Inspection Reports for
Aberdeen Heights
505 COUCH AVE, KIRKWOOD, MO, 63122-5536
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
34 residents
Based on a August 2025 inspection.
Occupancy 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
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inadequate assistance with activities of daily living resulting in residents being left soiled, contradictory and outdated physician orders for oxygen therapy, and failure to implement proper infection prevention and control practices including Enhanced Barrier Precautions and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
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
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 |
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