Westfield Quality Care of Aurora

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H)Based on observations, record review, and interview the facility failed to ensure a thorough investigation for 3 of 3 resident to resident abuse incidents affecting Residents 3, 4, 6, 1, and 2; and failed to develop interventions to protect other residents from further adverse behaviors for 2 residents (Residents 6 and 1). The facility census was 54.

Inspectors wroteLicensure Reference Number 175NAC 12-006.04(H)(ii)(2) Based on observation, record review, and interview the facility failed to ensure that it employed a Certified Dietary Manager (CDM) (a CDM has completed education to be a nationally recognized expert in managing dietary operations and ensuring food safety) to oversee the facility food service. This affected all facility residents. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(D) Based on observation, record review, and interview; the facility failed to ensure that foods were held at the required temperatures during meal service to ensure meals were palatable and at an appetizing temperature; and the facility failed to ensure that pureed foods (a cooked food item that has been ground with a blender into a smooth, soft, pudding-like consistency for residents with difficulty chewing or swallowing) were prepared to maintain nutritive value for 1 of 1 residents (Resident 43). The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure that dietary staff performed hand washing to prevent the potential for cross contamination and food borne illness during food preparation and food service; the facility failed to maintain held foods within the required safe temperature range during meal service to prevent the potential for foodborne illness; the facility failed to perform daily testing of sanitizer chemical concentration to ensure sanitizer was at the required levels for use; and the facility failed to maintain dietary equipment and areas free of soiling and debris. This had the potential to affect all residents who resided within the facility. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.19(C) Based on observations, interviews, and record review, the facility failed to properly handle clean and soiled linens throughout the building, this had the potential to affect all facility residents. The facility failed to [NAME] resident care equipment in a manner to prevent transfer of microorganisms for 2 of 3 sampled residents, Resident 7 and Resident 30, and failed to clean and disinfect glucometers between resident use for 2 of 3 sampled residents, Resident #0 and Resident #34. The facility census was 50.

Inspectors wroteLicensure Reference Number 175NAC 1-009.01(B) Licensure Reference Number 175NAC 12-006.19 Based on observation, record review, and interview; the facility failed to ensure resident rooms were kept free of soiling and debris for 19 of 24 residents (Residents 38, 3, 2, 12, 47, 37, 28, 22,16, 23, 35, 43, 44, 21, 15, 34, 49, 26, and 29); and the facility failed to maintain facility toilet seats in a cleanable condition for 3 of 24 residents (Residents 47, 34, and 49). The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10(D) Based on observation, record review, and interview; the facility failed to have a medication error rate of 5% or less. This affected 4 (Resident 9, 45, 48, and 49) of 7 sampled residents. The facility census was 50.

Inspectors wroteLicensure Reference Number 175NAC 12-006.11(A)(i) Based on observation, record review, and interview; the facility failed to ensure that facility menus were followed to provide the required food portions to meet resident nutritional needs for 14 of 15 residents observed (Residents 49, 44, 32,16, 40, 19, 1, 22, 47, 8, 15, 39, 13, and 6). The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(S) Based on observation, record review, and interview; the facility failed to promote or maintain dignity for 1 (Resident 37) of 2 sampled residents. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.05(D) Based on record review and interview, the facility failed to inform and or educate the resident and or their representative in advance of the risks or possible side effects of the use of psychotropic medication for 2 (Resident 35 and Resident 49) of 2 sampled residents. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(E) Based on observation, record review, and interview; the facility failed to ensure an insulin pen was labeled for 1 (Resident 34) of 4 sampled residents. The facility census was 50.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.01(g)(h) Based on interviews and record reviews, the facility failed to notify the Department in writing within 5 working days of vacancy and filling of the Administrator position. This had the potential to affect all facility residents. The facility census was 50. Findings Are: The Facility Administrator (FA) was interviewed on 04/07/2025 at 2:45 PM. The interview with the FA revealed that the Business Office Manager (BOM) was the provisional administrator prior to their tenure which began on 02/14/2025. The BOM was interviewed on 04/07/2025 at 2:49 PM revealing that they were the Provisional Administrator prior to the current Administrator and their term ended on 02/14/2025. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review, observations, and interviews, the facility failed to complete control testing on the facility glucometers (a machine that is used to monitor blood sugar levels) each night in order to maintain accurate blood sugar readings for the administration of sliding scale insulins and to ensure the accuracy of all blood sugars being monitored in the facility. This affected 6 residents who received Sliding Scale Insulin. (Residents 8, 9, 17, 30, 31, and 34). The facility failed to ensure that thorough skin checks were implemented for 1 Resident (Resident 30), of 4 sampled Residents. The facility census was 53.

