Westfield Quality Care Of Aurora
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Nebraska.
- Location
- 1313 1st Street, Aurora, Nebraska 68818
- CMS Provider Number
- 285263
- Inspections on file
- 18
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Westfield Quality Care Of Aurora during CMS and state inspections, most recent first.
Surveyors found that the facility failed to conduct thorough investigations and implement adequate protective interventions following multiple resident-to-resident abuse incidents in a memory care unit. In several cases, a resident was physically or sexually abused by another resident, but investigation reports lacked required interviews of involved staff, residents, and witnesses, and contained only basic descriptions of the events. Two residents with dementia and ongoing aggressive or sexually inappropriate behaviors continued to have repeated incidents involving other residents, staff, and visitors, while care plans reflected only limited, short-term checks and environmental measures. Staff reported relying on informal monitoring and positioning strategies and were not aware of specific, individualized care plan interventions to protect others from these residents’ behaviors.
The facility did not notify the Department in writing within the required timeframe about the vacancy and filling of the Administrator position. The Business Office Manager, acting as provisional administrator, submitted a Change of Notification Form before their provisional license was active, leading to the Department declining the notification. This lapse in following notification procedures had the potential to affect all residents.
The facility did not complete nightly control testing on glucometers, leading to potential inaccuracies in blood sugar readings for residents on sliding scale insulin. Glucometer QC logs were incomplete, lacked differentiation between devices, and showed calibration numbers outside acceptable ranges. Additionally, a resident's foot blister was missed due to incomplete skin checks, as assessments did not include the feet. Interviews with nursing staff revealed inconsistencies in glucometer calibration procedures and a lack of training, highlighting gaps in staff competency and adherence to facility policies.
A survey identified deficiencies in the facility's Quality Assessment Performance Improvement (QAPI) plan, which failed to address ongoing issues related to Emergency Preparedness (EP) and quality of care standards. The facility's QAPI policy assigned the Quality Assessment and Assurance Committee (QAA) the responsibility to design the QAPI program, focusing on care outcomes and quality of life indicators. However, the survey revealed the absence of an active QAPI program and a system for data collection to address ongoing concerns. Interviews with the Infection Preventionist (IP) and Administrator (ADM) confirmed the lack of an active Performance Improvement Program (PIP) and deficiencies in monitoring and correcting ongoing issues.
The facility failed to implement a water Legionella management program and did not perform proper indwelling catheter care for two residents, increasing the risk of infection. Interviews confirmed that the catheter care provided did not adhere to the facility's established procedures.
The facility did not ensure that residents could access their personal trust funds on weekends, impacting 46 out of 53 residents. During interviews, one resident reported being unable to access funds on weekends, and the Business Office Manager confirmed the lack of access on Saturdays and Sundays.
A resident was admitted with a diagnosis of unspecified psychosis, but the required PASARR was not completed until after admission, contrary to facility policy. The Kepro Level 1 Screen did not reflect the resident's mental health diagnosis, and this oversight was confirmed by the Social Worker.
