Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aurora Brule Nursing Home Inc during CMS and state inspections, most recent first.
Incomplete Investigation of Alleged Abuse: A blind resident reported that a CNA was rude, told him to do it himself, gave him a brief, and left him on the toilet without care. The facility identified the CNA as the staff member involved, but the investigation did not include interviews of other residents under the CNA’s care, and key parts of the investigative protocol form were left incomplete. The DON and administrator confirmed that no broader review was done to determine whether other residents may have been affected.
A provider failed to ensure required physician visits were alternated with PA visits for several residents under SNF stays. Four residents had provider encounters documented primarily by a PA, with no documentation of the required physician visits after admission or during the certification period. The administrator stated she believed a PA could complete all standard visits, and the PA stated she usually saw residents in the nursing home for their medical care and visits.
Failure to Protect Confidential EMR Information: A CNA left a hallway computer screen displaying two residents' EMR information and later a screen showing all residents' names while stepping away to enter rooms and answer call lights. RN, DON, and the Administrator confirmed staff were expected to lock the screen after charting to protect residents' private medical information, and the resident rights booklet stated residents control access to their personal and care records.
Failure to Protect Resident From Abuse: A blind resident with reduced mobility and a hx of lumbar fusion reported that a CNA threw an incontinence brief at him, told him to do it himself, and left him on the toilet without assistance. The resident’s care plan called for staff help with ADLs and personal hygiene, but the facility’s investigation found the CNA did not follow the care plan and substantiated abuse; the investigation file was incomplete, and no audits of the CNA’s interactions were completed.
A facility failed to ensure two residents using electronic lift chairs were assessed for safe independent use of the chair remote and footrest. Both residents had severely impaired cognition, and one had diagnoses including Alzheimer’s disease and dementia with a history of fractures and high assistance needs, while the other had anxiety, rheumatoid arthritis, and prior hip fracture with transfer and toileting assistance needs. Observations showed both residents seated with the footrest elevated and the remote left within reach, despite each resident stating they did not know how to use it. The administrator stated residents were not assessed for safety concerns when using a recliner, and the DON said staff knew which residents could use the remote.
A resident receiving hospice services was given lorazepam from a blister pack whose pharmacy label did not match the EMR order. The CNA/MA observed that the label still directed twice-daily dosing while the EMR showed four times daily, and the resident had multiple lorazepam cards that remained labeled with outdated instructions despite prior order changes. RN and DON interviews confirmed the facility expected updated labeling or destruction of outdated controlled-medication packs when orders changed.
Unsafe Handling of Ready-to-Eat Foods During Meal Service: A dietary aide handled RTE salad with a bare hand, did not perform hand hygiene or wear gloves while delivering meals, and placed salad dressing cups directly on top of plated food. The CDM stated staff were expected to avoid bare-hand contact with RTE foods and to use utensils, hand hygiene, and gloves when handling them.
Failure to Provide Correct Medicare Non-Coverage Notice: The facility did not provide the required SNF ABN, CMS-10055, for two residents when Medicare Part A skilled coverage ended. Instead, the CMS-R-131 form was used, and for one resident it was not signed by the resident or representative; for the other, there was no documentation that the correct notice was explained, issued, or given. The Administrator confirmed the wrong form was used and that no signed CMS-10055 was available for either resident.
A resident’s representative signed a binding arbitration agreement form that omitted required disclosures, including the 30-day rescission right and that signing was not required for admission or continued care. The administrator acknowledged the facility’s form lacked some required information, even though the policy contained it, and the admission packet included only a blank arbitration form.
Two residents with a history of repeated falls did not have their care plans reviewed or revised after multiple subsequent falls, despite facility policy requiring updates. Staff interviews revealed unclear responsibility for updating care plans, and the administrator was unaware of the missed updates. Policy lacked specificity on who should update care plans and how often, contributing to the deficiency.
The facility did not ensure that nursing services provided met professional standards of quality, as identified by surveyor observation and review of facility practices.
