Aurora on France

Inspectors wroteBased on interview and record review, the facility failed to promote and maintain dignity for 1 of 3 residents reviewed for dignity (R29) when staff directed a continent resident to roll over and have a bowel movement in his brief rather than assessing and implementing toileting interventions consistent with his needs, preferences, and dignity. The facility failed to ensure assessments, care plans, and staff practices provided clear direction regarding R29's toileting status and preferences, despite documentation identifying him as continent of bowel and bladder and his expressed distress regarding having bowel movements in bed. This had the potential to cause psychosocial harm, loss of dignity, and diminished quality of life by failing to respect the resident's autonomy, preferences, and right to receive care in a dignified manner.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a self-administration of medications (SAM) assessment was completed to allow resident to safely administer own medications for 1 of 1 (R1) resident observed with medications at bedside.

Inspectors wroteBased on interview and record review, the facility failed to offer a written notice of transfer which included a statement of the resident's appeal rights and the contact information of the Office of the State Long-Term Care Ombudsman. In addition, the facility failed to provide written information on the duration of the bed-hold, and reserve bed payment for 2 of 3 residents (R51, R69) reviewed for hospitalizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure a discharge return anticipated (DRA) Minimum Data Set (MDS) was transmitted for 1 of 3 residents (R42) and a discharge return not anticipated (DRNA) MDS was transmitted for 1 of 1 residents (R8), to the Centers for Medicare and Medicaid (CMS) reviewed for no MDS record in 120 days.

Inspectors wroteBased on interview and document review, the facility failed to ensure a level I Pre-admission Screening (PAS) and, if needed, a Level II Pre-admission Screening and Resident Review (PASARR) was completed to screen for mental health needs for 1 of 1 residents (R45) reviewed for PAS.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine/as-needed nail trimming and cleaning was completed for 1 of 1 residents (R13) reviewed for nail care who required staff assistance with their activities of daily living (ADLs).

Inspectors wroteBased on interview and document review, the facility failed to implement hospital discharge recommendations and facility standing orders for daily weight monitoring for a resident with a primary diagnosis of congestive heart failure (CHF). The facility also failed to assess and implement a low-sodium diet recommendation, failed to monitor for weight changes indicative of fluid retention, and failed to develop a care plan addressing CHF management after the resident's diuretic therapy was placed on hold pending further clinical evaluation for 1 of 1 residents (R84) reviewed for quality of care.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide pharmaceutical services that ensured medications were available to meet residents' needs for 2 of 5 residents reviewed for medication administration (R29 and R57). This deficient practice resulted in multiple prescribed medications being unavailable for administration and created the potential for residents to miss ordered medications or receive doses that differed from the physician's prescribed regimen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was properly stored in refrigeration units. In addition the facility failed to ensure dishes were properly air dried prior to stacking for storage. These deficient practices had the potential to impact all residents who consumed facility prepared food.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff adhered to infection control standards including the use of personal protective equipment (PPE) in enhanced barrier precaution (EBP) and contact precaution rooms, as well as failing to properly perform hand washing and gloving for 3 of 3 residents (R208, R23, R259) reviewed for infection prevention and control.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure care was provided to preserve dignity for 2 of 2 residents (R20, R307) who were reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement new orders for 1 of 1 resident (R26) with fluid retention and failed to recognize hypertensive blood pressure readings and follow provider orders for as-needed (PRN) blood pressure medication for 1 of 1 resident (R307) reviewed with hypertension. Findings Include: R26: R26's admission MDS (Minimum Data Assessment) dated 5/12/25, indicated R26 was cognitively intact and had diagnoses of cardiorespiratory (heart & lung) conditions, coronary artery disease, heart failure, hypertension, diabetes mellitus, and respiratory failure. R26's care plan dated 5/16/25, indicated diuretic therapy, congestive heart failure intervention such as assessments, monitored labs, documented weights, recorded fluid amounts, and administered cardiac medications. R26's provider orders identified the following: [...]

Inspectors wroteBased on interview and document review, the facility failed to report immediately, no later than 2 hours, to the State Agency (SA), in accordance with established policies and procedures, an allegation of staff to resident abuse for 1 of 3 residents (R5) who were reviewed for allegations of abuse.

Inspectors wroteBased on interview and document review, the facility failed to complete an investigation and ensure protection for residents following an allegation of a staff to resident abuse for 1 of 3 residents (R5) investigated for abuse.

Inspectors wroteThe facility failed to ensure dishware was cleaned and sanitized in a manner to reduce the risk of foodborne illness. This had potential to affect all 42 residents.

Inspectors wroteBased on interview and document review the facility failed to ensure comprehensive care plans were developed for montioring side effects in 2 of 5 residents (R4, R147) reviewed for antipsychotic drug use.

Inspectors wroteBased on observation, interview, and document review the facility failed to develop and implement interventions to prevent pressure ulcers. The facility further failed to ensure residents with current pressure ulcers were turned and repositioned timely for 1 of 2 residents (R13) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a Foley catheter was removed according to physician orders for 1 of 1 resident (R4) who was admitted to the facility with an indwelling Foley catheter.

Inspectors wroteBased on interview, and document review, the facility failed to ensure residents that were prescribed psychotropic medications were monitored for side effects, for 2 of 5 residents (R4, R147) reviewed for unnecessary medications and the facility failed to ensure non pharmacologic interventions were in place for R4 who had psychotropic medications ordered.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) for 1 of 3 (R4) residents who had a Foley catheter reviewed for infection prevention and control.

Inspectors wroteBased on interview and document review, the facility failed to ensure 3 of 5 resident (R2, R16, R27) were offered or received pneumococcal vaccination in accordance to Center for Disease Control (CDC) recommendations.

Inspectors wroteBased on interview and document review, the facility failed to ensure the Coronavirus Disease (COVID-19) vaccination was offered and/or provided to reduce the risk of severe illness to 1 of 5 residents (R16) reviewed for immunizations.