Failure to Thoroughly Investigate Resident-to-Resident Abuse and Implement Protective Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to conduct thorough investigations into multiple resident-to-resident abuse incidents and to develop adequate interventions to protect residents from further adverse behaviors. The facility’s Abuse, Neglect, and Exploitation policy requires immediate, comprehensive investigations, including identifying responsible staff, handling evidence, interviewing all involved persons and witnesses, determining whether abuse occurred, and documenting the investigation. In the incident involving two residents in the memory care unit dining room, one resident was found with pants down and reported being hit on the bottom by another resident, who was seated at a table. Progress notes documented the event and that the residents were separated and placed on 15‑minute checks, but the investigation report contained no documentation of interviews with staff, residents, or witnesses, and did not include an actual investigation beyond restating the incident. A similar deficiency occurred in another physical abuse incident between two residents with dementia in the memory care unit. One resident was witnessed hitting another in the upper back when the second resident attempted to enter the aggressor’s room. Progress notes documented the event, assessment of the victim, and notification of leadership and the resident’s representative. The investigation report again lacked documentation of identifying and interviewing involved persons or witnesses and did not include a substantive investigation of the circumstances. The facility’s own policy requires efforts to protect residents from additional abuse during and after investigations, but the documentation showed only basic separation and monitoring, without a detailed investigative process. The deficiency extended to a resident-to-resident sexual abuse incident involving a resident with vascular dementia and a history of sexually inappropriate behavior toward staff and visitors, and another resident with Alzheimer’s dementia. Prior to the incident, progress notes documented that the sexually disinhibited resident had attempted to grope staff and a visitor and had made vulgar sexual comments. Later, this resident was found in the dining room with a hand in another resident’s groin area, while that resident’s pants and brief were down around the knees. The investigation report described the sequence of events and immediate separation and monitoring, but again contained no documentation of interviews with involved staff, residents, or witnesses, and did not include a full investigation as required by policy. Surveyors also found that the facility failed to develop and implement ongoing, individualized interventions to prevent further resident-to-resident abuse by two residents with known behavioral issues. One resident with dementia, agitation, and a conduct disorder had a documented history of physical aggression toward other residents, including hitting, punching, and difficulty with redirection when seeing others in the hallway. The care plan reflected time-limited 15‑minute checks after an altercation, but no new interventions were added following subsequent aggressive incidents. Staff interviews indicated that they informally tried to keep this resident within arm’s length and stand between the resident and others, but they were not aware of specific care plan interventions to protect other residents. Another resident with vascular dementia and ongoing sexually inappropriate behaviors toward staff, visitors, and other residents also lacked sufficient care-planned interventions to protect others. Documentation showed repeated incidents of groping attempts, sexual comments, and demands for physical contact even after a substantiated sexual abuse incident with another resident. The care plan included separation from the victim, 15‑minute checks, and a mesh gate at the doorway, but no additional interventions were developed to address the continuing behaviors. Observations showed the gate not in place and the resident ambulating unattended near other residents, while staff reported relying on informal strategies such as avoiding turning their backs and trying to keep the resident in view. The Assistant Director of Nursing confirmed that no new interventions beyond the initial actions were developed after the abuse incidents for either aggressive resident.
Failure to Timely Notify Department of Administrator Vacancy and Appointment
Penalty
Summary
The facility failed to notify the Department in writing within 5 working days regarding the vacancy and subsequent filling of the Administrator position, as required by state regulations. Interviews with the Facility Administrator (FA) and Business Office Manager (BOM) revealed that the BOM served as the provisional administrator prior to the current FA's tenure. The BOM submitted a Change of Notification Form to the Department before their provisional administrator license was activated, resulting in the Department declining the notification due to the lack of an active license at the time of submission. Records showed that the Change of Notification Form was sent on the same day the provisional license was requested, but the BOM was unaware of the required timeline for obtaining the provisional license and for notifying the Department about the vacancy and filling of the Administrator position. The Department advised the BOM to resubmit the notification once the provisional license was available or another individual was selected. This failure to follow the required notification process had the potential to affect all 50 residents in the facility.
