Inspection Reports for
Aberdeen Heights
505 COUCH AVE, KIRKWOOD, MO, 63122-5536
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
9.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
37% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Aug 15, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure staff followed abuse and neglect policies after a resident alleged being beaten by another individual.
Complaint Details
The visit was complaint-related due to a resident's allegation that a black fellow beat him/her up. The allegation was not reported by the CNA or RN to the Administrator or Director of Nursing. Staff interviews confirmed the failure to report despite policy requirements.
Findings
The facility failed to report a resident's allegation of abuse to the Administrator or Director of Nursing as required by policy. Staff interviewed acknowledged the failure to report, despite being trained on abuse and neglect policies. The resident had severe cognitive impairment but was able to communicate basic needs.
Deficiencies (1)
Failure to ensure staff followed abuse and neglect policy when a resident alleged being beaten and staff did not report the allegation to the Administrator or Director of Nursing.
Report Facts
Residents sampled: 6
Census: 34
Inspection Report
Plan of Correction
Census: 35
Deficiencies: 4
Date: May 7, 2025
Visit Reason
The inspection was conducted to identify deficiencies in the facility's compliance with federal and state regulations and to document a plan of correction for the cited deficiencies.
Findings
The facility was found deficient in reasonable accommodations for residents' needs, activities of daily living care, respiratory/tracheostomy care and suctioning, and infection prevention and control. Specific issues included failure to ensure call lights were within reach, inadequate toileting and hygiene assistance, outdated oxygen orders, and failure to follow infection control protocols.
Deficiencies (4)
F558 Reasonable Accommodations Needs/Preferences: The facility failed to ensure call lights were within reach or that a call light pendant was worn by a resident at risk of falls.
F677 ADL Care Provided for Dependent Residents: The facility failed to ensure residents received necessary assistance with toileting and hygiene, resulting in soiling and inadequate care for a resident.
F695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to ensure oxygen orders were current and consistent, and staff did not follow physician orders for oxygen therapy.
F880 Infection Prevention & Control: The facility failed to implement proper infection control practices, including enhanced barrier precautions and hand hygiene, for residents requiring peri-care.
Report Facts
Sample size: 13
Census: 35
Plan of correction completion dates: Jun 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Named in relation to ensuring residents wear call light pendants and infection control practices |
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed about call light pendant use and infection control |
| Certified Nursing Assistant G | Certified Nursing Assistant | Interviewed about call light pendant use and infection control |
| Certified Medication Technician H | Certified Medication Technician | Observed providing care to residents |
| Certified Nursing Assistant A | Certified Nursing Assistant | Observed assisting resident with toileting |
| Certified Nursing Assistant D | Certified Nursing Assistant | Observed assisting resident with peri-care and transfers |
| Certified Medication Technician E | Certified Medication Technician | Observed assisting resident with peri-care and transfers |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed applying gloves and isolation gown during resident care |
| Administrator | Administrator | Signed the plan of correction |
Inspection Report
Life Safety
Census: 35
Capacity: 38
Deficiencies: 2
Date: May 7, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations.
Findings
The facility failed to ensure corridor doors were free of impediments and could resist the passage of smoke as required. Decorative objects were found blocking corridor doors in multiple resident rooms, posing a potential risk to residents and staff.
Deficiencies (2)
K363 Corridor doors did not resist the passage of smoke due to decorative objects blocking door swings in resident rooms 27, 30, and 53. The facility failed to ensure corridor doors could freely close and latch as required by NFPA 101.
A1086 The facility did not meet the Life Safety Code requirements for the date of the facility plan, referencing deficiency K363 for details.
Report Facts
Resident census: 35
Total capacity: 38
Inspection Report
Routine
Census: 35
Deficiencies: 4
Date: May 7, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey of Aberdeen Heights nursing home to assess compliance with health and safety regulations and standards of care.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were accessible to residents, inadequate assistance with activities of daily living resulting in residents being left soiled, contradictory and outdated physician orders for oxygen therapy, and failure to implement proper infection prevention and control practices including Enhanced Barrier Precautions and peri-care for residents with wounds.
