Aurora Manor Special Care Cent

In the surveyor’s words

From the most serious findings on record at Aurora Manor Special Care Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 9, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on observation of video footage, closed medical record review, Self-Reported Incident review, review of witness statements, policy review, and interview, the facility failed to protect Resident #70's right to be free from physical abuse by Certified Nursing Assistant (CNA) #80. This resulted in Immediate Jeopardy and Actual Harm on 03/02/26 when Certified Nursing Assistant (CNA) #80 was observed via facility video footage physically assaulting Resident #70, a resident who was alert and oriented and totally dependent on staff for all activities of daily living (ADL). On 03/02/26 at approximately 11:35 P.M. […]

• Actual harm, isolatedF689Apr 23, 2024

  Based on closed record review and interview, the facility failed to ensure Resident #65, who had a history of substance use disorder was assessed for these risks and had comprehensive and individualized care planned interventions initiated and implemented to ensure the resident's safety to prevent drug overdose. Actual harm occurred on [DATE] when Resident #65 was found unresponsive in the facility due to a drug overdose. The resident subsequently passed away. This affected one (#65) of one resident reviewed for death. Findings include: Review of Resident #65's Preadmission Screening and Resident Review Result (PASRR) Notice form dated [DATE] revealed the resident did not require level two services. […]

• No harm, potential for more than minimal, widespreadF921Jan 28, 2022

  Based on observation and interview the facility failed to provide a clean and sanitary environment. This had the potential to affected all 52 residents residing in the facility. Findings include: Observation of Resident #10's and Resident #16's room on 01/28/22 at 7:58 A.M. with State tested Nursing Assistant (STNA) #201 revealed a large amount of fecal matter on the toilet seat and bottom portion of the toilet bowel. STNA #201 confirmed the observation and stated the facility did not have housekeeping staff and it had been a few weeks since the facility was cleaned. Observation after exiting Resident #10's and #16's room on the 200 hall revealed the hallway floors were dirty and had various debris on them. […]

• No harm, potential for more than minimal, patternF921Nov 21, 2024

  Based on observations, interview and policy review the facility failed to ensure resident rooms were clean and sanitary for Resident #36, #1, #34, #59 and #50. This affected five residents (#36, #1, #34, #59 and #50) out of eight residents reviewed for physical environment. The facility census was 65. Finding Include: Observation on 11/20/24 at 11:41 A.M. of Resident #36's room revealed a black grimy buildup on the floor showing wheelchair tracks all over the floor, and tables and tops of furniture were dusty. Resident #36 stated they don't clean his room every day and he would like the room cleaned. Observation on 11/20/24 at 11:54 A.M. […]

• No harm, potential for more than minimal, patternF580May 13, 2024

  Based on record review and staff interview, the facility failed to notify the physician of residents not receiving medications as physician ordered. This affected five (Residents #1, #3, #8, #24, and #55) of 13 residents receiving insulin in the facility. The facility census was 63. Findings include: 1. Review of the medical record for Resident #1 revealed an admitted d 04/25/24. Diagnoses included type II diabetes mellitus and end stage renal failure. Review of the medication administration record (MAR) for May 2024 revealed on 05/05/24 at 9:30 P.M., Resident #1 did not have his blood sugar check and did not receive any insulin as physician ordered. At the bottom of the MAR under reasons not administered on 05/05/24 at 9:30 P.M. stated drug/item unavailable. […]