Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Aurora Health And Rehabilitation during CMS and state inspections, most recent first.
Unlabeled and expired eye drops were found in a medication cart, including open artificial tears, Fluorometholone, Dorzolamide, Lumigan, and Cyclosporin vials, along with a loose vial of unknown eye drops. Staff stated eye drops are good for 30 days once opened, but the RN, DON, and administrator were unaware the cart contained outdated or unlabeled medications, and the facility’s policy required medications to be stored per manufacturer guidance and outdated or illegible medications to be destroyed.
Facility staff failed to provide written bed-hold notice to two residents and/or their representatives when they were transferred to the hospital. Records for both residents showed hospital discharges and returns, but no documentation that the required bed-hold information was issued or signed and dated in the chart. Staff interviews showed confusion about whether nursing or SSD was responsible for completing and following up on bed holds.
Facility staff did not complete a comprehensive facility-wide assessment, as the documented assessment lacked specific guidance on shift times and did not address staffing needs for each resident unit. The DON and administrator, though involved in the assessment process, were unaware of the requirement to include unit-specific staffing details.
Staff did not consistently use required PPE or follow Enhanced Barrier Precautions when providing care to two residents with wounds, and failed to display EBP signage on their doors. Additionally, mechanical lifts used for transferring two residents were not sanitized before or after use, contrary to facility policy and manufacturer guidelines. Staff interviews revealed confusion about responsibilities for EBP signage and a lack of awareness regarding proper disinfection protocols.
Staff failed to complete required pre-employment screenings, such as background checks and registry verifications, for multiple new hires before they began working. Documentation showed that several employees started work without all necessary checks being completed, and interviews with the DON, HR director, and administrator confirmed that these screenings were not consistently performed as required by facility policy.
Staff did not report allegations of abuse and neglect involving two residents to DHSS within the required two-hour timeframe. One resident with severe cognitive impairment reported being slapped by an employee, and another cognitively intact resident experienced verbal neglect from a CNA. Delays in reporting occurred due to lapses in responsibility transfer and documentation, as well as communication failures during the administrator's absence.
Staff failed to provide necessary bathing and personal hygiene assistance to multiple dependent residents, with documentation showing that some received only one or two baths or showers per month instead of the required twice weekly. Interviews with residents and staff revealed that chronic understaffing led to missed showers and inadequate hygiene care, as staff prioritized other essential tasks and were unable to complete all required ADLs.
Facility staff did not provide enough nursing staff to meet resident care needs, resulting in missed showers, inadequate personal hygiene, and insufficient assistance with meals and transfers. Multiple residents were observed with poor grooming, and staff reported being responsible for large numbers of residents, including those needing mechanical lifts. Non-nursing staff were only observed assisting during surveyor visits, and both staff and residents confirmed that care tasks were frequently missed due to inadequate staffing.
The DON was assigned to work as a charge nurse on multiple occasions while the facility census exceeded 60 residents, contrary to regulatory requirements. The facility assessment did not specify the DON's full-time status or allocation of hours, and interviews confirmed the DON worked the floor due to staffing shortages and the resignation of the ADON.
Facility staff did not provide a required discharge notice for a resident who was sent to the hospital for suicidal ideation and subsequently denied reentry to the facility. The Social Service Director was unaware of the discharge and reentry rules, and the administrator stated the facility could not meet the resident's care needs but did not follow proper discharge procedures.
Staff did not notify a resident's physician and family after the resident experienced a fall and a separate medical emergency involving vomiting and unresponsiveness. Documentation was lacking for both incidents, and interviews confirmed that the resident's representative was not informed, despite the resident's significant medical history and cognitive impairment.
Staff did not maintain wheelchairs in safe condition for three residents, resulting in torn armrests, worn or missing vinyl, and a bent metal piece secured with a bandage. Staff interviews revealed that required reporting and documentation procedures for equipment concerns were not followed, and maintenance staff were unaware of the issues.