Deficiencies (4)
Failure to ensure call lights were within reach or call light pendants worn for residents at risk of falls.
Failure to provide necessary assistance with activities of daily living resulting in a resident being left soiled for an extended period.
Failure to ensure physician orders for oxygen therapy were current and consistent, resulting in contradictory orders and improper documentation.
Failure to implement Enhanced Barrier Precautions and proper infection control practices including peri-care for a resident with a chronic wound, including failure to change gloves and perform hand hygiene appropriately.
Report Facts
Sample size: 13
Census: 35
Dates of oxygen therapy documentation: 7
Date of Resident #31 MDS: Feb 23, 2025
Date of Resident #2 MDS: Apr 4, 2025
Date of Resident #30 MDS: Mar 18, 2025
Date of Resident #4 MDS: Mar 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse C | Licensed Practical Nurse | Interviewed regarding call light pendant use and oxygen therapy orders |
| Certified Nursing Assistant G | Certified Nursing Assistant | Interviewed regarding call light pendant use and Enhanced Barrier Precautions |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for call light use, resident checks, oxygen orders, and infection control practices |
| Certified Medication Technician H | Certified Medication Technician | Observed providing care to Resident #31 |
| Certified Nursing Assistant A | Certified Nursing Assistant | Observed assisting Resident #2 with toileting and hygiene |
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding oxygen therapy orders |
| Administrator | Administrator | Interviewed regarding expectations for oxygen therapy orders |
| Certified Nursing Assistant D | Certified Nursing Assistant | Observed providing care to Resident #4 including wound care and hygiene |
| Certified Medication Technician E | Certified Medication Technician | Observed assisting with Resident #4 care |
| Assistant Director of Nursing | Assistant Director of Nursing | Observed providing care to Resident #4 and interviewed regarding infection control |
| Certified Nursing Assistant F | Certified Nursing Assistant | Observed providing care to Resident #4 |
Inspection Report
Plan of Correction
Census: 28
Deficiencies: 6
Date: Sep 10, 2024
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Aberdeen Heights following a survey conducted on September 10, 2024. It addresses multiple regulatory deficiencies identified during the inspection.
Findings
The facility failed to maintain required personnel records, document employee hours, complete timely community-based assessments, ensure semiannual assessments, administer medications safely, and maintain adequate staffing and CPR-trained personnel. Multiple deficiencies were cited with varying severity levels.
Deficiencies (6)
19 CSR 30-86.047(20)(I) Personnel Record-physician statement. The facility failed to ensure employees had a written statement by a licensed physician or designee indicating work limitations for two sampled employees.
19 CSR 30-86.047(22) Employee Hours Documented. The facility failed to document actual hours worked by salaried employees for one day of observation.
19 CSR 30-86.047(28)(F)(1)(A) Community Based Assessment-Time Period, 5 day. The facility failed to complete community based assessments within five calendar days of admission for two sampled residents.
19 CSR 30-86.047(28)(F)(1)(B) Community Based Assessment - Semi-Annually. The facility failed to ensure semiannual community based assessments were completed for two sampled residents.
19 CSR 30-86.047(46) Safe & Effective Medication System. The facility failed to ensure safe medication administration when a Certified Medication Technician did not hold the inner canthus during eye drop administration for one resident. Severity: Class II.
19 CSR 30-86.047(61)(A) Staffing Ration, Resident Care & Fire Safety. The facility failed to develop a system to ensure CPR-trained staff were available on each shift for one of two sampled residents who was a full code. Severity: Class II.
Report Facts
Census: 28
Inspection Report
Routine
Census: 34
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to evaluate compliance with medication administration, injectable medication storage, infection prevention, and control policies at the nursing home.
Findings
The facility failed to ensure medication error rates were below 5%, with a 7.14% error rate observed. Staff did not consistently record dates on opened insulin pens or monitor refrigerator temperatures as required. Infection control lapses were noted with glucometer cleaning and use, including failure to use approved disinfectants and barriers between glucometers and surfaces.
Deficiencies (3)
Medication error rate exceeded 5%, with discontinued medications administered to a resident.