Inspectors wroteLicensure Reference Number 175NAC 12-006.05(19) Based on observation, record review, and interview; the facility failed to ensure residents could access their personal resident trust funds on weekends. This affected 46 of 53 residents. With the facility stated census of 53.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.07C Based on record review and staff interviews; the facility Quality Assessment Performance Improvement plan (QAPI) failed to identify ongoing issues relevant to F567, F645, F684, F865 and F880 and Emergency Preparedness (EP) regulation relevant to E-0004, E-0006, E0015, E0024, E0036. This deficient practice had the potential to affect all residents who reside in the facility. The facility staff identified a census of 92.

Inspectors wroteLicensure Reference Number 175NAC 12-006.17D Based on observation, record review, and interview the facility failed to develop and implement a water Legionella management program in the facility. This had the potential to affect all residents residing in the facility, and failed to perform indwelling catheter (tube placed into the bladder to drain urine)care in a manner that reduced the risk of infection for 2 residents, (Resident #27 and Resident #21), of 4 sampled residents. The facility stated census was 53.

Inspectors wroteThe facility failed to ensure a Preadmission Screening and Resident Review (PASARR), (a screening program mandated by the federal Centers for Medicare and Medicaid Services (CMS) to ensure that nursing home applicants and residents with mental illness and intellectual/developmental disabilities are appropriately placed and receive necessary services to meet their needs) was completed prior to admission to the facility and reflected the residents mental illness for 1 resident, (Resident 34), of 4 sampled residents. The facility census was 53.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11C LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observation, interview and record review, the facility failed to A) ensure food was dated upon opening, B) failed to ensure dishwasher temperatures were maintained to ensure the sanitization of utensils to prevent the potential for food borne illness for 55 of 55 residents receiving food from the kitchen and C) failed to serve food and fluids in a manner to prevent cross contamination. This practice had the potential to affect all residents. The facility census was 55. Findings Are: A. Observation of the kitchen on 04/05/23 at 08:30 AM revealed 1 stack of 3 boxes and another stack of 2 boxes on the floor. In the freezer, observation revealed; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents, families and/or representatives of confirmed Covid-19 cases within the facility. This had the potential to affect all residents. The facility census was 55. Findings Are: An interview on 04/05/23 at 12:58 PM revealed Resident 52's representative had not been notified of the facility's Covid-19 status since admission on [DATE]. An interview on 4/6/23 at 11:30 AM with the facility Administrator revealed that only the families/representatives of Covid-19 positive residents were updated of the facility's Covid-19 status. An interview with Resident 47's spouse, on 4/5/23 at 11:00 AM confirmed the resident's spouse had not been notified of any of the COVID 19 outbreaks. A review of the facility's undated testing logs and of positive residents and staff revealed positive staff and residents on the following dates: [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.4C3a(6) Based on interview and record review, the facility failed to notify the physician and Resident 52's representative of a significant weight loss for Resident 52. This affected 1 of 1 residents sampled (Resident 52). The facility identified a census of 55. Findings Are: A record review of the weights documented from 1/1/23 through 4/4/23 for Resident 52 revealed the following weights: -4/4/2023 1:55PM, 144.0 Lbs (pounds); [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to report abuse to the state agency within 2 hours of the allegation for 1 (Resident 46) of 5 sampled residents. The facility identified a census of 55 at the time of survey.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09B Based on record review and interview, the facility failed to ensure the MDS ((Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) reflected the current status of the resident at the time the assessment was completed related to a Serious Mental Illness diagnosis for Resident 34 and the MDS not being coded for PASRR Level II for Resident 26. This affected 2 of 2 residents sampled (Resident 34 and 26). The facility identified a census of 55. Findings Are: A. A record review of the admission diagnosis list for Resident 34, revealed the following diagnoses: -Schizoaffective Disorder, Unspecified dated 11/9/22; -Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms dated 12/9/22; -Delirium due to known Physiological condition dated 12/9/22; -Anxiety Disorder, Unspecified dated 11/9/22. [...]