Aurora Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Aurora Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 26, 2025

  Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide a safe, hazard-free environment for a resident when a portable heater was used in the resident's room and caused a burn to the resident's skin for one (1) of three (3) incidents reviewed. Resident #1. Based on corrective actions implemented 5/5/25, the State Agency determined this to be Past Non-Compliance. Findings include:Record review of facility policy titled, Incidents and Accidents Policy, undated, revealed, Accident - Any unexpected or unintentional incident which results, or may result, in injury or illness to a resident. […]

• Actual harm, isolatedF686Feb 26, 2021

  Based on staff interview, record review, observation and facility policy review, the facility failed to prevent the development of pressure ulcers and the worsening of existing pressure ulcers for one (1) of five (5) residents reviewed, (Resident #1). Findings include: Review of the facility's policy titled, Skin Management Standards - Routine Preventative Care, last updated ,d+[DATE], revealed, According to AHCPR (Agency for Healthcare Policy and Research) Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Vanguard requires .a minimum skin check of at least weekly by a licensed nurse. […]

• No harm, potential for more than minimal, widespreadF812Jan 22, 2026

  Based on observations, staff interviews, and facility policy review, the facility failed to maintain food service areas in a sanitary manner to prevent the potential for food contamination. Specifically, the facility failed to ensure ventilation ductwork was free from a black mold-like substance in areas located above food preparation and food storage locations on two (2) of (2) kitchen tours. Findings include:Review of facility policy titled Sanitation and Infection Control with no date, revealed, Standard: .to ensure sanitary conditions.in the dining service department.On 1/20/2026 at 10:21 AM, during an initial tour of the facility kitchen accompanied by the Dietary Manager revealed an observation of a black mold-like substance on the ventilation ductwork above the stove, with visible… […]

• No harm, potential for more than minimal, isolatedF550May 20, 2026

  Based on record review, staff interview and facility policy review, the facility failed to ensure residents were treated with respect and dignity when a staff member spoke rudely and in a disrespectful manner to one (1) of three (3) residents reviewed. Resident #2 Findings included:Record review of the facility policy titled, Resident Rights, revealed Standard, Employees shall treat all residents with kindness, respect and dignity .Record review of Grievance/Concern/Comment Report dated 1/29/26, revealed that Resident #2's family reported that Certified Nursing Assistant (CNA) #1 talked down to the resident and overheard CNA #1 state to the resident I told you that I was coming back to change you!An interview with the Social Services Director (SSD) on 5/20/26 at 8:35 AM, he stated he made… […]

• No harm, potential for more than minimal, isolatedF578May 20, 2026

  Based on staff interview, record review, and facility policy review the facility failed to ensure a resident was provided education and sufficient information regarding advance directives and the implications of assigning a Power of Attorney (POA) prior to obtaining the resident's agreement for one (1) of three (3) residents reviewed for advanced directives. Resident #1Findings Included:Record review of the facility policy titled, OBRA (Omnibus Budget Reconciliation Act) Resident Self-determination Checklist revealed, Policy.Every resident has the right to give informed consent before diagnosis or treatment. […]