Failure to record dates on opened insulin pens and inconsistent monitoring of medication refrigerator temperatures.
Failure to properly clean and disinfect glucometers and failure to use barriers between glucometers and surfaces.
Report Facts
Medication error rate: 7.14
Census: 34
Insulin pens observed: 9
Refrigerator temperature checks: 24
Refrigerator temperature checks: 22
Refrigerator temperature checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician F | Administered discontinued medications despite knowing they were not on EMAR | |
| Director of Nurses | Director of Nurses (DON) | Provided expectations on medication administration policy and insulin pen dating |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Provided information on insulin pen dating and refrigerator temperature monitoring |
| Nurse A | Observed improperly cleaning and handling glucometers | |
| Nurse E | Reported recent availability of approved disinfectant wipes and prior use of alcohol wipes for glucometers | |
| Regional Nurse | Stated preference for disinfecting glucometers with Sani-Cloth and use of barriers |
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal and state regulations related to medication administration, medication storage, labeling, infection control, and other nursing home regulatory requirements.
Findings
The facility was found to have deficiencies related to medication error rates exceeding 5%, improper medication labeling and storage, failure to follow injectable medication storage and stability policies, and lapses in infection prevention and control practices. The facility failed to ensure proper documentation and handling of medications and blood glucose monitoring devices.
Deficiencies (3)
F759 Medication error rates exceeded 5% with a 7.14% error rate observed in medication administration for Resident #9. The facility failed to ensure medications were properly documented and administered according to orders.
F761 The facility failed to properly label and store drugs and biologicals, including insulin pens and medication refrigerator temperature monitoring. Several insulin pens were undated or improperly stored.
F880 The infection prevention and control program was deficient as staff failed to ensure proper cleaning and disinfection of glucometers, and failed to use barriers between glucometers and surfaces, risking cross-contamination.
Report Facts
Medication error rate: 7.14
Resident census: 34
Insulin pens identified: 9
Temperature log checks: 24
Temperature log checks: 22
Temperature log checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding medication administration policy and insulin pen storage |
| Certified Medication Technician F | Certified Medication Technician (CMT) | Observed administering medications and interviewed about medication discrepancies |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Interviewed regarding insulin pen storage and glucometer cleaning practices |
| Nurse A | Nurse | Observed handling glucometers and interviewed about cleaning practices |
| Nurse E | Nurse | Interviewed about glucometer cleaning and medication cart practices |
Inspection Report
Life Safety
Census: 34
Capacity: 38
Deficiencies: 3
Date: Dec 7, 2023
Visit Reason
The inspection was conducted as an emergency preparedness investigation and life safety code survey to assess compliance with emergency power systems and smoke barrier door requirements.
Findings
Deficiencies were found related to the facility's failure to develop a detailed emergency preparedness plan for emergency power and generator use, and failure to ensure smoke barrier doors met clearance requirements. The facility had a capacity of 38 beds and a census of 34 residents at the time of the survey.
Deficiencies (3)
E041 Emergency power systems: The facility failed to develop an emergency preparedness plan including detailed information on the emergency generator and power system operation during an emergency. Staff training and documentation on generator operation were inadequate.
K374 Smoke barrier doors: The facility failed to ensure smoke barrier doors did not exceed maximum clearance between vertical meeting edges, compromising fire safety in four smoke compartments.
A2071 Wastebaskets, Metal/UL/FM: The facility failed to ensure all trash cans were UL or FM approved, with non-approved trash cans found in resident rooms, posing a fire hazard.
Report Facts
Facility capacity: 38
Resident census: 34
Inspection Report
Plan of Correction
Census: 13
Deficiencies: 2
Date: Dec 7, 2023
Visit Reason
The inspection was conducted to assess compliance with fire safety regulations and medication administration standards at Aberdeen Heights.
Findings
The facility failed to ensure smoke barrier doors met clearance requirements, potentially affecting residents in two smoke compartments. Additionally, the medication error rate exceeded the acceptable threshold, with two errors out of 31 opportunities observed.
