Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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 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.
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.
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.
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.
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.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Memorial Community Care | 0.4 mi | ★★★★★ | 4 | 0 |
| Legacy Square | 12.5 mi | ★★★★★ | 10 | 1 |
| Adept Nursing & Rehab Of Central City | 16.3 mi | ★★★★★ | 1 | 0 |
| Litzenberg Memorial County Hospital | 16.4 mi | ★★★★★ | 5 | 0 |
| Harvard Rest Haven | 17.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.