Aberdeen Heights

In the surveyor’s words

From the most serious findings on record at Aberdeen Heights, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 25, 2022

  Based on interview and record review, the facility failed to ensure one resident (Resident #1) received care in a safe environment when a staff member used a Hoyer lift (full body lift) to transfer the resident by him/herself and did not properly position the resident into his/her tilt wheelchair (a tilting wheelchair has a seat frame that tilts backward in varying degrees), which caused the resident to fall out of the chair. This resulted in the resident sustaining a fractured leg. The sample size was three. The census was 36. […]

• No harm, potential for more than minimal, patternF880Dec 7, 2023

  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. […]

• No harm, potential for more than minimal, patternF812Jun 7, 2021

  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 [DATE] at 8:42 A.M., [DATE] at 7:00 A.M. and [DATE] at 6:37 A.M., showed: -One opened box, which included four, three pound boxes of breaded cream cheese stuffed jalapeno, dated [DATE]; -One opened box, which included six, one pound boxes of bone-in chicken thighs, dated [DATE]; -One sealed ten pound box, of wavy lasagna sheets, dated [DATE]; -One sealed one pound box, of blue water shrimp, dated [DATE]; -One sealed box, which included 16, one pound beef patties, dated… […]

• No harm, potential for more than minimal, isolatedF607Aug 15, 2025

  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… […]

• No harm, potential for more than minimal, isolatedF558May 7, 2025

  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. […]