Glucometer Calibration and Skin Assessment Deficiencies Identified
Penalty
Summary
The facility failed to complete control testing on the facility glucometers each night as required to maintain accurate blood sugar readings for residents receiving sliding scale insulin. The Glucometer QC logs lacked proper documentation, with incomplete entries and no differentiation between the two glucometers used daily. Calibration numbers for both high and low ranges were consistently out of the acceptable range, indicating potential inaccuracies in blood sugar readings. The lack of proper calibration and documentation raised concerns about the reliability of blood sugar monitoring for residents, impacting their diabetes management and insulin administration. Additionally, the facility did not ensure thorough skin checks for one resident, resulting in a missed observation of a popped blister on the top of the resident's foot. The skin observation assessments did not include the feet, leading to a delay in identifying and addressing the foot issue. This deficiency in skin checks and documentation highlighted gaps in the facility's monitoring of residents' skin integrity, potentially compromising the prevention and management of pressure injuries. The failure to conduct timely and comprehensive skin assessments could have adverse effects on residents' overall skin health and wound prevention. Interviews with nursing staff revealed inconsistencies in performing glucometer calibrations during night shifts, with varying levels of understanding and adherence to proper procedures. The lack of education and training on glucometer calibration, as well as inadequate monitoring of skin assessments, indicated deficiencies in staff competency and compliance with facility policies. These findings underscored the importance of consistent training, oversight, and adherence to protocols to ensure accurate monitoring and quality care for residents in the facility.
Deficiency in QAPI Program Implementation and Monitoring
Penalty
Summary
The facility's Quality Assessment Performance Improvement (QAPI) plan was found deficient during a survey, as it failed to identify ongoing issues related to various regulations, including Emergency Preparedness (EP) and quality of care standards. The facility's QAPI policy outlined the responsibility of the Quality Assessment and Assurance Committee (QAA) to design the QAPI program, focusing on indicators of care outcomes and quality of life. However, findings from the survey indicated that the facility did not have an active QAPI program in place, with no system for data collection to identify and address ongoing concerns within the facility. Interviews with the Infection Preventionist (IP) and Administrator (ADM) revealed a lack of awareness and implementation of an ongoing and active QAPI program within the facility. The IP confirmed the absence of a Performance Improvement Program (PIP) in the past year and a deficiency in monitoring and correcting ongoing issues. The ADM also acknowledged a failure to identify and monitor areas of deficient practice through the QAA committee or QAPI, indicating a gap in the facility's quality assessment and performance improvement processes.
Failure to Implement Water Management and Proper Catheter Care
Penalty
Summary
The facility failed to develop and implement a water Legionella management program, which had the potential to affect all residents. Despite having policies in place for a water management program and Legionella surveillance, the Physical Plant Manager was unaware of such a plan, and the facility Administrator confirmed that no completed water management program existed. This indicates a significant oversight in the facility's infection prevention and control measures related to waterborne pathogens. Additionally, the facility failed to perform proper indwelling catheter care for two residents. Resident #27, who had a neurogenic bladder and a history of urinary tract infections, was observed receiving catheter care that did not follow the correct procedure. The Medication Assistant did not separate the labia or clean the catheter tubing from the meatus down, as required by the facility's policy. Similarly, Resident #21, who had an intellectual disability and a history of urinary tract infections, received improper catheter care. The Medication Assistant did not cleanse from the meatus down the shaft of the penis, as stipulated in the facility's policy. Interviews with the Medication Assistants and the Director of Nursing confirmed that the catheter care provided did not adhere to the facility's established procedures. The facility's policy on catheter care clearly outlines the steps for proper cleaning, which were not followed in these instances. This failure to adhere to proper catheter care protocols increases the risk of infection for the residents involved.
Resident Trust Fund Access Limited on Weekends
Penalty
Summary
The facility failed to ensure residents could access their personal resident trust funds on weekends, affecting 46 out of 53 residents. During interviews, Resident 30 expressed inability to access funds on weekends, and the Business Office Manager confirmed the lack of access on Saturdays and Sundays.
Failure to Complete PASARR Prior to Admission
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed prior to the admission of a resident with a mental illness. Resident 34 was admitted with diagnoses including Type 2 Diabetes, unspecified psychosis, and cerebral infarction. Despite the diagnosis of unspecified psychosis, the Kepro Level 1 Screen completed the day after admission did not reflect any known or suspected mental health diagnosis. This oversight was confirmed by the Social Worker during an interview, who acknowledged that the PASARR was not completed until after the resident's admission, contrary to the facility's policy requiring it to be done beforehand. The Quarterly Minimum Data Set (MDS) for Resident 34 indicated that the resident was cognitively intact, had no mood or behavior problems, and was not receiving psychotropic medications. However, the MDS also confirmed an active diagnosis of a psychotic disorder other than schizophrenia. The failure to accurately document and complete the PASARR prior to admission represents a significant lapse in following federal and facility guidelines designed to ensure appropriate placement and necessary services for residents with mental illnesses or intellectual disabilities.