Staff failed to provide necessary nail care and facial hair grooming for several residents with cognitive and physical impairments who required assistance with ADLs. Observations showed residents with long, dirty nails, unkempt hair, and poor clothing condition, despite staff being responsible for these tasks. Staff interviews revealed that a shortage of shower aides led to reduced frequency of showers and inconsistent hygiene care.
An LPN at a long-term care facility misappropriated narcotic medications from seven residents by inaccurately subtracting pills from the narcotic count and taking them without authorization. Despite the facility's investigation concluding no misappropriation, police found empty medication cards with residents' names in the LPN's car. The residents were cognitively intact and experienced occasional pain, receiving scheduled and as-needed pain medications.
The facility failed to report an allegation of narcotic misappropriation involving an LPN to the State Survey Agency within the required 24-hour timeframe. Discrepancies in narcotic counts were noted, and empty narcotic cards were found in the LPN's car. Despite concerns, the corporate office advised against reporting, as the investigation did not substantiate misappropriation.
A resident suffered multiple fractures after falling from a wheelchair during transport due to improper securing by facility staff. The resident was not fastened with a shoulder strap, leading to severe injuries when the vehicle stopped abruptly. The driver was inadequately trained, and the facility failed to monitor proper securing of residents.
The facility failed to maintain the mechanical dishwasher in good repair, leading to ineffective dishwashing and potential cross-contamination. Observations showed the dishwasher's temperature was consistently below the required 120 degrees Fahrenheit, and the facility lacked a temperature log for June 2024. Interviews revealed staff were unaware of the correct temperature standards, and the Dietary Supervisor and administrator were not monitoring the equipment properly.
Facility staff failed to protect resident privacy and confidentiality by leaving EMRs open and unattended, posting personal information in public areas, and not ensuring personal privacy for residents. Observations showed that staff did not adhere to protocols for closing screens or covering residents, and interviews confirmed these lapses in privacy protection.
The facility failed to document neurological assessments after falls for four residents, did not follow physician orders for tube feedings and skin assessments for two residents, and neglected to complete weekly weights for a newly admitted resident. Additionally, the facility did not clarify a medication order or obtain necessary lab values for a resident on Lithium, highlighting lapses in protocol adherence and care quality.
Facility staff failed to provide adequate bathing and personal hygiene for several residents, leading to a deficiency in care. Observations showed residents with greasy hair and strong body odor, and interviews revealed dissatisfaction with infrequent showers. Staffing issues were identified as a contributing factor, with only one shower aide available when two were needed. The discrepancy between care documentation and actual provision resulted in residents not receiving necessary hygiene assistance.
The facility failed to maintain a safe environment by leaving chemicals accessible in the dining room and did not assess two residents for safe self-administration of medications. One resident with COPD had an inhaler from home without a self-medication assessment, and another with GERD had antacids at the bedside without proper authorization. Staff interviews revealed a lack of awareness and adherence to policies regarding chemical safety and medication self-administration.
Facility staff failed to ensure medication regimens were free from unnecessary medications by not obtaining appropriate diagnoses for psychotropic medications in three residents and not limiting as-needed orders to 14 days for another resident. Interviews with staff revealed a lack of adherence to policies requiring diagnoses to match prescribed medications and a 14-day stop date for as-needed psychotropic medications.
The facility failed to obtain reasons for urinary catheter use for two residents, did not update a care plan for one resident, and inadequately documented catheter care for another. The Catheter Care policy lacked guidance on orders and documentation. Staff interviews revealed inconsistencies in catheter care orders and documentation, with challenges noted in using the electronic health record system.
The facility did not post required daily nurse staffing information, including total staff numbers and actual hours worked by licensed and unlicensed nursing staff per shift. Observations over three days showed non-compliance with the policy, which mandates accessible and updated postings. Interviews revealed a lack of responsibility due to a vacant Human Resource position, leading to oversight of this task.