Deficiencies (2)
19 CSR 30-85.022(29) Smoke Section Walls/Doors: The facility failed to ensure smoke barrier doors did not exceed maximum clearance allowed, affecting residents in two smoke compartments. Observation showed a 1/4 inch gap between door edges during fire alarm testing.
19 CSR 30-85.042(46) Safe/Effective Medication System: The facility failed to maintain a medication error rate below 5%, with a 6.45% error rate observed in 31 medication opportunities involving Residents #1 and #3.
Report Facts
Census: 13
Medication opportunities observed: 31
Medication error rate: 6.45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse A | Observed preparing and administering medications during inspection | |
| Director of Nurses | Interviewed regarding medication policy and expectations | |
| Maintenance Supervisor | Interviewed about smoke barrier door conditions | |
| Administrator | Interviewed about maintenance staff responsibilities and signed plan of correction |
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 6
Date: Jun 16, 2022
Visit Reason
This document is a Plan of Correction submitted by Aberdeen Heights following a survey conducted on 06/16/2022 by the Missouri Department of Health and Senior Services.
Findings
The facility was found deficient in multiple areas including fire drill and emergency preparedness, tuberculosis screening for residents and staff, individualized service plan development and proper care, medication storage and accessibility, and toxic material storage. Several deficiencies were related to failure to maintain required documentation, failure to provide individualized care, and failure to secure medications and toxic materials.
Deficiencies (6)
19 CSR 30-86.022(5)(B)(1-10) Fire Drill/Evacuation Plan Requirements. The facility failed to maintain an emergency preparedness plan that included a floor plan outlining all areas of refuge for two days of observation. The census was 27.
19 CSR 30-86.047(19) TB Screen Residents & Staff. The facility failed to ensure the required two-step tuberculosis screening test was completed prior to hire for three of four sampled employees and prior to admission for one of four sampled residents. The census was 27.
19 CSR 30-86.047(28)(G) Individual Service Plan - Develop. The facility failed to develop individualized service plans for four of four sampled residents. The census was 27.
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to provide proper care for three of four sampled residents as defined in their individualized service plans. The census was 27.
19 CSR 30-86.047(41) Medication Storage/Accessibility. The facility failed to properly store residents' medications in a secure locked location when medications were kept in an unlocked medication cart for one day of observation. The census was 27.
19 CSR 30-87.020(5) Toxic Material Storage. The facility failed to ensure poisonous or toxic materials were kept locked up or stored in a place not accessible to residents for two days of observation. The census was 27.
Report Facts
Census: 27
Days of observation: 2
Sampled residents: 4
Sampled employees: 4
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 4
Date: Feb 25, 2022
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at the facility.
Complaint Details
The complaint investigation substantiated allegations that the facility failed to follow abuse prevention policies and failed to ensure safe resident transfers, resulting in a resident fall and injury.
Findings
The facility failed to follow its abuse policy by allowing an alleged staff member to return to work prior to completing an investigation, which resulted in a resident fall. Additionally, the facility failed to ensure safe use of a Hoyer lift during resident transfer, causing a resident to fall and sustain a fractured leg.
Deficiencies (4)
F610: The facility failed to investigate and prevent alleged abuse by allowing an accused staff member to return to work before completing the investigation, resulting in a resident fall.
F689: The facility failed to ensure safe use of assistive devices when a staff member improperly positioned a resident during transfer with a Hoyer lift, causing the resident to fall and sustain a fractured leg.
A4074: The facility failed to provide 24-hour protective oversight and supervision for residents on voluntary leave.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, and to require reporting to the department.
Report Facts
Resident census: 36
Sample size: 3
Plan of correction completion date: F610 and F689 corrective actions to be completed by 2022-03-28
Inspection Report
Complaint Investigation
Census: 14
Deficiencies: 1
Date: Jun 23, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure proper nursing care and communication related to a resident's fall and subsequent injuries.
Complaint Details
The investigation was triggered by a complaint about Resident #7's fall outside the facility and subsequent pain and injuries. The complaint was substantiated as the facility failed to properly assess, notify, and document care related to the fall and injuries.
