Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Aurelia, Llc during CMS and state inspections, most recent first.
Failure to notify the physician when a resident with CHF, COPD, emphysema, and oxygen dependence stopped using BiPAP at night. The resident said she had not worn the BiPAP for about three months because the mask fit poorly, and a CNA reported the resident first used it inconsistently before stopping altogether. The TAR did not accurately reflect BiPAP use, the care plan lacked BiPAP information, and the DON stated she only learned of the nonuse during survey review.
Failure to refer a resident for PASRR Level II evaluation after new mental health findings were identified. The resident had dementia, anxiety, depression, suicidal ideation, and adjustment disorder, with psych services and medications including memantine, Prozac, and Zyprexa. The SW stated a new PASRR was submitted later, and the DON reported the facility had no PASRR policy and relied on standards of care.
Inaccurate BiPAP Documentation: A resident with CHF, COPD, and emphysema was ordered to use BiPAP at bedtime, but the resident reported not wearing it for about three months because of poor mask fit and personal preference. Staff documentation on the TAR inaccurately showed BiPAP use and removal on multiple days, and the DON later confirmed the records were inaccurate and that staff had been documenting treatments as completed when they were not.
Failure to Perform Hand Hygiene During Catheter Care: A CNA failed to perform hand hygiene before donning PPE and emptying urine from a resident’s catheter bag, and again failed to perform hand hygiene after doffing PPE before arranging the catheter bag, privacy bag, and the resident’s blanket. The DON and Infection Preventionist stated staff are expected to perform hand hygiene before glove use, after glove removal, and when leaving the resident’s room.
A resident with severe cognitive and physical impairments was subjected to repeated verbal abuse and rough handling by a CNA, as reported by multiple staff. The CNA made derogatory remarks, threatened the resident during transfers, and handled her in a way that caused fear of falling, despite the resident's total dependence on staff for care.
Staff failed to promptly report allegations of verbal abuse by a CNA toward a resident with severe cognitive impairment and total dependence on staff. Multiple staff observed or were aware of the abuse but delayed reporting, and the facility's self-report lacked specific incident dates, contrary to policy requiring immediate notification to authorities.
The facility failed to monitor and treat pressure ulcers for two residents, leading to significant health deterioration. One resident's diabetic foot ulcer worsened over several months, resulting in amputation due to inadequate documentation and communication with healthcare providers. Another resident's sacral pressure ulcer was not consistently treated as prescribed, with a lack of follow-up documentation. The facility's inadequate documentation practices and communication contributed to these deficiencies.
The facility failed to follow physician orders for two residents, leading to deficiencies in care. A resident on anticoagulants did not receive a scheduled INR test, resulting in high INR levels. Another resident with diabetes had multiple instances of elevated blood glucose levels that were not reported to the physician as required. The DON acknowledged these oversights and the lack of a specific policy for reporting blood glucose levels.
A resident with cognitive ability and multiple diagnoses, including heart failure and anxiety, fell in the shower room due to a CNA's failure to use a Gait Belt (GB) during a transfer. The care plan required the use of a GB for all transfers, but the resident was found on the floor without one. The facility's competency checklist for GB use was not adhered to, contributing to the incident.
A resident with intact cognitive ability reported feeling disrespected and unsafe during an early morning interaction with a CNA. The CNA responded to the resident's call light with a rough tone, dismissed the urgency of the resident's need to use the bathroom, and assisted without using a gait belt, contrary to the care plan. The CNA's harsh instructions during toileting further upset the resident. Other staff corroborated the resident's account, and the DON acknowledged the CNA's loud voice, indicating a failure to provide dignified and respectful care.
Failure to Notify Physician of BiPAP Nonuse
Penalty
Summary
The facility failed to notify the physician when a resident with a history of CHF, COPD, centrilobular emphysema, and oxygen dependence stopped using a BiPAP machine at night. The resident’s clinical orders included BiPAP at bedtime and oxygen at 3 liters per nasal cannula, along with multiple respiratory and cardiac medications. The care plan identified the resident’s CHF, COPD, high blood pressure, and atrial fibrillation, but it did not include BiPAP use or related information. During interview, the resident stated the pulmonologist ordered BiPAP use at night and reported placing the device on a shelf because the mask fit poorly and she did not want to use it. The resident said she had not worn the BiPAP for about three months. A CNA reported the resident began inconsistent use in October and stopped using it altogether in November. The December 2025 and January 2026 TAR did not accurately reflect BiPAP usage. The DON stated she learned of the nonuse during the survey, had not known the resident had not worn the BiPAP for three months, and agreed physician notification was necessary because the resident could have breathing issues. The DON also stated the resident should have been documented as refusing treatment and that the facility lacked a policy regarding physician notification.
