North Aurora Living & Rehab CTR

In the surveyor’s words

From the most serious findings on record at North Aurora Living & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Jul 15, 2024

  Based on observation, interview and record review, the facility failed to initiate CPR (Cardiopulmonary Resuscitation) for a resident (R1) with full code status (attempt CPR). The facility also failed to have a system in place to ensure that Advance Directives are completed timely and available to direct care staff. These failures resulted in R1 not receiving CPR and expiring at the facility. These failures have the potential to affect all residents residing in the facility. The [DATE], Facility Data Sheet showed 96 residents reside at the facility. These failures resulted in Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE], when R1 was found not breathing and no CPR was initiated. […]

• Immediate jeopardy, widespreadF725Aug 31, 2022

  Based on interview and record review, the facility failed to ensure licensed nurses were always present in the building to care for residents. For a period of over 12 hours, on August 14, 2022 from 10:42 AM until 11:00 PM the facility did not have licensed nursing staff in the building. On August 14, 2022, this failure resulted in 19 residents (R1, R4-R21) not receiving their physician-ordered medications due to the lack of a licensed nurse, including cardiac and blood pressure medications, diabetes and insulin medications, diuretic medications, blood thinners, antipsychotic medications, and anti-[CONDITION(S)] medications. […]

• Immediate jeopardy, patternF689Nov 2, 2023

  Based on interview and record review, the facility failed to supervise a newly admitted male resident (R4) with known hyper-sexual behaviors resulting in R4 entering 5 female residents' rooms (R1, R2, R3, R5, R6), sexually abusing (R1), and getting into bed with R2 and touching her shoulder. This applies to 5 of 5 residents (R1, R2, R3, R5, R6) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. […]

• Immediate jeopardy, isolatedF600Nov 2, 2023

  Based on interview and record review, the facility failed to ensure a female resident was protected from a male resident with a known history of hyper-sexual behaviors resulting in the sexual abuse of 1 female resident (R1). This applies to 1 of 5 residents (R1) reviewed for sexual abuse in the sample of 6. The Immediate Jeopardy began on October 12, 2023 when R4 was admitted to the facility and direct care staff were not made aware of R4's history of hyper-sexual behaviors, and no interventions were put in place to protect other residents, resulting in a resident being sexually abused. V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the Immediate Jeopardy on October 31, 2023 at 11:45 AM. […]

• Immediate jeopardy, isolatedF692Oct 4, 2023

  Based on interview and record review, the facility failed to obtain weekly weights, failed to monitor and review for weight loss, and failed to make recommendations for nutritional support for 1 resident (R90) that resulted in a severe weight loss of 23.83% (percent) over 4 months and required an 8-day hospitalization for treatment of rhabdomyolysis and hypokalemia. The facility also failed to complete a quarterly dietary assessment for 1 resident (R33) with a history of significant weight loss. Four residents were reviewed for weight loss in the sample of 20. […]