Findings
The facility failed to ensure staff appropriately communicated pertinent information about a resident's fall and pain, failed to notify the physician timely, and did not assess or obtain treatment orders for injuries. Documentation and follow-up care were inadequate, and staff did not properly monitor or report changes in residents' conditions.
Deficiencies (1)
19 CSR 30-85.042(67) Nursing Care per Resident Condition: The facility failed to ensure staff communicated pertinent information about a resident's fall and pain, notify the physician timely, and assess or obtain treatment orders for injuries. Documentation of clinical assessments, communication, and pain management was incomplete or missing.
Report Facts
Sample size: 3
Census: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident 7 charge nurse | Named in plan of correction as responsible for documentation | |
| MC Nurse manager | Named in plan of correction for investigation of incidents | |
| DON | Director of Nursing | Named in plan of correction and interviews related to findings |
| ADON | Assistant Director of Nursing | Named in interviews and plan of correction |
Inspection Report
Routine
Census: 36
Deficiencies: 2
Date: Jun 7, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically regarding proper dating of food in the walk-in freezer and the use of hair restraints by staff during food service.
Findings
The facility failed to ensure food in the walk-in freezer was properly dated and staff wore hair restraints while serving food. Observations revealed outdated food items without expiration dates and a lack of a system to track opened food. Additionally, a dietary aide was observed serving food without a hair restraint.
Deficiencies (2)
Failed to ensure food in the walk-in freezer was dated properly.
Failed to ensure staff wore hair restraints while serving food.
Report Facts
Census: 36
Dates on food items: 2018
Dates on food items: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sous-Chef | Interviewed regarding food dating practices | |
| Dietary Manager | Interviewed regarding food dating and expiration tracking | |
| Dietary Aide | Observed serving food without hair restraint | |
| Director of Food and Beverages | Interviewed regarding hair restraint policy | |
| Administrator | Interviewed regarding food safety and hair restraint policies |
Inspection Report
Plan of Correction
Census: 36
Deficiencies: 3
Date: Jun 7, 2021
Visit Reason
The inspection was conducted to assess compliance with food safety requirements, specifically related to food procurement, preparation, and sanitary practices at Aberdeen Heights.
Findings
The facility failed to ensure food in the walk-in freezer was properly dated and staff wore hair restraints while serving food. These deficiencies had the potential to affect all residents who ate at the facility.
Deficiencies (3)
F812 Food safety requirements were not met as the facility failed to ensure food in the walk-in freezer was dated properly and staff wore hair restraints while serving food. This deficient practice could affect all residents.
A7003 The outer clothing of all employees was not clean and employees did not use effective hair restraints to prevent contamination of food or food-contact surfaces. This regulation was not met as evidenced by the deficiency cited at F812.
A7015 Food was not protected from potential contamination during storage, preparation, display, service, or transport. The temperature of potentially hazardous food was not maintained as required. This regulation was not met as evidenced by the deficiency cited at F812.
Report Facts
Resident census: 36
Inspection Report
Life Safety
Census: 36
Capacity: 38
Deficiencies: 2
Date: Jun 7, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code of the National Fire Protection Association (NFPA) and related regulations, focusing on elevator safety and oxygen cylinder storage.
Findings
The facility failed to ensure monthly operation and testing of the Firefighter's Service on three elevators and did not maintain oxygen cylinder storage according to NFPA code requirements. These deficiencies had the potential to affect all occupants in the event of a fire.
Deficiencies (2)
K531 Elevators: The facility failed to ensure the Firefighter's Service was operated monthly with a written record for three elevators. The director of plant operations confirmed no monthly inspections were performed.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage according to NFPA code, including improper storage of empty and full cylinders and inadequate separation from combustibles.
Report Facts
Facility capacity: 38
Resident census: 36
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 11/17/2020 through 11/19/2020 to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 23, 2020
Visit Reason
The document is a Plan of Correction submitted by Aberdeen Heights following a deficiency cited during a survey conducted on October 23, 2020.
Findings
The facility failed to provide proper care per the resident's individualized service plan, resulting in a fall with injury for one sampled resident. Deficiencies included lack of documentation of fall interventions, unsteady gait, and failure to update the resident's individualized service plan.