Latest citations in Nebraska
Surveyors found that the facility failed to follow oxygen therapy orders and ensure adequate oxygen supply for three residents with chronic respiratory and cardiac conditions. One resident ordered to be on continuous O2 at 3 L/min was repeatedly documented on room air and was observed in a wheelchair without an O2 tank or nasal cannula until staff briefly removed the resident to change the tank. Another resident ordered to use O2 at 3–4 L/min and to have a full tank for meals and activities was repeatedly observed in the dining room with the tank set at 3 L/min while the gauge remained in the red zone, and a family member reported the tank was empty and needed changing. A third resident with COPD, heart failure, and sleep-related hypoventilation, ordered to receive 1 L/min O2 via NC at bedtime, had documentation showing missed O2 administration at ordered times and confirmed that staff did not provide O2 at bedtime or for a period in the morning, despite care plan interventions requiring O2 administration and respiratory monitoring.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that the facility failed to follow its own skin and wound management policy for two residents at risk for pressure ulcers. One resident returned from the hospital with multiple documented unstageable pressure ulcers on the right foot and ankle, but the facility did not obtain or document treatment orders, did not include these wounds in weekly skin assessments, and provided no wound treatments for 13 days. Another resident with impaired mobility and documented DTIs to both heels did not have timely care plan updates or treatments initiated as first documented, later developed an unstageable ulcer on the bottom of the right foot without corresponding orders or TAR entries, and was observed on an air mattress set for more than double the resident’s weight while wearing heel protectors that did not offload the heels as ordered. Staff interviews confirmed incorrect support surface settings, use of the wrong heel devices instead of ordered Prevalon boots, and failure to transcribe and carry out treatment orders for the new foot ulcer.
Surveyors found that hot lunch items, specifically BBQ pork, were held on a second-floor steam table at temperatures below required standards, with documented readings as low as 119–125°F despite facility procedures and FDA Food Code requirements that hot foods be held at or above 135°F and reheated to 165°F if they fall below that threshold. The Food Service Director acknowledged that cold BBQ sauce had been added to cooked pork and that the initial steam table temperature should have been 165°F, yet temperature logs and on-site measurements during the meal service showed the food remained below the required hot-holding temperature for residents on the unit.
A resident with multiple open wounds, a PICC line, and an active MRSA infection was not managed under the facility’s Enhanced Barrier Precautions (EBP) policy, which requires gown and glove use and door signage for residents with wounds, indwelling devices, or MDROs during high-contact care. Observations showed no EBP signage or gowns available at the room, and an LPN performed wound care using only gloves without a gown, later confirming that EBP should have been used but was not.
Surveyors found that medications were not stored securely as required by facility policy and regulations. A container of Gavilyte-G solution labeled for a resident was left on a bathroom sink, and a clear plastic bag containing multiple medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, was found on a dresser in another resident’s room. The second resident was cognitively intact per BIMS, required extensive assistance with ADLs, was at risk for pressure ulcers, and had two venous ulcers. An LPN and the Wound and Infection Nurse confirmed these medications should not have been stored in these unsecured locations and should have been kept locked.
A resident with hemiplegia and moderate cognitive impairment had been formally evaluated and approved only to self-administer nystatin powder, with no care plan focus on self-administered medications. Despite this, a labeled container of Gavilyte-G solution, ordered as a single large oral dose, was left in the resident’s bathroom with some solution remaining. An LPN reported mixing the laxative with juice and giving it to the resident, who stated they drank part of it and vomited, and it appeared no more was taken afterward. The ADON stated there was no policy on self-administration beyond an evaluation form and confirmed the resident had not been evaluated to self-administer the laxative.