A resident with a history of falls and impaired mobility was transferred multiple times between a recliner and a wheelchair by various staff members, including CNAs, a CMA, an RN, and the administrator, without the use of a gait belt. Despite the resident's care plan indicating a high fall risk and the need for assistance, staff used their hands to lift the resident by the arms. Interviews revealed inconsistent understanding of gait belt requirements, and the facility's policy only addressed therapy staff, not all staff involved in transfers.
A certified medication aide was observed making multiple medication administration errors, including failing to verify physician orders with prescription labels, not documenting PRN eyedrop administration, and preparing medications for the wrong resident. These actions resulted in a medication error rate above 5%, in violation of facility policy and standard medication administration procedures.
Staff did not consistently monitor or document food temperatures for numerous meals, and opened applesauce used for medication administration was left unrefrigerated on medication carts and used for over 21 hours. Three residents received applesauce that had been improperly stored, and staff were unaware of the need to refrigerate it after opening.
Surveyors found that staff failed to follow infection prevention and control protocols, including improper labeling and storage of personal care products, inadequate hand hygiene and glove use during resident care and medication administration, and failure to clean mechanical lifts between uses. Expired and unlabeled supplies were found in storage areas, and the salon was maintained in an unsanitary condition. Staff interviews confirmed inconsistent adherence to infection control policies and a lack of awareness regarding proper procedures.
A resident was transferred to the hospital, and although the responsible party was notified and the bed-hold policy was sent, there was no documentation of a signed bed-hold notice from the resident or responsible party. Staff interviews revealed that while the policy was reviewed and notices were sent, the facility did not obtain or require a signed acknowledgment, contrary to its own procedures.
A CMA prepared to administer medications without verifying prescription labels, nearly giving a resident another individual's levothyroxine and propranolol. The error was caught by surveyors before administration. The CMA was unable to describe the rights of medication administration, and the facility's policy requiring verification of the right resident, drug, and dose was not followed.
A resident received Novolog insulin injections from pens that lacked required pharmacy prescription labels, with staff relying on handwritten identifiers on storage containers rather than labels affixed to the pens themselves. Both an RN and an LPN administered insulin using these unlabeled pens, despite facility policy and pharmacy practice requiring complete labeling on each medication container.
An incident of elopement occurred due to inadequate supervision and failure to ensure the nursing home area was free from accident hazards. The facility's care planning, staff response to door alarms, and elopement policy were found to be insufficient at the time of the incident.
The facility was found deficient in ensuring safe hot beverage temperatures, posing a burn risk to residents. The lack of adequate supervision and monitoring during assisted dining led to this accident hazard.
Incomplete Investigation of Alleged Abuse
Penalty
Summary
The provider failed to thoroughly investigate an allegation of abuse involving a CNA and a blind resident who reported that a staff member was rude, told him to do it himself when he needed help in the bathroom, gave him a brief, and left him on the toilet without providing care. The facility identified the CNA as the staff member involved after interviewing staff scheduled to work that night, and the CNA did not provide care according to the resident’s care plan. The CNA’s employment was terminated after the allegation was substantiated. The investigation was incomplete because the social services designee did not interview other residents assigned to the CNA to determine whether additional residents may have been abused, stating that nobody else came to her. The investigative protocol form for the incident was also not fully completed, with root cause analysis, in-service education form, and focus audit form left blank. The administrator and DON confirmed that no other residents under the CNA’s care were interviewed, and they stated that another incident could have occurred while the CNA worked at the facility. The facility’s abuse policy required prompt investigation of alleged abuse and a complete review of existing incidents, including interviews of staff, residents, or other witnesses.