Deficiencies (1)
19 CSR 30-86.047(36) Proper Care Per Individual Service Plan. The facility failed to provide proper care per the resident's individualized service plan, resulting in a fall with injury for one sampled resident.
Report Facts
Date of survey: Oct 23, 2020
Plan of correction completion date: Dec 9, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sally Dendy | Administrator | Signed the plan of correction and mentioned as Director of Nursing (DON) in findings |
Inspection Report
Routine
Deficiencies: 0
Date: Jun 12, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from 06/11/2020 through 06/12/2020 to assess compliance with CMS and CDC recommended practices and related regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted from 05/22/2020 through 05/27/2020 to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were cited.
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 4
Date: Jul 31, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with fire safety, electrical wiring, floor surface cleanliness, and exit sign requirements at Aberdeen Heights.
Findings
The facility failed to post exit signs at required locations, did not conduct fire drills on all shifts quarterly, stored items improperly near electrical panels, and had unclean floors in the kitchen and storage areas. These deficiencies had the potential to affect all occupants of the building.
Deficiencies (4)
19 CSR 30-85.022(22) Exit Sign Requirements. The facility failed to ensure exit signs were placed within exit stairwells and exit corridors for two of three emergency exits.
19 CSR 30-85.022(33)(D) Fire Drill Requirements, Evacuation. The facility failed to conduct fire drills on each shift quarterly for two of four quarters reviewed.
19 CSR 30-85.032(31)(A) Electrical Wiring & Equipment Maintained. The facility failed to maintain a clear three-foot perimeter around electrical panels on one day of observation.
19 CSR 30-87.020(12) Floor Surfaces. The facility failed to keep floors in the kitchen, walk-in refrigeration units, and dry storage area free of dirt and debris for three days of observation.
Report Facts
Census: 14
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding exit sign placement and electrical panel storage | |
| Environmental Services Director | Interviewed regarding fire drill scheduling | |
| Executive Chef | Interviewed regarding kitchen floor cleaning practices |
Inspection Report
Census: 38
Deficiencies: 2
Date: Jul 31, 2019
Visit Reason
The inspection was conducted to assess compliance with environmental and sanitary conditions in the facility's kitchen and food preparation areas.
Findings
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen, with floors and storage areas dirty and covered with food debris over multiple days of observation. The kitchen floor was not properly cleaned despite scheduled cleaning routines, and the source of a white substance behind the braising pan was unknown.
Deficiencies (2)
F 921: The facility failed to keep kitchen floors, walk-in refrigeration units, and dry storage areas free of dirt and debris over three days of observation. The kitchen floor was dirty with food particles, debris, and grease in multiple areas.
A6012: Floors in all food-preparation, food-storage, and utensil-washing areas were not maintained in good repair and cleanliness as required. See deficiency cited at F921.
Report Facts
Census: 38
Inspection Report
Life Safety
Census: 38
Capacity: 38
Deficiencies: 4
Date: Jul 31, 2019
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety regulations and emergency preparedness at Aberdeen Heights.
Findings
The facility failed to maintain portable fire extinguishers according to NFPA standards, did not conduct required quarterly fire drills on all shifts, and failed to maintain clear perimeter around electrical panels. Additionally, oxygen cylinder storage did not meet NFPA requirements.
Deficiencies (4)
K355 Portable Fire Extinguishers: The facility failed to maintain all fire extinguishers to NFPA standards, including improper installation height and lack of monthly checks.
K712 Fire Drills: The facility failed to ensure fire drills were conducted on each shift quarterly, missing drills in the fourth quarter of 2018 and first quarter of 2019.
K919 Electrical Equipment - Other: The facility failed to maintain a clear three-foot perimeter around electrical panels, with items stored underneath panels.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain oxygen cylinder storage according to NFPA code, with combustibles stored in the oxygen closet and improper separation of empty and full tanks.
Report Facts
Facility capacity: 38
Census: 38
Inspection Report
Plan of Correction
Census: 32
Deficiencies: 3
Date: Jul 24, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to care plan timing and revision, pressure ulcer prevention and treatment, and food safety requirements at Aberdeen Heights nursing facility.
