1) of three (3) PASRRs reviewed. Resident #24.

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review, the facility failed to provide adequate supervision during smoke breaks to prevent residents from obtaining smoking paraphernalia and to maintain resident safety during smoke breaks for one (1) of 15 residents who smoke. Resident #45. Findings Include: Record review of the facility policy titled Smoking Policies and Regulations with a revision date of 10/22 revealed, .Cigarette lighters and matches are not permitted in a resident's room and will be kept at the nurse stations. The facility will provide matches and will light cigarettes upon request in designated areas set aside for smoking. These areas will be monitored by designated staff . Resident #45 An observation and interview on 11/13/23 at 3:30 PM, with Resident # 45, revealed him standing in the day room waiting to go outdoors to smoke. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of two (2) quarters reviewed.