Inspection Reports for
Aurora Health and Rehabilitation

Complaint numbers 2659561 and 2663004 triggered the investigation. The complaints involved failure to complete required pre-employment screenings, delayed reporting of abuse allegations, inadequate resident care, insufficient staffing, and infection control failures.

The facility failed to complete required pre-employment background checks for six employees, delayed reporting abuse allegations to authorities, did not provide adequate personal hygiene care to ten residents, had insufficient nursing staff to meet resident needs, allowed the Director of Nursing to work as a charge nurse contrary to regulations, lacked a thorough facility-wide staffing assessment by unit, and failed to follow infection control protocols including use of PPE and sanitizing mechanical lifts.

Based on interview and record review, the complaint was substantiated. Facility staff failed to provide discharge notice for Resident #1 and denied reentry after hospital discharge. The Social Service Director and administrator were unaware of the proper discharge and reentry rules.

The facility failed to provide a 30-day discharge notice to Resident #1 and denied the resident reentry after hospital discharge despite the resident's right to return. The facility staff and administrator were unaware of the proper discharge procedures and requirements to allow reentry.

The complaint investigation found that the facility failed to notify the resident's family and physician timely about a medical emergency and fall. Interviews with the Director of Nursing, administrator, Licensed Practical Nurse, Nurse Practitioner, and resident's guardian confirmed lack of notification. Additional complaints included failure to maintain wheelchairs and provide personal hygiene care.

The facility failed to notify the physician and family in a timely manner about a resident's medical emergency and fall, failed to maintain wheelchairs for three residents, and failed to provide adequate personal hygiene care including nail care and facial hair grooming for four residents. The facility census was 76.

The complaint involved allegations that LPN A misappropriated narcotic medications for seven residents. The facility's investigation was inconclusive, and LPN A did not cooperate. The police arrested LPN A at another facility with narcotic cards from this facility found in their car. The facility failed to report the incident to the State Survey Agency within 24 hours as required.

The facility failed to prevent the misappropriation of narcotic medications by LPN A, who was found to have empty narcotic pill cards in their possession. The facility also failed to timely report the suspected abuse to the State Survey Agency within the required 24-hour timeframe. The investigation concluded the narcotic counts were off due to incorrect subtraction by LPN A, but no pills were confirmed missing. LPN A did not cooperate with the investigation and was arrested at another facility.

The complaint investigation substantiated that the resident was not properly secured in the transport vehicle on 08/07/24, resulting in the resident falling and sustaining fractures. The resident was transported from dialysis, and the driver failed to use the shoulder strap due to resident preference. The facility lacked proper training documentation for the driver and did not monitor securement practices.

The facility failed to protect one resident from neglect by not properly securing the resident with a shoulder strap during transport, leading to the resident falling from the wheelchair and sustaining multiple fractures. The facility staff were found to have inadequate training and monitoring regarding proper resident securement in transport vehicles.

The facility staff failed to provide adequate bathing and personal hygiene assistance to six out of twelve sampled dependent residents, resulting in residents having greasy, disheveled hair and strong odors. Staff interviews revealed staffing shortages and documentation issues related to showering and hygiene care.

The facility was found deficient in multiple areas including failure to protect resident privacy, inadequate documentation and follow-up of neurological assessments after falls, failure to follow physician orders for tube feedings and skin assessments, inadequate bathing and personal hygiene for dependent residents, unsafe storage of chemicals and medication self-administration, failure to post nurse staffing information daily, and failure to maintain dishwasher temperature for proper sanitation.

The visit was complaint-related due to concerns about residents not being allowed to smoke and lack of appropriate care planning for smoking residents. The complaint was substantiated as the facility suspended smoking and lacked proper care plans.

The facility failed to honor residents' rights to self-determination by not allowing four residents to smoke and suspended smoking breaks pending investigation. Additionally, the facility failed to develop comprehensive, person-centered care plans addressing smoking supervision, assessment, and safety risks for these residents.

The complaint investigation found that the resident's guardian was not notified until 11 days after the injury was discovered, and the investigation was delayed and incomplete. The resident's guardian expressed a preference for timely notification. The facility staff cited miscommunication and misunderstanding of reporting requirements as reasons for the failures.

The facility failed to notify the resident's guardian promptly about the injury and allegation of abuse. Additionally, the investigation was incomplete as staff did not interview all relevant witnesses or residents in a timely manner. The resident was severely cognitively impaired, and the facility census was 68.

The complaint investigation found that the facility did not allow two residents to return after hospital stays and failed to provide proper discharge location documentation. Resident #39 was discharged due to lack of attending physician and non-compliance, with EMS called after 30 days when no new physician was found. Resident #401 was verbally discharged due to safety concerns related to hepatitis C and non-compliance, without written discharge notice.

The facility failed to allow two residents (Resident #39 and Resident #401) to return after hospital stays and did not provide adequate discharge notices or locations. Resident #39 was discharged due to lack of attending physician and non-compliance, and Resident #401 was discharged verbally without written notice due to safety concerns and non-compliance.

The facility was found deficient in multiple areas including failure to maintain resident dignity, improper posting of abuse hotline information, inadequate background screening, improper resident transfers and discharges, failure to notify residents of bed hold policies, failure to follow physician orders and complete neurological assessments after falls, unsafe wheelchair and shower chair use, improper medication storage and labeling, inadequate infection control practices, failure to maintain a quality assurance program, poor food safety and sanitation practices, improper waste disposal, lack of antibiotic stewardship program, and failure to designate a qualified infection preventionist.

The complaint investigation found that the facility failed to notify family members of a resident's change in condition and failed to complete weekly skin assessments for four residents as ordered. The Director of Nursing and Licensed Practical Nurse acknowledged these failures during interviews. The Administrator stated the Director of Nursing would be responsible for ensuring completion of skin assessments.

The facility failed to notify the family of a resident's significant change in condition in a timely manner and failed to complete weekly skin assessments for four residents as ordered by the physician. Documentation was missing for notification and skin assessments, and staff acknowledged these deficiencies during interviews.

The facility was found deficient in multiple areas including failure to maintain resident dignity, improper catheter bag privacy, failure to notify residents of non-smoking policy, inadequate call light accessibility, failure to provide timely SNF ABN notices, unsafe wheelchair propulsion, lack of timely fire alarm and HVAC maintenance due to unpaid vendor bills, incomplete infection control program including water management and TB screening, failure to implement antibiotic stewardship, improper medication labeling, inadequate food safety and sanitation practices, and failure to maintain facility environment and equipment in good repair.