The facility failed to honor residents' right to self-determination by suspending smoking breaks for all residents due to an ongoing investigation. This decision affected residents with varying cognitive impairments, none of whom exhibited behaviors justifying the restriction. Staff confirmed the suspension and offered nicotine patches as an alternative.
Facility staff failed to develop comprehensive care plans for residents who smoke, lacking necessary interventions for supervision, assessment, or safety risks. Interviews revealed a lack of awareness and responsibility among staff regarding the inclusion of smoking in care plans.
Facility staff failed to notify a resident's guardian in a timely manner about an abuse allegation and an injury of unknown source. The resident, who was severely cognitively impaired, had a large bruise on the chest. Despite the facility's policy requiring notification of changes in condition, the guardian was not informed until several days later due to miscommunication among staff.
A resident with severe cognitive impairment reported being held down by a staff member, but the facility delayed investigating the allegation. The facility's policy requires immediate investigation, including interviews with all involved parties. However, interviews with potential witnesses were conducted 11 days later due to a misunderstanding by the administrator regarding the investigation requirements.
Unlabeled and Expired Eye Drops Found in Medication Cart
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with accepted professional principles, and expired medications were not destroyed. During observation of the 400-hall medication cart, surveyors found one bottle of artificial tear eye drops that was open, undated, and unlabeled; one bottle of Fluorometholone 0.1% eye drops that was open and dated 09/01/25; one bottle of Dorzolamide eye drops that was open and dated 09/07/25; two bottles of artificial tears that were open and undated; one bottle of Lumigan 2.5 eye drops that was open and undated; one container of Cyclosporin 0.05% eye drops single-use vials that was opened and dated 08/23/25; and one loose vial of an unknown eye drop. The facility’s Medication Storage policy stated medications were to be stored according to manufacturer recommendations, and the consultant pharmacist routinely inspected for discontinued, outdated, defective, deteriorated, worn, illegible, or missing labels, with those medications to be destroyed. During interviews, the CMT stated eye drops are only good for 30 days once opened and said if a bottle is not labeled, it could be unstable and should not be used. The RN stated it was the nursing team’s responsibility to ensure medication carts were checked for expired, outdated, and discontinued medications, and that pharmacy helps monthly, but she was not aware outdated and discontinued medications were in the cart. The DON stated medication carts should be checked routinely by nurse managers, CMTs, and the pharmacist, and at minimum monthly by the consultant pharmacist, and that staff should date bottles when opened; however, she did not know expired and outdated medications were in the medication cart. The administrator stated night shift nurses were responsible for removing outdated and expired medications from the medication cart on a weekly basis and that staff were expected to remove eye drops that were outdated or expired.
Failure to Provide Bed-Hold Notice After Hospital Transfers
Penalty
Summary
Facility staff failed to provide written bed-hold information to the resident and/or the resident representative at the time of transfer to the hospital for two residents, Resident #6 and Resident #73. The facility's Bed Hold policy, dated 08/01/25, required written notice at the time of hospitalization transfer that specified the duration of the bed-hold policy and explained the resident's return to the next available bed, and required that a signed and dated copy of the notice be kept in the resident's file. The policy also stated that for emergency transfers, written notice of the bed-hold policy would be provided within 24 hours. Resident #6's record showed two hospital discharges and returns to the facility, but the record did not contain documentation that a bed hold was issued to the resident or the responsible party for either transfer. Resident #73's record also showed two hospital discharges and returns, and likewise did not contain documentation that staff issued a bed hold to the resident or the resident's responsible party. During interviews, RN B said he/she does not complete bed holds and thought social services did; the SSD said he/she was not aware it was his/her responsibility until that week and believed nurses were completing them; the DON said a process was being worked on and that he/she was not aware until that week that bed holds were not being completed; and the administrator said nurses were expected to initiate bed holds and the SSD should follow up within 24 hours, but was not sure if bed holds were being completed.