Failure to Refer Resident for PASRR Level II Evaluation After New Mental Health Findings
Penalty
Summary
The facility failed to refer one resident with a negative Level I PASRR result for a Level II PASRR evaluation and determination after the resident was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition. The deficiency involved Resident #27, who had diagnoses documented in the clinical record including dementia, anxiety disorder, adjustment disorder with depressed mood, depression, and suicidal ideations. The resident’s MDS assessment included a BIMS score of 13, indicating intact cognition, and the medical diagnosis list also showed general anxiety disorder, major depressive disorder, suicidal ideation, and adjustment disorder with depressed mood. The record also showed psych-related treatment and medications for the resident, including memantine, Prozac, and Zyprexa, along with a telehealth psych progress note indicating the resident was receiving psych services and had a future appointment scheduled. During interviews, the SW stated a new PASRR had been submitted that morning for the resident and confirmed that PASRR submission was needed when new mental health diagnoses, medications, and services were present. The DON and Administrator discussed that responsibility for resubmission was assigned to the SW, and the DON stated the facility did not have a PASRR policy and followed standards of care.
Inaccurate BiPAP Documentation
Penalty
Summary
The facility failed to accurately document BiPAP machine usage for one resident with CHF, COPD, and centrilobular emphysema. The resident’s MDS showed a BIMS score of 15, indicating no cognitive impairment, and the physician order directed BiPAP use at bedtime and removal in the morning. During interview, the resident stated the pulmonologist ordered BiPAP use at night but reported placing the device on a shelf because she did not want to use it due to a poorly fitting mask, despite trying several different masks. The resident said the BiPAP had been unused for at least three months and clarified that she had not worn it at all for about three months. Staff interviews and TAR review showed inaccurate documentation of BiPAP use. A CNA reported the resident began inconsistent use in October and stopped using it altogether in November. Review of the December TAR showed staff documented the resident applied and/or removed the BiPAP every day of the month, and review of the January TAR showed staff documented BiPAP use, removal, or failed to document every day of the month. The DON initially stated she had not known the resident was not using the BiPAP and had not looked at the documentation, then later confirmed the documentation was inaccurate and stated staff had been documenting that treatments were done when they were not.
Failure to Perform Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to provide proper hand hygiene before and after catheter care for one resident reviewed. During an observation, a CNA did not perform hand hygiene before donning PPE and emptying urine from the resident’s catheter bag. After doffing PPE, the CNA again failed to perform hand hygiene and then arranged the catheter bag, privacy bag, and the resident’s blanket before leaving the room. The facility’s Hand Hygiene Policy, last updated on 11/13/24, states that hand hygiene is required immediately before donning and doffing gloves. The DON stated staff were expected to perform hand hygiene immediately before applying gloves and when gloves are removed, and the Infection Preventionist stated staff are expected to perform hand hygiene before putting on gloves, immediately after removing gloves, and when leaving the resident’s room.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
The facility failed to protect a resident with severe cognitive deficits and total dependence on staff from verbal abuse by a Certified Nurse Aide (CNA). The resident, who had diagnoses including heart failure, renal insufficiency, and quadriplegia, required two staff for all transfers and was unable to care for herself. Multiple staff members reported that the CNA addressed the resident in a disrespectful and derogatory manner during care activities, including making statements such as hoping the resident would be hit by equipment and telling her that no one visited her because of her condition. Staff also described the CNA as rough during transfers and rolling, causing the resident to express fear of falling. Staff interviews revealed that the CNA made repeated negative comments to the resident, including suggesting she should be placed on hospice and threatening to drop her during transfers. Several staff members observed the CNA pulling the resident abruptly and handling her in a way that made her afraid. The resident, who was unable to physically defend herself, would express fear and plead not to be dropped. Staff noted that the CNA appeared annoyed by the resident and was more verbally aggressive toward her compared to other residents. The facility's own self-report to the Department of Inspections and Appeals and Licensing confirmed that concerns about the CNA's behavior had been brought to management's attention, though specific dates of incidents were not documented. The facility policy required staff to treat residents with dignity and to refrain from verbal abuse, including sarcastic or derogatory remarks. Despite these policies, the resident was subjected to repeated verbal mistreatment and rough handling by the CNA, as corroborated by multiple staff statements and observations.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report allegations of verbal abuse in a timely manner for one resident with severe cognitive deficits and total dependence on staff for activities of daily living. Multiple staff members reported that a CNA was verbally abusive and disrespectful to the resident, including making inappropriate comments during care and being rough. However, staff were unable to provide specific dates or times for when the incidents occurred, and some delayed reporting due to fear of retaliation. Written statements and interviews confirmed that staff had observed or were aware of the alleged abuse but did not immediately report their concerns. The facility's self-report to the Department of Inspections and Appeals and Licensing lacked details regarding the dates of the alleged incidents. The facility's policy required immediate reporting of all allegations of abuse to the charge nurse and subsequent notification to the administrator and state authorities within two hours. Despite this policy, the allegations were not reported promptly, and staff involved were later educated on the importance of immediate reporting. The resident involved had significant medical conditions, including heart failure, renal insufficiency, and quadriplegia, and was unable to care for herself or communicate effectively due to cognitive impairment.
