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? |
---|---|---|---|---|
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 | 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 |
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 |
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 |
Provide and implement an infection prevention and control program. | Health | 2021-07-01 | 2021-08-03 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-07-01 | 2021-07-29 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-12 | 2020-01-15 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-12 | 2020-01-15 | 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 | 2019-12-12 | 2020-01-15 | N |
Provide and implement an infection prevention and control program. | Health | 2019-12-12 | 2020-01-15 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-12 | 2020-01-15 | N |