Inspection Reports for
Northfield Retirement Communities Care
2100 Circle Drive, SCOTTSBLUFF, NE, 69361
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
107% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
68% occupied
Based on a May 2025 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 45
Deficiencies: 10
Date: May 8, 2025
Visit Reason
Routine inspection of Northfield Retirement Communities Care Center to assess compliance with state and federal regulations related to resident care, medication management, staffing, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify medical providers of elevated blood pressures, failure to attempt gradual dose reductions for psychotropic medications, failure to develop baseline care plans within required timeframes, failure to follow physician orders, inadequate treatment for contractures, insufficient RN staffing coverage, unnecessary antibiotic use, improper food storage, and inadequate staff training and ongoing education.
Deficiencies (10)
Failed to notify the medical provider of elevated blood pressures for Resident 22.
Failed to attempt gradual dose reductions or provide clinical rationale for not attempting for psychotropic medications for Residents 19 and 24.
Failed to develop a baseline care plan within 24 hours for Resident 41.
Failed to follow physician's orders for Resident 44, including missed doses of bumetanide.
Failed to provide appropriate treatment and care for contractures for Resident 1.
Failed to ensure RN coverage for at least 8 consecutive hours daily on multiple dates.
Failed to provide rational or clinical indicators for continued use of antibiotic for Resident 14.
Failed to identify and dispose of spoiled fruits and vegetables in the walk-in refrigerator.
Failed to implement effective initial training for new employees on resident rights, emergency procedures, abuse/neglect, dementia care, and medical emergency directives.
Failed to ensure nurse aides and medication aides completed required ongoing training including abuse/neglect and dementia care.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Census: 45
Dates with no RN coverage: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed confirming failures in blood pressure notification, psychotropic medication management, baseline care plan development, and contracture care |
| Nurse Practitioner | Nurse Practitioner | Confirmed antibiotic was ordered for prophylaxis for Resident 14 |
| Certified Dietary Manager | Certified Dietary Manager | Confirmed spoiled fruits and vegetables should have been discarded immediately |
| Nurse Consultant | Nurse Consultant | Confirmed RN staffing deficiencies and inadequate ongoing training for staff |
| Nursing Home Administrator | Nursing Home Administrator | Confirmed staffing challenges and lack of RN coverage on multiple dates |
| Human Resources | Human Resources | Confirmed lack of initial orientation training for new employees |
| Physical Therapist | Physical Therapist | Interviewed regarding contracture treatment attempts and refusals |
Inspection Report
Census: 51
Deficiencies: 2
Date: Jan 15, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care plan requirements and administrative notification rules, including the provision of a written summary of baseline care plans and timely notification of changes in facility administration.
Findings
The facility failed to provide a written summary of the baseline care plan to one sampled resident within 48 hours of admission and failed to notify the State Agency of a change in administrator within the required 5 working days, with notification delayed until nearly a month later.
Deficiencies (2)
Failed to provide a written summary of the baseline care plan to Resident 1 within 48 hours of admission.
Failed to notify the State Agency of a change in administrator within 5 working days as required.
Report Facts
Facility census: 51
Change in administrator date: Oct 11, 2024
Notification date: Nov 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding failure to provide written summary of baseline care plan | |
| Administrator | Interviewed regarding delayed notification of change in administrator |
Inspection Report
Routine
Census: 47
Deficiencies: 10
Date: Jun 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident notification of Medicare coverage, staff background checks, safety, pain management, medication regimen reviews, food safety, infection control, and water management.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare coverage notices to residents, incomplete background checks for employees, unsafe oxygen equipment use, inadequate pain management, lack of monthly pharmacist medication reviews, improper use of psychotropic medications, medication administration errors, failure to follow food preparation and storage protocols, and inadequate infection control and water management programs.
Deficiencies (10)
Failed to provide CMS-10055 form to 3 sampled residents regarding Medicare coverage and potential liability.
Failed to complete background checks for 5 employees and failed to provide rationale for hiring one staff member with negative findings.
Failed to ensure oxygen concentrator was turned off when not in use and nasal cannula was not left on unoccupied bed.
Failed to evaluate and implement interventions to manage pain for one resident.
Failed to ensure monthly medication regimen reviews by pharmacist and physician review of recommendations for 3 residents.
Failed to limit PRN antipsychotic medication use to 14 days and document rationale for continued use for one resident.
Medication error rate of 11.11% due to crushing medications that should not be crushed affecting 2 residents.
Failed to follow recipe and properly weigh ingredients during meal preparation affecting nutritive value.
Failed to discard expired foods, improperly stored foods, and maintain sanitary kitchen conditions.
Failed to implement Enhanced Barrier Precautions for resident with indwelling catheter and lacked a water management program to prevent Legionella growth.
Report Facts
Residents affected: 3
Facility census: 47
Employees with incomplete background checks: 5
Medication error rate: 11.11
Medications observed: 36
Medication errors: 4
PRN antipsychotic medication order start date: Sep 9, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medication Aide-A | Medication Aide | Observed administering medications incorrectly by crushing tablets |
| Director of Nursing | Director of Nursing (DON) | Confirmed multiple deficiencies including lack of pharmacist reviews and pain management issues |
| Registered Nurse-B | Registered Nurse (RN) | Provided information on pain assessment practices for Resident 39 |
| Human Resources | Human Resources (HR) | Confirmed incomplete background checks and hiring rationale issues |
| Assistant Food Supervisor | Assistant Food Supervisor (AFS) | Confirmed expired food items and improper food storage |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed lack of Enhanced Barrier Precautions and water management program |
| Plant Director | Plant Director (PD) | Confirmed lack of water management program and Legionella risk assessment |
Inspection Report
Annual Inspection
Census: 47
Deficiencies: 4
Date: May 1, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, dietary services, food safety, and infection prevention at Northfield Retirement Communities Care Center.
Findings
The facility was found deficient in multiple areas including inappropriate use of indwelling Foley catheters without clinical indication, lack of credentialing for the Dietary Manager, improper food storage and handling practices, failure of staff to wear hair restraints during food preparation, and absence of a qualified infection preventionist with required certification.
Deficiencies (4)
Failure to ensure residents were free of indwelling Foley catheters without an approved clinical diagnosis for one resident.
Dietary Manager lacked required certification or credentialing for the position.
Food was stored improperly with expired items and uncovered portions; staff failed to wear hair restraints during food preparation.
Facility failed to employ a qualified infection preventionist with required training and certification.
Report Facts
Sample size: 12
Facility census: 47
Expired food items: 9
Uncovered portion cups: 5
Unopened Yoplait yogurts: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed lack of clinical indication for indwelling catheter and responsible for Infection Control Program without required certification |
| Dietary Manager | Dietary Manager | Confirmed lack of required credentials and discussed food safety deficiencies |
| Cook-A | Observed without facial hair restraint and interviewed about dietary manager credentials | |
| Cook-E | Observed without facial hair restraint and handling food improperly | |
| Cook-F | Observed without facial hair restraint and handling food improperly | |
| Nurse Consultant | Nurse Consultant | Confirmed lack of clinical indication for indwelling catheter and infection preventionist certification |
| Facility Administrator | Administrator | Confirmed lack of clinical indication for indwelling catheter |
| Maintenance Supervisor | Maintenance Supervisor | Observed walking through kitchen without hair restraint |
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