Physician Visit Schedule Not Followed for SNF Residents
Penalty
Summary
The provider failed to ensure required physician visits were alternated between personal visits by the physician and visits by the physician assistant after the physician’s initial comprehensive visit for residents under SNF stays. Record review showed that four sampled residents had SNF stays during the review period, and their provider visits were completed by PA C without documentation of the required physician involvement. Resident 8 had multiple PA C visits documented, but there was no documentation of a physician medical visit within the last year. Resident 29 was seen by PA C for the initial certification visit, second certification visit, and final 90-day certification visit, with no documentation of any physician visit since admission. Resident 4 had two SNF stays during the review period and was seen by PA C for multiple provider visits, while physician documentation was limited to a hospital follow-up and an acute issue, not the required alternating physician visits for the SNF stay. Resident 43 had a SNF stay and was seen by PA C for the initial certification visit, second certification visit, and 90-day certification visit, with no documentation of a physician visit or examination after admission. The administrator stated she believed a PA could see all residents for standard medical visits and was not aware that a physician had to conduct the initial visit and every other 30-day physician visit for residents under SNF stays. PA C stated she usually saw residents in the nursing home for their medical care and visits, and that a physician was available on call if needed.
Failure to Protect Confidential EMR Information
Penalty
Summary
The provider failed to protect residents' personal and medical records as confidential when a CNA left EMR information displayed on a wall-mounted computer screen in the East hallway. During observation on 7/27/26 at 3:40 p.m., CNA S was entering data on the hallway computer and then left resident 41's EMR information visible on the screen while entering another resident's room. CNA S later returned to the computer, then left again to answer another resident's call light at 3:42 p.m. with resident 40's EMR information displayed on the screen. At 3:46 p.m., CNA S again left the computer to answer a call light, and the computer remained on a screen displaying all residents' names until CNA I locked the screen at 3:50 p.m. During interview, RN Q stated the hallway computers were used by staff to chart resident care in the EMR system and that staff were expected to lock the screen when finished to protect private medical information. DON B and Administrator A later confirmed staff were expected to keep residents' medical information private by locking the computer screens after charting, and agreed that a visitor or other resident could potentially access residents' medical information if the screen was not locked. The resident admission packet also stated that residents have the right to approve or refuse anyone outside the nursing home access to their personal and care records.
Failure to Protect Resident From Abuse
Penalty
Summary
The provider failed to protect a resident from verbal and physical abuse when a CNA threw an incontinence brief at him, told him to do it himself, and left him on the toilet without assistance. The resident was blind, had reduced mobility, and had a history of lumbar fusion. His care plan directed staff to assist him as needed with ADLs and to provide partial to moderate assistance with personal hygiene, but he reported that he needed help putting on a new brief because of his blindness and difficulty bending over. He recalled that after asking for help, the staff member left the room and another staff member later assisted him after he pulled the call light cord. The facility’s investigation identified CNA V as the staff member involved and determined that she did not provide care according to the resident’s care plan and substantiated the allegation of abuse. The social services designee interviewed the resident but did not interview other residents assigned to CNA V, and the investigative protocol form was incomplete because the root cause analysis, in-service education form, and focus audit form were left blank. The administrator confirmed that no audits of CNA V’s interactions with residents or other staff interactions with residents were completed, and the facility’s abuse policy required prompt investigation and complete documentation of alleged or suspected abuse.
Failure to Assess Safe Use of Electronic Lift Chairs
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for two residents who used electronic lift chairs in their rooms. On observation, one resident was seated in an electronic lift chair with the footrest elevated and the remote draped over the armrest within reach, but he stated he did not know what the remote was for or how to use it. Another resident was observed in the same condition, with the chair remote within reach, and she also denied knowing how to use the remote or what it was for. Additional observations showed the second resident repeatedly seated in the chair with the footrest elevated and the remote left accessible. Review of the first resident’s EMR showed diagnoses of Alzheimer’s disease, dementia, and anxiety, along with a history of falls and fractures, including a right arm and hip fracture before admission and a left hip fracture repaired surgically on 12/31/25. His BIMS score was 4, indicating severely impaired cognition. His care plan noted severely impaired cognition, substantial to maximum assistance for transfers, and fall risk related to impaired cognition and mobility. A care plan intervention initiated on 2/23/26 directed staff to encourage him not to elevate the footrest while in the electronic lift chair, and staff were educated about that intervention. Review of the second resident’s EMR showed diagnoses of anxiety and rheumatoid arthritis, with a prior right hip fracture before admission. Her BIMS score was 4, indicating severely impaired cognition. Her care plan identified an ADL self-care performance deficit related to impaired balance, limited mobility, and musculoskeletal impairment from the hip fracture, and she required partial to moderate assistance for stand-pivot transfers and a sit-to-stand mechanical lift for toileting. Interviews with staff showed that the contracted CNA used the resident care plans in PCC to guide care, the administrator stated residents were not assessed for safety concerns when using a recliner, and the DON stated staff knew which residents could use the electronic lift chair remote and that the remote should be left in the side pocket if the resident did not know how to use it.
