Aurora Health and Rehabilitation

Inspectors wroteBased on record review, staff interview and facility policy review, the facility failed to ensure residents were treated with respect and dignity when a staff member spoke rudely and in a disrespectful manner to one (1) of three (3) residents reviewed.

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to ensure a resident was provided education and sufficient information regarding advance directives and the implications of assigning a Power of Attorney (POA) prior to obtaining the resident's agreement for one (1) of three (3) residents reviewed for advanced directives. Resident #1Findings Included:Record review of the facility policy titled, OBRA (Omnibus Budget Reconciliation Act) Resident Self-determination Checklist revealed, Policy. Every resident has the right to give informed consent before diagnosis or treatment. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to ensure medications were stored in a safe and secure manner by leaving one (1) of eight (8) medication carts unlocked and unattended.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to maintain food service areas in a sanitary manner to prevent the potential for food contamination. Specifically, the facility failed to ensure ventilation ductwork was free from a black mold-like substance in areas located above food preparation and food storage locations on two (2) of (2) kitchen tours.

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident's wheelchair was maintained in a safe manner for one (1) of 68 residents requiring a standard wheelchair for locomotion. Resident #12 Findings Include:Review of the facility policy titled Preventative Maintenance for Wheelchairs undated, revealed under, Policy: It is the practice of this facility to develop and implement a preventative maintenance program to ensure wheelchairs are maintained in a safe and operable manner. Also revealed under, Policy Explanation and Compliance Guidelines: . 4. Preventative maintenance should be performed weekly or as indicated: . e. Check seats, backs, arm rest and cushions for tears, cracks or missing screws-replace or repair if present. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review and facility policy review the facility failed to implement a comprehensive care plan related to applying a hand splint (Resident #61) and nail care (Resident #66, and #89) for three (3) of twenty four care plans reviewed.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide personal hygiene for two (2) of the twenty-one sampled residents. Resident #66 and Resident #89.

Inspectors wroteBased on observation, family and staff interview, record review, and facility policy review, the facility failed to ensure prescribed splinting devices were applied as ordered for one (1) of (35) residents reviewed for range of motion impairments. Resident #61Findings Include:Record review of the facility policy titled Restorative Nursing Standard with a revision date of 3/19 revealed under, 4. Splints . Its purpose is to prevent deformities when an increase of tone is noted in hand and occasionally with a flaccid hand .On 1/20/26 at 10:40 AM, an observation of Resident #61 revealed she was lying in bed, nonverbal, with her eyes open. A hand/wrist splint was lying on the bedside dresser. She had contractures to both hands, with the left worse than the right. A soft hand roll was inside the left hand. [...]

Inspectors wroteDuring observation, staff interviews, and facility policy/document review, the facility failed to ensure medications were secured properly to prevent unauthorized access for one (1) of three (3) days of survey.

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to ensure medications were accurately labeled and corresponded with the physician's order for two (2) of three (3) residents observed during medication pass. (Resident #5 and #20). Findings Include: Review of the pharmacy's policy titled Long Term Care Facilities/Pharmacy Operations/Medication Packaging: Strip Packaging with review date 04/2023, revealed: Strip packaging is provided for efficient and accurate medication administration and accountability of routine oral solid medications .Remember to always check your MAR prior to administering medications. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide a safe, hazard-free environment for a resident when a portable heater was used in the resident's room and caused a burn to the resident's skin for one (1) of three (3) incidents reviewed. Resident #1. Based on corrective actions implemented 5/5/25, the State Agency determined this to be Past Non-Compliance.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review the facility failed to properly code a resident for a restraint on the Minimum Data Set (MDS) for one (1) of 21 residents MDS assessments reviewed during survey. Resident #56 Findings Include. A review of the facility policy revised 04/2019 titled Resident Assessment Instrument (RAI)/CARE PLANNING MANAGEMENT revealed it is the practice of this facility to conduct a comprehensive, accurate assessment of each resident's functional capacity. A record review of Resident #56's Minimum Data Set (MDS) Quarterly assessment dated [DATE] section P revealed used a trunk restraint less than daily. An observation and interview, on 04/02/24 at 10:29 AM, of Resident #56 revealed the resident lying in bed resting. The observation revealed that the resident did not have a restraint on. [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to prevent the possibility of an infection as evidence by a suction connecting tubing not being replaced after making contact with a trash can during respiratory care for one (1) of seven (7) residents direct care observations. Resident #47 Findings Include Review of the facility policy titled, Infection Control with a revision date of 5/2023 revealed under Standard Explanation and Compliance Guidelines #11. Equipment Protocol: e. All contaminated disposable items shall be discarded in a waste receptacle lined with a RED plastic bag. An observation and interview on 4/3/24 at 8:12 AM, revealed the Respiratory Therapist (RT) performed suctioning and trachea care on Resident #47. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to make a referral for a resident with a new diagnosis of schizophrenia for a Pre-admission Screening and Resident Review (PASARR) Level II screen for one (1) of six (6) residents reviewed. Resident #46 Findings Include: Review of the facility policy titled, Resident Assessment-coordination with the PASARR program with a revision date of 10/2019 revealed under Policy Explanation and Compliance Guidelines .#6. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. [...]