La Bella of Aurora

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve the correct protein entrees as planned per the facility approved menu. This applies to all 50 residents receiving regular, mechanical soft, low concentrated sweets, and no added salt diets in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to offer residents a variety of appealing meal substitutions based on resident preferences per facility policy. This applies to all 57 residents receiving oral diets at the facility.

Inspectors wroteBased on interview and record review, the facility failed to prevent diversion of resident's money by a staff member. This applies to 1 of 3 residents (R3) reviewed for misappropriation of funds in the sample of 11. This failure resulted in psychosocial harm when R3 stated she feels terrible and bothered when the staff member took her hard-earned money without her consent.

Inspectors wroteBased on interview and record review, the facility failed to ensure dressing changes were done as ordered (R1), and failed to ensure weekly wound assessments and documentation of the assessments were completed, for 2 of 5 residents (R1, R4) reviewed for non-pressure wound care in the sample of 6. This failure resulted in R1's wound getting a maggot infestation, and the wound dehiscing and getting infected. R1 was sent out to a local emergency room, diagnosed with osteomyelitis, requiring two intravenous (IV) antibiotics to prevent sepsis, surgical intervention, and critical care hospital admission. This failure resulted in an Immediate Jeopardy. The Immediate jeopardy began on 7/3/2025 when the facility failed to do the dressing change as ordered and failed to assess R1's surgical site and document an assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to document a resident's discharge correctly for 1 of 3 residents (R2) reviewed for discharge. This failure resulted in R2 losing his Medicare coverage from [DATE]-[DATE], having to cancel important diagnostic testing and a follow-up appointment with his neurosurgeon, not having CPAP (continuous positive airway pressure) supplies due to lack of medical coverage, and having to spend many hours and days trying to get his Medicare coverage reinstated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform a pressure risk screen for a resident (R6) at risk for developing pressure ulcers, failed to ensure pressure-reducing interventions were implemented correctly for one resident (R6), and failed to perform weekly facility wound assessments for one resident (R5). These failures affected two of three residents (R5, R6) reviewed for pressure ulcers in the sample size of 6.

Inspectors wroteBased on record review and interview the facility failed to perform CPR (Cardio-Pulmonary Resuscitation) correctly as per standards of practice, failed to call a code blue within the facility, and failed to call EMS system (911) for an unresponsive resident identified as a full code on the physician's orders in accordance with the Facility policy. This failure resulted in Immediate Jeopardy. The Immediate Jeopardy began on [DATE], at 5:25 AM, when R55, who had full code orders, expired in the facility after being found unresponsive and staff did not perform CPR as per the Standards of Practice and did not follow their policy for Medical Emergencies. V1 (Administrator) and V24 (Regional Director of Operations) were informed of the Immediate Jeopardy on [DATE], at 4:17 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that an RN (Registered Nurse) was assigned to serve as a full time DON (Director of Nursing) to coordinate nursing care and supervision, to provide quality care to residents. This applies to all the 52 residents that reside at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow sanitary practices in the facility kitchen. This applies to all 52 residents that received foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide hand hygiene during medication administration, failed to use PPE (Personal Protective Equipment) while providing direct care for a resident on EBP (Enhanced Barrier Precautions) and failed to do complete infection control surveillance monitoring for the facility. This applies to all 52 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility had incomplete documentation on the Antibiotic Surveillance log and failed to evaluate the presence of infection utilizing the standardized criteria to define infections, in accordance with facility policy. This applies to all 52 residents who reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure that the facility's IP (Infection Preventionist) had completed specialized training in infection prevention and control. This applies to all 52 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents have a comprehensive care plan, that identifies their individual needs and includes all aspects of their care including assistance needed with ADLs (Activities of Daily Living), urinary catheter care, oxygen administration, and wound care. This applies to 4 of 4 residents (R19, R51, R53 and R158) reviewed for care plans in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that narcotic medication was stored in a sealed packaging. This applies to 4 of 4 residents (R2, R28, R37, R47) reviewed for controlled medications in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label medication for the date it was opened to determine expiration date. This applies to 4 of 5 residents (R2, R8, R37, R49) reviewed for labeling and storage in the sample of 20. The findings Include: On April 15, 2025, at 5:29 PM, the unit 2 medication cart was inspected with V7 (Nurse), and the following were observed: 1. R2's Incruse Ellipta was opened and not dated. The manufacturer's recommendation shows to safely throw away Incruse Ellipta in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label of the inhaler. 2. R37's Insulin Lispro was opened and not dated. The pharmacy list for expiration date shows that this medication expires 28 days after first use or removal from refrigerator. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents signed POLST (Practitioner Order for Life-Sustaining Treatment) form and the physician's order are consistent, to reflect the resident's treatment wishes in an event of a medical emergency. This applies to 3 of 3 residents (R15, R32, and R51) reviewed for advanced directives in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure grooming for residents who require assistance for ADLs (Activities of Daily Living). This applies to 3 out of 3 residents (R13, R21, and R51) reviewed for ADL care in the sample of 20.