Lorazepam blister pack labels did not match physician orders
Penalty
Summary
Medication labeling and administration instructions for lorazepam were not consistent with the physician’s orders for one resident who was receiving hospice services. During observation, a CNA/medication aide administered 0.5 mg lorazepam from a blister pack while comparing the resident’s EMR order to the pharmacy label and noted that the two sources had different directions for frequency of administration. The EMR showed lorazepam 0.5 mg ordered as 1 tablet by mouth four times daily for anxiety disorder, while the blister pack label instructed 1 tablet by mouth two times daily. The CNA/medication aide stated, “That is weird,” and gave the resident one tablet. The resident had been admitted to the facility and had a history of lorazepam orders that changed over time: initially twice daily, then three times daily, and later four times daily. RN Q stated that when a controlled medication order changed, two nurses were expected to destroy the tablets in the blister pack and order a new card with the updated instructions. DON B later observed that the resident had three lorazepam blister packs, all still labeled for twice-daily administration, and stated that she expected staff to place stickers on the label when the instructions changed. The facility’s medication administration policy stated that staff should check for discrepancies between the card, label, and MAR and hold the medication until the medication pass is completed and the physician’s order is verified.
Unsafe Handling of Ready-to-Eat Foods During Meal Service
Penalty
Summary
The provider failed to ensure that staff followed standard safe food service practices when handling ready-to-eat foods during lunch service. During observation in the kitchen, a dietary aide dished lettuce salad onto plates using a serving spoon with his right hand, but also used his bare left hand to touch the salad so it would stay on the plate. He also placed plastic cups of salad dressing directly on top of the food on the plates instead of on the side, and he delivered resident meals back and forth between the kitchen and dining room at least five times without performing hand hygiene or putting on gloves. During interview, the dietary aide confirmed that he touched the lettuce salad with his bare hands and did not perform hand hygiene or put on gloves before doing so. The certified dietary manager stated he expected staff not to touch ready-to-eat foods with bare hands, to use serving utensils or perform hand hygiene and wear gloves when touching ready-to-eat foods, and to perform hand hygiene each time they entered and exited the kitchen. The provider's policies also stated that foods are to be prepared and served with clean utensils or gloves to minimize handling and avoid manual contact, and that employees will wear gloves when handling ready-to-eat foods such as salad items, produce, sandwiches, cooked foods, deli meats, cheeses, breads, and ice.
Failure to Provide Correct Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), CMS-10055, was provided for two residents when their Medicare Part A skilled coverage ended. For one resident, the electronic medical record showed a Medicare Part A skilled services episode start date of 5/6/26 and a last covered day of 7/23/26, but the facility used the CMS-R-131 form instead of the correct SNF ABN; the form was not signed by the resident or representative, and the record only showed a phone consent on 7/20/26. For the other resident, the record showed a Medicare Part A skilled services episode start date of 12/16/25 and a last covered day of 1/7/26, but the facility again used the CMS-R-131 form rather than the CMS-10055; although the CMS-R-131 was signed by the resident, there was no documentation that the correct SNF ABN was explained, issued, or given to the resident or representative. During interview on 07/28/2026 at 9:50 a.m., the Administrator confirmed the CMS-R-131 form was used instead of the CMS-10055 form and acknowledged there was no signed CMS-10055 for either resident.
