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 facility was found deficient in timely notification of changes in resident condition to physicians and family representatives, maintenance of wheelchairs, and provision of personal hygiene care to residents. Several residents had unmet hygiene needs and wheelchair repairs were delayed. The facility also failed to maintain a safe, clean, and homelike environment.

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 was substantiated as the facility failed to prevent misappropriation of narcotics by an LPN and failed to report the allegations timely to the State Survey Agency. The LPN was arrested at another facility with narcotic cards from this facility. The investigation was conducted following allegations involving seven residents.

The facility failed to prevent misappropriation of narcotic medications by an LPN who took medications without authorization. The facility also failed to report the allegations to the State Survey Agency within the required timeframe. The investigation found discrepancies in narcotic counts and missing narcotic cards in the LPN's possession.

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 failed to protect one resident from neglect during transport, resulting in multiple fractures due to improper securing in a vehicle. The facility staff did not properly secure the resident with a shoulder strap, and the transport driver did not follow the manufacturer's device user instructions.

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 facility was found deficient in multiple areas including privacy and confidentiality of resident records, professional standards of care, medication administration, bathing and hygiene assistance, chemical safety, nurse staffing information posting, psychotropic medication use, and food safety. The facility census was 83 at the time of the survey.

The facility failed to meet several Life Safety Code requirements including fire alarm system testing and maintenance, sprinkler system maintenance, portable fire extinguisher inspections, fire drills, electrical system maintenance, and electrical equipment safety. Multiple deficiencies were identified that could affect all facility occupants.

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 substantiated that the facility restricted four residents from smoking independently, violating their rights to self-determination. The facility suspended smoking breaks pending investigation and failed to include smoking-related interventions in care plans.

The facility failed to allow four residents to make choices about smoking, restricting their ability to smoke independently. Additionally, the facility did not develop comprehensive person-centered care plans addressing residents' supervision and safety risks related to smoking.

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 facility failed to notify the resident's guardian timely about an injury of unknown origin and did not conduct a thorough investigation of the alleged abuse. Staff lacked knowledge of the incident and did not interview all relevant parties.

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 facility was found to have multiple deficiencies related to resident rights, privacy, dignity, medication management, infection control, and safety hazards. Several residents' care plans and assessments were incomplete or not properly documented. The facility failed to maintain a safe environment free of hazards and ensure proper staff training and supervision.

The facility was found to have multiple deficiencies related to emergency preparedness policies, fire safety equipment maintenance, exit access, and fire alarm system testing. Several fire doors, sprinkler systems, and emergency procedures were not maintained or documented as required.

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 complaint investigation substantiated that the facility failed to notify the family/resident representative timely of a significant change in a resident's condition and failed to meet professional standards for skin assessments.

The facility failed to notify the family/resident representative timely about a resident's significant change in condition and did not complete required weekly skin assessments for four sampled residents as ordered by the physician.

The facility failed to meet requirements for maintaining and testing the diesel-powered emergency generator, including lack of a functional remote annunciator, manual stop station, and proper instruction manuals. The facility census was 70 with a capacity of 116, and the administrator acknowledged the expired waiver for the generator.

The investigation was complaint-driven, focusing on allegations that the facility failed to provide proper discharge notices and documentation. The findings confirmed these deficiencies.

The facility failed to provide appropriate 30-day discharge notices to residents and their responsible parties, did not document transfers or discharges properly in medical records, and did not provide necessary information for appeals. Several residents' medical records lacked documentation of discharge reasons and notices, and family members reported inadequate communication and guidance regarding discharges and unit closures.

The facility had previously failed to follow infection control guidelines by allowing two staff members to work while COVID-19 positive. The deficiency was initially classified as Immediate Jeopardy level 'K' but was lowered to level 'E' at exit. The facility implemented corrective actions and lowered the severity to Class II at exit.

The complaint investigation was substantiated with findings that the facility failed to protect resident rights, dignity, and privacy, including issues with catheter bag visibility and staff not knocking before entering rooms.

The facility failed to ensure residents' rights to dignity and privacy, specifically regarding catheter bag visibility and staff knocking before entering rooms. Multiple residents were observed with catheter bags hanging in clear view without privacy covers, and staff failed to follow policies on knocking and privacy. Additional deficiencies were noted in resident care plans, smoking policies, and facility maintenance.

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.