Findings
The facility failed to timely revise individual resident care plans to address pressure ulcers and use of position change alarms. The facility also failed to ensure proper treatment and prevention of pressure ulcers and maintain food safety standards during food preparation and storage.
Deficiencies (3)
F 657 Care Plan Timing and Revision: The facility failed to revise individual resident care plans timely to address pressure ulcers and use of a position change alarm for two residents.
F 686 Treatment/Services to Prevent/Heal Pressure Ulcer: The facility failed to assure that a resident with a history of pressure ulcers received care and monitoring to prevent redevelopment of pressure ulcers.
F 812 Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to ensure staff used clean utensils during pureed food preparation, covered trash receptacles, properly handled bulk food storage, and maintained clean ceiling panels and vents.
Report Facts
Resident census: 32
Number of sampled residents: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lily Dendy | Administrator | Signed the plan of correction document |
| Director of Nursing (DON) | Interviewed regarding care plan revisions and skin assessments | |
| Licensed Practical Nurse (LPN) E | Interviewed regarding wound care and dressing application | |
| Assistant Director of Nursing (ADON) | Interviewed regarding skin assessments and care plan updates |
Inspection Report
Life Safety
Census: 32
Deficiencies: 8
Date: Jul 24, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 Existing Edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to maintain required fire resistance ratings between different occupancies, hazardous areas, sprinkler system maintenance, and smoke barrier doors. These deficiencies affected all residents, staff, and occupants in the event of a fire.
Deficiencies (8)
K131: The facility failed to maintain a two hour fire resistance rating between different occupancies as required by NFPA. Doors separating the skilled nursing facility from the administrative hall did not close with the fire alarm.
K321: The facility failed to maintain hazardous areas with a one hour fire barrier. An open eight inch air duct was observed in the electrical room compromising the fire barrier.
K353: The facility failed to maintain the fire sprinkler system to NFPA code. Sprinkler heads in multiple locations showed accumulation of dust and debris.
K374: The facility failed to maintain smoke barrier doors to NFPA code. Smoke barrier doors showed no fire resistance rating tags and were not properly maintained.
A1086: The facility did not comply with the 1997 edition of the Life Safety Code as required by the 1985 edition of the Life Safety Code for facilities with plans approved between 1981 and 1998.
A2008: Hazardous areas were not properly separated by fire-resistant construction and automatic sprinkler systems as required.
A2034: The sprinkler system was not inspected, maintained, and tested in accordance with regulatory requirements.
A2054: Smoke sections were not properly separated by one-hour fire-rated walls and doors as required by regulation.
Report Facts
Facility census: 32
Inspection Report
Plan of Correction
Census: 14
Deficiencies: 5
Date: Jul 24, 2018
Visit Reason
The inspection was conducted to evaluate compliance with medication administration, kitchen cleanliness, food safety, and other health regulations at Aberdeen Heights.
Findings
The facility failed to maintain a safe and effective medication system with a medication error rate above 5%. Additionally, deficiencies were found in kitchen cleanliness, waste container coverage, food protection, and utensil storage, all potentially affecting residents.
Deficiencies (5)
19 CSR 30-85.042(47) Safe/Effective Medication System: The facility failed to ensure a medication error rate of less than 5%, with a 17.85% error rate observed. The census was 14.
19 CSR 30-87.020(19) List Fixtures, Vent Covers, Décor Cleanable: The facility failed to keep ceiling panels and vents free from dust and debris, affecting all residents. The census was 14.
19 CSR 30-87.020(31) Kitchen Waste Containers Covered: Trash receptacles were not covered when not in use, posing a risk to all residents. The census was 14.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: The facility failed to ensure proper handling of bulk food storage, risking contamination. The census was 14.
19 CSR 30-87.030(41) Food Service-Dispensing Utensils Use/Storage: Staff failed to use clean utensils during pureed food preparation, risking contamination to all residents. The census was 14.
Report Facts
Medication error rate: 17.85
Medication opportunities observed: 28
Medication errors occurred: 5
Census: 14
Trash cans observed: 10
Ceiling tiles replaced: 15
Viewing
Loading inspection reports...