Incomplete Arbitration Agreement Form
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement form provided to residents or their representatives contained required information for one sampled resident. The business manager stated she was assigned to develop and implement the facility’s binding arbitration agreement policy in January 2026, and the policy was approved in March 2026. Resident 25’s representative signed the arbitration agreement form on 4/22/26, but the form did not include that the resident or representative had the right to rescind the agreement within 30 calendar days of signing or that signing was not required as a condition of admission or continued care. During a phone interview, Resident 25’s legal representative stated she understood the agreement as a way to try to resolve disagreements or grievances with the provider rather than taking concerns to the state survey agency, but she could not remember whether she was told she was exempt from litigation by signing it. The administrator acknowledged that the facility’s arbitration form did not include some of the required information, explaining that the policy contained the information but the form given to residents or representatives did not. Review of the admission packet showed a blank Arbitration Agreement form was included, but the policy containing the required information was not included in the packet.
Failure to Update Care Plans After Multiple Resident Falls
Penalty
Summary
The facility failed to ensure that care plans for two residents with a history of repeated falls were reviewed and revised to reflect their current needs after each fall. For one resident with intact cognition and diagnoses including repeated falls, heart failure, and chronic kidney disease, the care plan was last updated in July 2024, despite multiple subsequent falls documented in the medical record and nursing progress notes. No new interventions were added to address these incidents. Similarly, another resident with moderately impaired cognition, repeated falls, weakness, and gait abnormalities had a care plan last revised in early March 2025, with no updates or new interventions following several additional falls. Interviews with staff revealed that the responsibility for updating care plans was unclear, with updates typically handled by the DON, RN, or designated LPNs, and not by charge nurses. The administrator confirmed that care plans were expected to be updated after falls but was unaware that this had not occurred for the two residents in question. Policy reviews showed that while the facility's policies required care plans to be updated with new interventions after changes or falls, they did not specify who was responsible or the frequency of updates. This lack of clarity contributed to the failure to update care plans after significant events.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines and expectations for quality in nursing services. No additional details regarding specific residents, staff actions, or particular incidents are provided in the report excerpt.
Failure to Use Gait Belt During Resident Transfers
Penalty
Summary
Staff failed to ensure the safety of a resident with a history of repeated falls, weakness, and impaired mobility by not using a gait belt during multiple observed transfers between a recliner and a wheelchair. On several occasions, various staff members, including CNAs, a CMA, an RN, and the administrator, assisted the resident in transferring without the use of a gait belt, despite the resident's care plan indicating a high risk for falls and the need for partial to moderate assistance with transfers. The resident was observed being transferred by staff members who used their hands to lift him by the arms, rather than utilizing a gait belt as a safety measure. Interviews with staff revealed inconsistent knowledge and application of gait belt use, with some staff acknowledging that a gait belt should be used for this resident and others uncertain about the care plan requirements. The administrator confirmed that gait belt usage had been an ongoing issue and that staff had been instructed to use them during transfers. Review of the facility's Gait Belt Safety policy indicated that therapy staff were required to use gait belts for all transfers, but the policy did not address requirements for non-therapy staff, contributing to the lack of consistent implementation.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 7.3%. Certified medication aide (CMA) K was observed making three medication administration errors out of forty-one opportunities. These errors included not verifying a resident's physician order with the medication prescription label before administering artificial tears, failing to document the administration of a PRN (as needed) eyedrop medication, and preparing medications intended for one resident to administer to another resident. During the medication pass, CMA K did not check the prescription labels to ensure the medications were for the correct resident and was unable to describe the 'rights' of medication administration when questioned. Further interviews with nursing staff and the administrator confirmed that facility policy requires staff to compare the medication administration record (MAR) with the medication prescription label before administering medications. Staff are also expected to document all administered medications immediately in the electronic MAR (eMAR) and to contact the pharmacy or physician if discrepancies are found. The facility's policy also outlines the need to verify resident identity and ensure medications are only administered to the resident for whom they are prescribed. The observed deficiencies occurred despite the facility's written policies and procedures, which specify safe and accurate medication administration practices, including the verification of the six 'rights' of medication administration. The errors made by CMA K were directly observed by surveyors and confirmed through interviews and record reviews, demonstrating a failure to follow established protocols for medication safety and documentation.
