Aurora Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Aurora Nursing and Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF600Nov 2, 2021

  Based on review of clinical records and facility investigative documents, as well as resident and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect, by failing to follow a resident's care plan while providing care for one of seven residents reviewed (Resident 1), resulting in harm due to a fall from bed with a fracture. Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated September 10, 2021, revealed that the resident was blind, alert and oriented, able to make her needs known, and required the extensive assistance of two staff for daily care activities, including bed mobility. […]

• No harm, potential for more than minimal, patternF605Dec 17, 2025

  Based on a review of facility policies and clinical records as well as staff interviews, it was determined that the facility failed to ensure that residents medication regimen was free from unnecessary psychotropic medication (drugs that affect a person's mental state, emotions, and behavior) for two of 19 residents reviewed (Residents 26 and 40).Findings include:The facility's policy regarding psychotropic medication use, dated September 24, 2025, indicated that non-pharmacological approaches would be used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.A quarterly Minimum Data Set (MDS) assessment (a federally mandated assessment of the resident's abilities and care needs) for… […]

• No harm, potential for more than minimal, patternF694Dec 17, 2025

  Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an implanted venous port (a medical device placed under the skin in your chest, arm or belly that allows for easy access to a vein for administering fluids or medications) was flushed according to facility policy for one of 19 residents reviewed (Resident 9) and failed to ensure that a peripherally inserted central catheter (PICC- a thin, flexible tube that is inserted into a vein in the upper arm for long term access) was flushed according to facility policy for one of 19 residents reviewed (Resident 41). […]

• No harm, potential for more than minimal, patternF755Dec 17, 2025

  Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 19 residents reviewed (Resident 6, 14).Findings include: The facility's policy regarding medication administration, dated September 24, 2025, indicated that staff are to document the administration of controlled substances in accordance with applicable law. […]

• No harm, potential for more than minimal, patternF609Nov 19, 2024

  Based on review of the Older Adults Protective Services Act, facility policies, information provided by the facility and residents' clinical records, as well as staff interviews, it was determined that the facility failed to report timely allegations of abuse to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for three of 30 residents reviewed (Residents 131, 132, 133). Findings include: The Older Adults Protective Services Act, 1997-13, Section 701 (a)(1)(2), indicated that it was mandatory to report to the Protective Services agency. An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse shall immediately make an oral report to the agency. […]