Incomplete Facility-Wide Assessment of Staffing Needs
Penalty
Summary
Facility staff failed to complete a thorough facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The facility's assessment, dated 10/09/25, included general staffing numbers for RNs, LPNs, CNAs, and CMTs across shifts, but lacked specific direction or guidance regarding shift times and did not address staffing needs for each resident unit. Observations confirmed the facility was organized into multiple halls, but the assessment did not specify staffing requirements for these individual units. During interviews, both the DON and the administrator acknowledged their involvement in the assessment process but were unaware that the assessment needed to include specific staffing needs for each resident unit.
Failure to Implement Infection Control Procedures and Equipment Disinfection
Penalty
Summary
Facility staff failed to adhere to appropriate infection prevention and control procedures, specifically in the use of Enhanced Barrier Precautions (EBP) and the cleaning of mechanical lifts. Observations revealed that staff did not wear required personal protective equipment (PPE), such as gowns and gloves, during the provision of care for two residents with wounds who required EBP. Additionally, there were no EBP signs on the residents' doors to alert staff of the necessary precautions, and staff interviews indicated confusion about who was responsible for ensuring signage and PPE availability. The care plans for these residents either lacked direction for EBP or were not properly implemented, and staff admitted to not following EBP protocols due to the absence of signage. Further deficiencies were noted in the cleaning and disinfection of mechanical lifts used for resident transfers. Staff were observed transferring two residents using mechanical lifts without sanitizing the equipment before or after use, contrary to facility policy and manufacturer guidelines. Interviews with staff revealed a lack of awareness or understanding regarding the need to disinfect the lifts between uses, with some staff only performing this task for residents known to be COVID-positive. The Director of Nursing and Administrator both stated that lifts should be sanitized before and after each use, but there was no consistent practice or clear policy enforcement observed. The residents involved in these deficiencies were assessed as having moderate to severe cognitive impairment and were dependent on staff for care, including wound care and transfers. The facility's policies required EBP for residents with wounds or indwelling devices and mandated staff training and competence in infection control practices. However, the lack of proper signage, inconsistent use of PPE, and failure to disinfect equipment contributed to the observed lapses in infection prevention and control.
Failure to Complete Pre-Employment Screenings for New Hires
Penalty
Summary
Facility staff failed to complete required pre-employment screenings, including Criminal Background Checks (CBC), Employee Disqualification List (EDL) verification, Family Care Safety Registry (FCSR), and Certified Nurse Aide (CNA) Registry checks for six out of ten sampled employees. Personnel files and timecards revealed that several staff members began working before these screenings were completed or documented, contrary to the facility's policies. For example, one registered nurse's file lacked CNA Registry verification, and another CNA's file was missing FCSR, CBC, and CNA Registry documentation. Additionally, some background checks and verifications were dated after the employees' hire or start dates, indicating that screenings were not completed prior to employment as required. Interviews with the Director of Nursing (DON), Human Resources (HR) director, and administrator confirmed that the HR director was responsible for completing all pre-employment screenings before new hires began work. The current HR director reported insufficient training and acknowledged gaps in the screening process, while the administrator was unaware that screenings were not being completed correctly or timely. The facility's own policies require all pre-employment checks to be finalized before staff members start work, but documentation and staff statements confirmed this was not consistently done.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
Facility staff failed to report allegations of abuse and neglect involving two residents to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility's policy mandates immediate investigation and reporting of such allegations, but documentation showed delays in reporting both incidents. In the first case, a resident with severe cognitive impairment reported being slapped by an employee, but the incident was not reported to DHSS until ten days after the initial report. The Director of Nursing (DON) indicated that responsibility for reporting was transferred to the Regional Nurse Consultant due to shift changes, but the required notification was not completed in a timely manner. In the second case, a cognitively intact resident was subjected to verbal neglect when a CNA refused to toilet the resident and made an inappropriate comment. Although the DON stated the incident was reported by phone to DHSS on the day it occurred, there was no documentation to support this claim, and the official report was not submitted until several days later. During the administrator's absence, the Regional Nurse Consultant was responsible for investigations and reporting but failed to ensure timely submission due to an email issue. The administrator was unaware of the late reporting until after returning from vacation.