Failure to Monitor Food Temperatures and Improper Storage of Opened Applesauce
Penalty
Summary
The facility failed to consistently monitor and document food temperatures for 29 out of 153 meals served over a specified period, as required by their own policy and food safety standards. Observations and interviews revealed that while staff were expected to check and record food temperatures for each meal, there were multiple instances where this was not done, and the dietary manager acknowledged missing entries with no way to verify if food was served at safe temperatures. The facility's policy required daily temperature checks and documentation for each meal, but review of logs confirmed these procedures were not always followed. Additionally, the facility did not properly store opened applesauce used for medication administration. Opened cups of applesauce were left unrefrigerated on medication carts and used for extended periods, with staff unaware that opened applesauce is considered a potentially hazardous food and should be kept at or below 40 degrees Fahrenheit. Three residents received applesauce that had been opened and left at room temperature for over 21 hours. The administrator was unaware of the need to refrigerate opened applesauce, and the facility's storage policy did not address proper storage of potentially hazardous foods.
Infection Control Failures in Personal Care, Equipment Cleaning, and Staff Practices
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices within the facility. Personal care products such as antifungal powder, barrier cream, lotions, and wet wipes were found in a shared resident bathroom without labels to indicate ownership, and incontinence briefs were stored uncovered near the toilet, increasing the risk of contamination. Staff interviews confirmed that personal care products were not consistently labeled and that shared items, such as wipes, were not always used for a single resident. Additionally, expired products and unlabeled items were found in the soiled utility room, storage room, and salon, with some care equipment stored under sinks, exposing them to potential contamination from plumbing leaks. Staff were observed failing to perform proper hand hygiene and glove use during resident care and medication administration. Certified nursing assistants, medication aides, and nurses did not consistently wash hands before donning gloves, between glove changes, or after removing gloves, despite facility policy requiring these actions. Staff were also seen administering medications, including eye drops and insulin, without performing hand hygiene at required times, and sometimes touched residents' eyes with medication applicators, contrary to policy. Contact precautions were not consistently followed for residents with infections, as staff failed to don appropriate personal protective equipment or perform hand hygiene as required by the facility's protocols. Mechanical lifts and slings used for resident transfers were not cleaned and sanitized between uses, despite being used for multiple residents. Staff interviews revealed a lack of awareness or adherence to cleaning protocols for this equipment. In the salon, used makeup and hair styling tools were not labeled for individual resident use, and the salon chair and equipment were found to be in unsanitary condition, with visible dirt, rust, and residue. The infection preventionist acknowledged the risks associated with improper storage and expired supplies, and staff interviews confirmed gaps in knowledge and practice regarding infection control policies.
Failure to Obtain Signed Bed-Hold Notice After Hospital Transfer
Penalty
Summary
The facility failed to provide documentation of a signed bed-hold notice from a resident or their responsible party following a hospital transfer. Record review showed that the resident was transferred to the hospital, and while the responsible party was notified of the transfer and a note indicated that the bed-hold policy was sent, there was no documentation of a signed bed-hold notice. Interviews with facility staff revealed that the bed-hold policy was reviewed with residents and responsible parties upon admission, and a bed-hold notice was sent with the resident to the hospital. Additionally, a reminder of the bed-hold policy was mailed to the responsible party. However, the administrator was unaware that a reply or signed acknowledgment from the resident or responsible party was required, and stated that such replies had never been received. The facility's bed-hold policy required that residents and/or responsible parties receive written notice of the bed-hold policy on admission and be informed in writing at the time of hospitalization. Despite these procedures, there was no evidence that the resident or responsible party signed or acknowledged the bed-hold notice after the hospital transfer. The social services designee confirmed reviewing the policy on admission but was unaware of the mailed bed-hold notice for this specific resident. The lack of a signed bed-hold notice constitutes a failure to meet the facility's own policy and regulatory requirements regarding notification and documentation related to bed-hold during hospitalization.
