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Deficiency Records for Aurora Health and Rehabilitation

A list of the most recent deficiencies for Aurora Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Aurora Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Keep residents' personal and medical records private and confidential. Health 2024-06-28 2024-08-07 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-06-28 2024-08-07 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-06-28 2024-08-07 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-06-28 2024-08-07 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-06-28 2024-08-07 N
Post nurse staffing information every day. Health 2024-06-28 2024-08-07 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2024-06-28 2024-08-07 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-06-28 2024-08-07 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2024-06-28 2024-08-07 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-06-28 2024-08-07 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-06-28 2024-08-07 N
Have simulated fire drills held at unexpected times. Fire Safety 2024-06-28 2024-08-07 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2024-06-28 2024-08-07 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-06-28 2024-08-07 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-01-25 2024-03-21 Y
Respond appropriately to all alleged violations. Health 2024-01-25 2024-03-21 Y
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2024-02-22 2024-03-16 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-02-22 2024-03-16 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2023-10-20 2023-11-13 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2023-08-31 2023-11-13 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-31 2023-11-13 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2023-08-31 2023-11-13 N
Provide and implement an infection prevention and control program. Health 2023-08-31 2023-11-13 N
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. Fire Safety 2023-08-31 2023-11-13 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-08-31 2023-11-13 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2023-08-31 2023-11-13 N
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. Fire Safety 2023-08-31 2023-11-13 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-08-31 2023-11-13 N
Address subsistence needs for staff and patients. Fire Safety 2023-08-31 2023-10-09 N
Provide family notifications of emergency plan. Fire Safety 2023-08-31 2023-10-09 N
Establish staff and initial training requirements. Fire Safety 2023-08-31 2023-10-09 N
Meet other general requirements. Fire Safety 2023-08-31 2023-10-09 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-08-31 2023-10-09 N
Provide properly protected cooking facilities. Fire Safety 2023-08-31 2023-10-09 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-08-31 2023-10-09 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2023-08-31 2023-10-09 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-08-31 2023-10-09 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-08-31 2023-10-09 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2023-08-31 2023-10-09 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-08-31 2023-10-09 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-08-31 2023-10-09 N
Have proper medical gas storage and administration areas. Fire Safety 2023-08-31 2023-10-09 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2023-08-31 2023-10-09 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-08-31 2023-09-29 N
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Health 2023-08-31 2023-09-29 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-08-31 2023-09-29 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2023-08-31 2023-09-29 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-08-31 2023-09-29 N
Provide activities to meet all resident's needs. Health 2023-08-31 2023-09-29 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-08-31 2023-09-29 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2023-08-31 2023-09-29 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-08-31 2023-09-29 N
Dispose of garbage and refuse properly. Health 2023-08-31 2023-09-29 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2023-08-31 2023-09-29 N
Implement a program that monitors antibiotic use. Health 2023-08-31 2023-09-29 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2023-08-31 2023-09-29 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-07-06 2023-08-11 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-07-06 2023-08-11 Y
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-11-22 2023-01-05 Y
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Health 2022-10-17 2022-11-07 Y
Provide and implement an infection prevention and control program. Health 2022-08-19 2022-09-23 Y
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-11-24 2022-07-15 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-01-21 2022-01-24 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-11-24 2022-01-24 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2021-11-24 2022-01-24 N
Implement emergency and standby power systems. Fire Safety 2021-11-24 2022-01-24 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2021-11-24 2022-01-24 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2021-11-24 2022-01-10 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2021-11-24 2022-01-10 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2021-11-24 2022-01-10 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-11-24 2022-01-10 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-11-24 2022-01-10 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-11-24 2022-01-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-11-24 2022-01-10 N
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Health 2021-11-24 2022-01-10 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2021-11-24 2022-01-10 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2021-11-24 2022-01-10 N
Provide and implement an infection prevention and control program. Health 2021-11-24 2022-01-10 N
Implement a program that monitors antibiotic use. Health 2021-11-24 2022-01-10 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2021-11-24 2022-01-10 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2021-11-24 2022-01-10 N
Keep all essential equipment working safely. Health 2021-11-24 2022-01-10 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-11-24 2022-01-10 Y
Reasonably accommodate the needs and preferences of each resident. Health 2021-11-24 2022-01-10 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2021-11-24 2022-01-10 Y
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2021-11-24 2022-01-10 N
Address patient/client population and determine types of services needed. Fire Safety 2021-11-24 2022-01-10 N
Establish staff and initial training requirements. Fire Safety 2021-11-24 2022-01-10 N
Meet other general requirements. Fire Safety 2021-11-24 2022-01-10 N
Provide properly protected cooking facilities. Fire Safety 2021-11-24 2022-01-10 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-11-24 2022-01-10 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-11-24 2022-01-10 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-11-24 2022-01-10 N
Meet requirements for the installation and maintenance of electrical systems. Fire Safety 2021-11-24 2022-01-10 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-11-24 2022-01-10 N
Have proper medical gas storage and administration areas. Fire Safety 2021-11-24 2022-01-10 N
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. Fire Safety 2021-11-24 2022-01-10 N

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