Failure to Provide Ordered Oxygen Therapy and Maintain Adequate Oxygen Supply
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered oxygen therapy and to ensure adequate oxygen supply for multiple residents with significant respiratory conditions. Facility policy required that residents’ care plans identify interventions for oxygen therapy based on assessments and provider orders, and that only medication aides and nurses change oxygen tanks. For one resident with chronic respiratory failure, COPD, diabetes, obesity, and a recent hospital discharge for stroke with an order for continuous oxygen at 3 L/min, provider orders directed continuous oxygen via nasal cannula at 3 L/min at rest and with activity, with staff to adjust flow to maintain oxygen saturation above 90%, monitor saturations every shift, and ensure oxygen supply at all times. The resident’s primary care provider documented that the resident needed oxygen at all times and had been taken to an appointment without supplemental oxygen. Vital sign records showed the resident was documented as being on room air (no supplemental oxygen) on multiple dates, and direct observation showed the resident sitting near the nurses’ station without an oxygen tank or tubing until staff took the resident to the room and returned with oxygen in place. Another resident, admitted with chronic respiratory failure, COPD, CHF, atrial fibrillation, diabetes, and obesity, had provider orders to use oxygen via nasal cannula at 3–4 L/min at rest and with activity, and a specific order that the oxygen tank be full for meals and activities. Observations over more than an hour in the dining room showed this resident seated in a wheelchair with the oxygen tank regulator set at 3 L/min while the gauge needle remained in the red area, indicating the tank was near empty or empty. The resident could not confirm whether oxygen was flowing. Later, the resident was observed in their room on an oxygen concentrator, with the same unchanged tank still on the wheelchair. A subsequent observation again found the resident in the dining room with the tank set at 3 L/min and the gauge needle still in the red, and the resident’s family member reported they had been trying to find a nurse because the tank was empty and needed to be changed. A third resident, admitted with a right femur fracture, COPD, chronic diastolic heart failure, and idiopathic sleep-related nonobstructive alveolar hypoventilation, had a care plan identifying routine or PRN oxygen therapy and risk for ineffective gas exchange, with interventions including administering oxygen per physician orders, monitoring for respiratory distress, and monitoring pulse oximetry and respiratory status. The care plan also identified impaired respiratory status with interventions to monitor for shortness of breath, respiratory distress, wheezing, fatigue, anxiety, and to assess lung sounds and vital signs. Provider orders directed oxygen at 1 L/min via nasal cannula at hour of sleep. Oxygen saturation documentation showed the resident was not receiving oxygen at times when it should have been provided, and the resident confirmed that staff did not give oxygen at bedtime and did not provide oxygen for a period in the morning, despite being dependent on staff for transfers and having been assessed as cognitively intact on the MDS.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Failure to Implement and Monitor Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to evaluate, monitor, and implement appropriate interventions for pressure ulcer prevention and treatment for two residents, despite having a written Skin and Wound Management policy. That policy required nursing staff and practitioners to assess and document significant risk factors for pressure ulcers, perform full wound assessments including measurements and tissue characteristics, obtain physician orders for wound treatments and pressure reduction surfaces, and monitor and document skin changes and intervention effectiveness on an ongoing basis. The facility did not follow these requirements for the identified residents. For one resident, the MDS showed the resident was cognitively intact, required extensive assistance with multiple ADLs, was at risk for pressure ulcers, and