Inspectors wroteBased on record review and interview the facility failed to further assess a resident for changes in breathing and notify resident's physician. This applies to 1 of 3 residents (R55) discharged records reviewed in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's indwelling urinary catheter was secured. This applies to 1 out of 2 residents (R51) reviewed for catheter care in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide double portions of protein to a resident with weight loss. This applies to 1 out of 3 residents (R41) reviewed for nutrition in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the insertion site of a resident's midline catheter is visible under a transparent dressing for assessment and failed to ensure that the central IV dressing was clean and intact. This applies to 1 of 2 residents (R158) reviewed for intravenous (IV) catheter in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the physician's order for oxygen administration was followed. The facility also failed to ensure that the oxygen tubing and nebulization tubing were changed and labeled per facility policy. This applies to 2 of 2 residents (R2 and R53) reviewed for oxygen therapy in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to address resident pharmacy medication regime review (MRR) recommendations. This applies to 2 of 5 residents (R31 and R28) reviewed for unnecessary medications in the sample 20.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide modified diet consistency for residents on thickened consistency liquids. This applies to 2 of 2 residents (R28, R24) reviewed for thickened liquids in the sample of 20.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that the resident refrigerators in the room are maintained in safe and sanitary manner. This applies to 2 of 2 residents (R36, R43) reviewed for personal food storage in the sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow food storage and thawing procedures and ensure that food service areas are maintained in a clean and sanitary manner. This apples to 44 residents that receive oral diets prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide treatment and services to increase range of motion and prevent a further decrease in range of motion. The facility failed to provide Splints or supportive equipment to maintain or improve mobility. This applies to 2 of 4 residents (R26 and R43) reviewed for range of motion in the sample of 14.

Inspectors wroteBased on interviews and record review, the facility failed to have fall interventions in place for a resident that is at high risk for falls. This applies to 1 of 2 residents (R41) reviewed for falls in the sample of 14.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a physician's order was obtained for the administration of oxygen. The facility failed to ensure that there was water in the humidifier bottle and the oxygen nasal cannula tubing and humidifier bottle were labeled. The facility also failed to ensure that the nebulization mask was covered when not in use to prevent contamination. This applies to 1 of 2 residents (R14) reviewed for oxygen use and respiratory care in the sample of 14.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that blister packs containing controlled medications are maintained intact to ensure safe and effective use of the medications. This applies to 2 of 3 residents (R4, R44) reviewed for controlled medications in the sample of 14.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received monthly medication regimen review (MRR) by a licensed pharmacist. This applies to 1 of 1 resident (R15) reviewed for medication regimen review in the sample of 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and ensure a resident on a gastrostomy tube feeding was receiving the total amount ordered. This failure resulted in a 10.44 percent weight loss in three months. This applies to 1 of 2 residents (R36) reviewed for gastrostomy tube feedings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the diet spreadsheet and standardized recipes to serve the portions as shown for pureed diets. This applies to 8 of 8 residents (R8, R11, R12, R13, R14, R33, R37, R207) observed for meal service in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to conduct an interdisciplinary team care plan meeting that included residents and/or their representative. This applies to 3 residents R7, R34 and R36 in a sample size of 19. 1. On April 26, 2023, at 2:53 pm R7 stated he has never attended a care plan meeting and he has never been invited to attend. On April 26, 2023, at 1:50 pm V28 Social Worker stated that since she has been at the facility only herself and V3 MDS Coordinator (Minimum Data Set Coordinator) have conducted care plan meetings. The sign in sheet is how the facility documents the care plan meeting has occurred. She had not attended a care plan meeting for R7. Care plan meetings should occur on admission, quarterly, after a major change in condition or if the resident or their POA (Power of Attorney) make a request. R7's EHR (Electronic Health Record) was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care and a bed bath to promote cleanliness and prevent infection. This applies to 2 of 2 residents (R28 and R33) reviewed for ADLs (Activities of Daily Living) in a sample of 19.

Inspectors wroteBased on observation, interview and record review the facility failed to communicate pertinent clinical information with the dialysis provider, failed to document a post dialysis assessment, failed to ensure necessary precautions to protect the access site, and failed to document adherence with fluid restriction for 1 of 1 resident (R49) reviewed for dialysis in a sample of 19.