Medication Administration Error Due to Failure to Verify Resident and Medications
Penalty
Summary
A certified medication aide (CMA) was observed preparing medications for a resident but failed to verify the prescription labels on the medication cards before administration. The CMA selected two medication cards from the cart without confirming they belonged to the correct resident. Upon intervention by surveyors, it was discovered that the medication cards were actually for a different resident. The CMA admitted that he would have administered the medications to the wrong resident if not stopped and was unable to describe the rights of medication administration when questioned. He also noted that the arrangement of medication cards in the cart may have been changed by night shift staff. Review of the resident's electronic medical record showed that the medications on the cards—levothyroxine sodium and propranolol—were not prescribed for the intended resident. The resident was only prescribed levothyroxine at a different dose and was not on any beta-blockers or similar cardiovascular medications. The facility's medication administration policy required staff to verify the right resident, drug, dose, dosage form, time, and route before administration, which was not followed in this instance.
Insulin Pens Administered Without Required Pharmacy Labels
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a licensed practical nurse (LPN) administered insulin to a resident using a Novolog insulin pen that did not have a pharmacy prescription label affixed to it. The insulin pen was stored in a plastic tube labeled with the resident's name in handwriting, but the pen itself lacked any identifying information, such as the resident's name, medication name, dosage, or instructions for use. Additional insulin pens for the same resident were found in a pharmacy-labeled bag, but none of the individual pens had prescription labels. Both nurses stated they identified the pen as belonging to the resident based on its storage location, not by any label on the pen itself. The RN acknowledged that the pen had been used consistently without a pharmacy label and that the pharmacy typically provided labeled pens. Review of the resident's electronic medical record confirmed that the resident was prescribed scheduled and as-needed doses of Novolog insulin. The facility's policy required that all medications be labeled in accordance with state and federal laws, with labels permanently affixed to the medication container and containing specific identifying and instructional information. The administrator confirmed that the pharmacy supplied the insulin pens and that the pens should have had complete prescription labels. The policy also stated that improperly labeled medications should be rejected and returned to the pharmacy.
Failure to Prevent Resident Elopement
Penalty
Summary
Based on a facility-reported incident review, observation, interview, record review, facility elopement investigation review, and facility policy review, past noncompliance was confirmed for an incident occurring on 5/3/24. The deficiency involved a failure to ensure that the nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. Specifically, the incident involved an elopement, where a resident managed to leave the facility unsupervised. The review revealed that care planning to minimize the risk of elopement was not adequately implemented at the time of the incident. Additionally, staff responses to door alarms and their understanding of how to recognize and minimize the risk for elopement were found to be insufficient. The exit door alarms were not consistently functional or monitored, and the facility's elopement policy lacked a clear definition of elopement at the time of the incident.
Accident Hazard Due to Unsafe Hot Beverage Temperatures
Penalty
Summary
The deficiency involved the presence of accident hazards related to hot beverage temperatures in the facility. The facility failed to ensure that hot beverages were served at safe temperatures, which posed a risk of burns to residents. This issue was identified during a review of the facility's practices and procedures concerning the serving of hot beverages during assisted dining. The deficiency was noted due to the lack of adequate supervision and monitoring of hot beverage temperatures, which could potentially lead to accidents or injuries among residents.
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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 White Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Platte Care Center | 24.3 mi | ★★★★★ | 1 | 0 |
| Good Samaritan Society Corsica | 25.6 mi | — | 0 | 0 |
| Weskota Manor Inc | 25.7 mi | ★★★★★ | 3 | 0 |
| Sanford Chamberlain Care Center | 31.1 mi | ★★★★★ | 11 | 0 |
| Prairie View Healthcare Center | 31.1 mi | ★★★★★ | 1 | 0 |
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