had venous ulcers. Hospital documentation prior to readmission identified multiple unstageable pressure ulcers on the right lateral ankle, right lateral foot, right 5th toe, and a questionable stage 1 or DTI on the right heel, as well as open wounds on both buttocks and an incision at a left BKA site. On readmission, the facility’s assessment noted unmeasured pressure ulcers on the right outer ankle, right lateral foot, and right 5th toe. However, the order summary and treatment administration record contained no treatment orders or evidence of treatment for the unstageable pressure ulcers on the right lateral ankle, right heel, right lateral foot, or right 5th toe. A weekly skin/wound observation documented MASD to the buttocks and a diabetic wound to the left outer ankle, but did not mention the left BKA site or the right foot and ankle wounds. When the wound and infection nurse and the assistant DON assessed this resident’s right foot and ankle, they observed multiple areas of denuded and black tissue, including a denuded area on the top of the right foot and black areas on the right lateral ankle, right heel, between all toes, the right 5th toe, and the right anterior ankle. The wound and infection nurse confirmed that the pressure ulcers on the right foot had not been treated from the time of readmission until the date of that assessment, a period of 13 days. This reflects a failure to implement ordered wound care, to obtain and document appropriate treatment orders, and to perform ongoing monitoring and documentation consistent with the facility’s own policy. For the second resident, the MDS indicated the resident was cognitively intact, had mononeuropathies of both lower limbs, required varying levels of assistance with mobility and ADLs, was at risk for pressure ulcers, and initially had no pressure ulcers. The comprehensive care plan identified actual skin integrity impairment related to fragile skin, impaired mobility, incontinence, and malnutrition, with goals to maintain intact skin and interventions such as keeping skin clean and dry, using lotion, providing a pressure-reducing cushion and mattress, and using caution during transfers. A subsequent weekly skin/wound observation documented new DTIs to both heels with specific measurements and noted a new treatment order for skin prep to both heels, but the care plan showed no new interventions added on or after that date, and the January TAR showed no new treatment initiated for the bilateral heel pressure ulcers. In the following month, an order was entered to cleanse the heels, apply skin prep, leave them open to air, and protect the heels at all times with Prevalon boots and offloading/floating. Later, a weekly skin/wound observation documented a new unstageable pressure ulcer on the bottom of the right foot, fully covered with eschar. The care plan printed after this finding contained no new interventions for this new pressure area, and the order summary and TAR showed no treatment orders or documentation of treatment for the right bottom foot. Observations showed the resident lying on an air mattress calibrated to a setting appropriate for a much higher body weight than the resident’s actual weight, and wearing green heel protectors that padded the heel and ankle but did not float the heel. Repeated observations confirmed continued use of the incorrectly set mattress and the green heel protectors. During wound care, staff observed that the resident had black areas on both heels, a black area on the right medial bottom foot, and a non-blanchable dark pink/purple area on the right lateral foot. An LPN confirmed that the green heel protectors did not protect the entire foot and that one protector had shifted, failing to relieve pressure on the left heel wound. The wound and infection nurse confirmed the resident was supposed to be wearing Prevalon boots, not the green heel protectors. The ADON confirmed the air mattress had not been set correctly for the resident’s weight and that the resident was not receiving treatment to the right bottom foot as ordered. The wound and infection nurse further confirmed that the treatment order for the right bottom foot had not been transcribed onto the TAR, resulting in the treatment not being performed.