Inadequate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to adequately monitor and treat pressure ulcers for two residents, leading to significant health deterioration. Resident #3, who had a diabetic foot ulcer and was dependent on staff for mobility and hygiene, experienced a worsening condition of his right great toe. Despite ongoing treatment, the ulcer deteriorated over several months, eventually leading to amputation. The staff failed to document changes in the wound's condition and did not contact the physician when the treatment was ineffective. The lack of timely intervention and communication with healthcare providers contributed to the resident's condition worsening to the point of requiring surgical intervention. Resident #21, who was at risk for pressure ulcers and required assistance with daily activities, had a pressure ulcer on her sacral region. The facility failed to ensure that the prescribed treatment, which included the application of a foam dressing, was consistently applied. Observations revealed that the dressing was not always in place as ordered, and there was a lack of follow-up measurements or documentation regarding the ulcer's condition. This oversight in care and documentation contributed to the resident's ongoing skin issues. The facility's documentation practices and communication between staff and healthcare providers were inadequate, leading to a failure in addressing the residents' skin conditions effectively. The absence of a specific policy for skin assessments and the reliance on a protocol that lacked guidance on when to contact a doctor further exacerbated the situation. These deficiencies highlight the need for improved monitoring, documentation, and communication to prevent similar occurrences in the future.
Failure to Follow Physician Orders for INR and Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure staff followed physicians' orders for two residents, leading to deficiencies in care. Resident #17, who had a history of atrial fibrillation and was on anticoagulant medication, required an INR blood test on a specific date, which was not conducted. This oversight was discovered when the resident's INR levels were found to be significantly high later. The nurse responsible for entering the order did not remember the process for lab draws, and the Director of Nursing acknowledged that the INR lab was missed, indicating a lapse in the facility's tracking and documentation processes. Resident #9, who had diabetes among other conditions, had orders for staff to report blood glucose levels outside specified parameters to the physician. However, multiple instances of elevated blood glucose levels were not reported as required. The Director of Nursing confirmed that the high blood glucose levels were not communicated to the physician, and there was no specific policy in place for reporting such levels. This lack of adherence to physician orders and absence of a clear reporting policy contributed to the deficiency in care for Resident #9.
Failure to Use Gait Belt Leads to Resident Fall
Penalty
Summary
The facility failed to ensure safe transfer techniques using a Gait Belt (GB) for a resident, leading to a fall incident. The resident, who had a Brief Interview for Mental Status (BIMS) score of 15, required partial assistance with various activities, including transfers. Diagnosed with conditions such as atrial fibrillation, heart failure, anxiety, and depression, the resident was at risk for falls, as noted in the care plan. The care plan specified the use of a GB for all transfers and appropriate footwear. However, during an incident in the shower room, the resident fell when a Certified Nurse Aide (CNA) did not use a GB while transferring him from the shower chair to the wheelchair. The incident was documented in a nursing note, which detailed that the resident slipped onto the floor after attempting to stand on a dry towel. The resident was found on the floor without a GB, and the CNA confirmed the absence of the GB during the transfer. The Director of Nursing (DON) later explained that the CNA should have dried the resident and dressed him before applying the GB. The facility had a competency checklist for ambulation with a GB, which required the GB to be applied over clothing and not on bare skin, but it appears this protocol was not followed during the incident.
Failure to Ensure Dignified and Respectful Care
Penalty
Summary
The facility failed to ensure that staff interacted with residents with dignity and respect, specifically in the case of Resident #9. Resident #9, who had an intact cognitive ability and was dependent on staff for various activities, reported an incident involving a Certified Nurse Aide (CNA), Staff I. The resident needed assistance to use the bathroom early in the morning and activated her call light. Staff I responded with a rough tone, dismissing the resident's need to use the toilet immediately, suggesting it could wait until the morning staff arrived. Despite the resident's insistence on needing to go, Staff I assisted her without using a gait belt, contrary to the resident's care plan and therapy instructions. During the toileting process, Staff I reportedly used a harsh tone, instructing the resident to push harder, which made the resident feel unsafe and disrespected. Interviews with other staff members, including a Licensed Practical Nurse (LPN) and the Activities Director, corroborated the resident's account of feeling upset and disrespected by Staff I's actions and tone. The Director of Nursing acknowledged that Staff I had a loud voice and could benefit from softening her tone around residents. The facility's policy on abuse prevention highlights that mental abuse includes verbal or nonverbal conduct that causes or has the potential to cause residents to experience negative emotions such as humiliation, intimidation, or fear. This incident reflects a failure to adhere to the facility's policy and the resident's care plan, resulting in a deficiency in providing dignified and respectful care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurelia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Accura Healthcare Of Cherokee, Llc | 5.7 mi | ★★★★★ | 6 | 0 |
| Cherokee Specialty Care | 6.2 mi | ★★★★★ | 0 | 0 |
| Careage Hills Rehabilitation And Healthcare | 6.3 mi | ★★★★★ | 9 | 0 |
| Methodist Manor Retirement Community | 12.4 mi | ★★★★★ | 5 | 0 |
| Good Samaritan - Holstein | 16.6 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.