Inspection Reports for
Ascend at Aurora

The complaint involved missing narcotic medication cards for two residents. The facility was notified on 11/23/25 but did not report the misappropriation to the State Survey Agency until 11/26/25. Interviews revealed staff confusion and improper documentation regarding destruction of medications. The missing medications were never recovered.

The facility failed to protect residents from misappropriation of property when two cards of controlled medications were missing and could not be accounted for. Additionally, the facility failed to timely report the allegations of misappropriation to the State Survey Agency within 24 hours. The missing medications were never found, and the facility corrected the noncompliance by auditing records, in-servicing staff, and reporting to authorities.

The investigation was complaint-related, focusing on residents' rights to receive showers as scheduled. Some residents substantiated complaints of receiving only one shower per week or going up to two weeks without showers. Staffing shortages and the absence of a shower aide were contributing factors.

The facility failed to honor residents' rights to self-determination by not providing showers as scheduled or preferred for three sampled residents. Staffing shortages and lack of a dedicated shower aide contributed to residents receiving fewer showers than planned, with some residents going over a week without a shower.

The facility failed to maintain a complete infection prevention and control program by not posting appropriate EBP signage and failing to ensure staff wore required personal protective equipment (PPE) and performed proper hand hygiene during perineal care for multiple residents.

The complaint investigation was initiated due to allegations that Resident #48 was subjected to mental abuse by a Certified Nurse Aide (CNA S) who made disparaging comments. The investigation confirmed the abuse and the facility was notified of an Immediate Jeopardy on 04/10/24, which was removed on 04/11/24 after corrective actions. Another complaint involved Resident #162 receiving medications without orders, causing serious adverse effects and hospitalization. Immediate Jeopardy was also cited and removed after corrective actions.

The facility failed to protect a non-verbal resident from mental abuse by a staff member who made disparaging comments, causing emotional distress. Additionally, the facility administered fentanyl and hydrocodone to another resident without physician orders, resulting in significant side effects and hospitalization.

Complaint investigation revealed mental abuse of a non-verbal resident by a staff member who made disparaging comments. Immediate Jeopardy was identified and removed after corrective actions.

The facility was found deficient in multiple areas including failure to maintain comfortable temperatures, mental abuse of a resident by staff, failure to conduct criminal background checks prior to resident contact, failure to notify residents and representatives of transfers and bed hold policies, incomplete care plans, inadequate dialysis communication, improper use and documentation of bed rails, lack of a full-time Director of Nursing, failure to address resident depression, failure to limit psychotropic PRN medication orders, significant medication errors resulting in immediate jeopardy, improper food preparation, food storage and sanitation issues, failure to update the facility assessment annually, and incomplete infection prevention and antibiotic stewardship programs.

Complaint MO00222355 was investigated, focusing on infection control practices during wound care. The complaint was substantiated by observations and interviews confirming failure to follow hand hygiene protocols.

The facility failed to ensure proper infection control measures during wound care for one resident with two pressure ulcers, as a nurse did not wash hands or change gloves appropriately between wound treatments, potentially spreading infection. Interviews with staff and administration confirmed the expected hand hygiene and wound care protocols.

The facility had multiple deficiencies including failure to complete criminal background checks for staff, incomplete PASRR screening for a resident, inadequate monitoring and documentation of resident bowel movements leading to missed laxative administration, failure to document discharge summaries, inconsistent documentation of resident code status, improper wound care technique, failure to apply physician ordered tubigrips, inadequate restorative nursing services, unsecured hazardous chemicals and unsafe access to hot water and razors in the special care unit, failure to obtain consent and complete assessments for bed rail use, failure to update care plans and monitor residents with suicidal ideations, failure to implement gradual dose reductions for psychotropic medications, failure to administer pneumococcal vaccines, failure to ensure all staff vaccinated or properly masked for COVID-19, failure to provide special eating equipment, and failure to maintain kitchen cleanliness.

The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering catheter bags, failure to provide bed hold policy upon hospital discharge, failure to update care plans for pressure ulcers, delayed response to call lights for toileting needs, failure to follow physician orders for lab tests and oxygen therapy, failure to discontinue unnecessary psychotropic medication, and failure to follow infection control procedures during incontinent and wound care.