Improper Hot Holding Temperatures for Lunch Entrée on Steam Table
Penalty
Summary
The facility failed to ensure that hot foods on the second-floor steam table were held at temperatures consistent with its own Standard Operating Procedures and the 2022 U.S. FDA Food Code. During a lunch meal service, surveyors observed that BBQ pork, after being removed from a heated cart and placed on the steam table, measured 125°F when checked by a staff member. The second-floor Daily Food Temperature log for that lunch also documented the meat entrée at 125°F. The Food Service Director stated that the pork had been cooked and then cold BBQ sauce was added, and further reported that the initial cooked pork temperature on the steam table should be 165°F. Subsequent temperature checks during the same meal period showed that the BBQ pork measured 133°F when taken by the Food Service Director with a different thermometer, and later 137.3°F at the end of meal service, while pork without sauce measured 119°F. The facility’s undated Daily Food Temperature Form specified that the steam table is for holding/serving only, that hot foods must be held above 135°F, and that any food dropping below this temperature must be reheated to 165°F for at least 15 seconds prior to serving. The 2022 U.S. FDA Food Code reviewed by surveyors stated that food shall be held at 135°F or above except during preparation, cooking, or cooling. These observations and records showed that hot food was held and recorded at temperatures below required standards for up to 40 of 41 residents on the second floor.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy during care of a resident with multiple wounds, an indwelling device, and an active MDRO infection. The facility’s EBP policy dated 01-2024 states that residents with wounds or indwelling medical devices, regardless of MDRO status, and residents known to be infected or colonized with an MDRO, are to be placed on EBP with signage on the door and targeted gown and glove use during high-contact activities, including wound care. EBP is required for activities such as dressing, bathing, hygiene, changing linens and briefs, toileting assistance, device care, and any wound care requiring a dressing. Record review showed that the resident was cognitively intact, required extensive assistance with multiple activities of daily living, was at risk for pressure ulcers, and had multiple wounds including venous ulcers, open wounds on both buttocks, a left BKA incision, several unstageable pressure ulcers on the right lower extremity, a PICC line in the right upper arm, and an active MRSA infection. Observations on separate days revealed there was no EBP signage on the resident’s door and no gowns available inside or outside the room. During observed wound care, an LPN used gloves but did not wear a gown, and later confirmed that EBP had not been utilized and should have been during the wound care encounter.
Medications Left Unsecured in Resident Rooms
Penalty
Summary
The facility failed to ensure medications were stored safely and securely in accordance with its policy and regulatory requirements. The facility’s policy on centralized medication storage, revised 8/2024, stated that medications are to be stored safely, securely, and properly, accessible only to authorized personnel. During an observation on 3/17/26 at 8:14 AM, surveyors found a container of Gavilyte-G solution, labeled by the pharmacy for Resident 3, sitting on the bathroom sink in Resident 3’s bathroom with approximately one inch of solution remaining. In an interview on 3/16/26 at 10:47 AM, the Wound and Infection Nurse confirmed that the Gavilyte-G container should not have been stored on the resident’s bathroom sink. The facility also failed to secure multiple medications in the room of Resident 2. Resident 2’s MDS dated 01-04-2026 showed the resident was admitted on a prior date, had a BIMS score of 13 indicating cognitive intactness, required extensive assistance with toileting, bathing, dressing, hygiene, bed mobility, and transfers, was at risk of developing a pressure ulcer, and had two venous ulcers. On 03-16-2026, an observation revealed a clear plastic bag containing medications, including furosemide, pantoprazole, carvedilol, Entresto, aspirin, and a Lantus insulin pen, sitting on the dresser in Resident 2’s room. In an interview on the same date, LPN D confirmed that these medications were on the dresser and acknowledged that medications are supposed to be kept locked up.
Failure to Evaluate Resident for Self-Administration of Laxative Medication
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was properly evaluated for self-administration of a laxative medication. The resident was admitted with hemiplegia affecting the right dominant side and had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate problems with thinking and memory. The resident’s care plan did not include any focus area related to self-administration of medications. A self-medication administration evaluation dated 3/3/26 documented that the resident was evaluated and approved to self-administer nystatin powder, but there was no indication the resident had been evaluated to self-administer any laxative medication. During observation, surveyors found a container of Gavilyte-G solution with a pharmacy label for the resident sitting on the bathroom sink, with approximately one inch of solution remaining. The MAR showed an order for a single 4000 ml oral dose of Gavilyte-G, with one administration entry documented. An LPN reported mixing the Gavilyte-G with apple juice and giving it to the resident, who later stated they drank two glasses and vomited, and by the next morning it appeared no additional solution had been consumed. The ADON confirmed there was no facility policy on self-administration of medications beyond the evaluation form and acknowledged that the resident had not been evaluated for self-administration of the Gavilyte-G laxative.
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