Failure to Provide Required Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
Facility staff failed to provide necessary care and assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, to ten residents who were dependent on staff for these tasks. Review of facility records, including Minimum Data Sets (MDS), care plans, and shower sheets, revealed that multiple residents received significantly fewer baths or showers than required by their care plans and facility policy. For example, several residents received only one or two baths/showers per month, despite being assessed as needing assistance with bathing at least twice weekly and as needed. Documentation for some residents showed entire weeks or months without any recorded bathing or showering. Interviews with residents confirmed dissatisfaction with the frequency of showers, with some expressing a desire for more regular bathing and noting that their families had raised concerns with staff. One resident reported receiving a shower for the first time in a long period and noted that staff put dirty clothes back on after bathing, despite the availability of clean clothing. These observations were corroborated by staff interviews, where multiple CNAs and a CMT reported chronic understaffing, which prevented them from completing showers, maintaining good hygiene, or providing oral care. Staff described prioritizing other care tasks, such as toileting, due to time constraints, and acknowledged that showers were often delayed or omitted entirely. Nursing staff, including an LPN and the Director of Nursing, acknowledged that showers were not being completed as required, citing high resident acuity and insufficient staffing as contributing factors. The DON reported being aware of the issue and described attempts to track and reschedule missed showers, but the documentation and staff interviews indicated that the deficiency persisted. The failure to provide regular bathing and hygiene assistance was directly linked to inadequate staffing and time management, as reported by both direct care staff and nursing leadership.
Insufficient Staffing Resulting in Missed Resident Care and Hygiene
Penalty
Summary
Facility staff failed to provide sufficient nursing staff to meet the care needs of residents, as required by the facility assessment and federal regulations. Observations and interviews revealed that multiple residents did not receive adequate personal hygiene, including regular showers, grooming, and oral care. Several residents were observed with long facial hair, disheveled or greasy hair, and long fingernails, indicating a lack of assistance with personal care. Residents reported going weeks without showers and feeling unclean, while staff confirmed that showers and hygiene tasks were often missed due to insufficient staffing. Staff interviews consistently described being assigned to care for large numbers of residents, sometimes up to 28 per aide, including many who required mechanical lifts for transfers. Staff reported that they often had to leave their assigned halls unattended to find assistance for lift transfers, further reducing the time available for other care tasks. During mealtimes, there were not enough aides to assist residents, leading to situations where one staff member was responsible for feeding multiple residents. Non-nursing staff, such as the housekeeping supervisor and social service director, were observed assisting with resident care during surveyor visits, but staff indicated this was not typical practice and only occurred due to the presence of surveyors. The facility's own assessment identified the need to adjust staffing based on resident acuity, census, and care needs, including the high number of residents requiring mechanical lifts. Despite this, staff and residents reported that the actual staffing levels were inadequate to meet these needs. The Director of Nursing and Administrator acknowledged that showers were not completed as scheduled and that complaints about staffing were received from residents and families. The deficiency affected at least five sampled residents and had the potential to impact all residents in the facility.
DON Worked as Charge Nurse Despite High Census
Penalty
Summary
Facility staff failed to ensure that the Director of Nursing (DON) did not work as a charge nurse when the facility's average daily occupancy was 60 or more residents, as required by regulation. The facility assessment indicated an average daily census of 77 residents and identified the DON as necessary for resident care, but did not specify if the DON was a full-time staff member or how many hours were dedicated to the DON role. Additionally, the assessment did not clarify whether the DON was allocated to direct care duties. Review of the nursing schedules for September and October showed that the DON worked multiple night shifts as a charge nurse while the census ranged from 76 to 81 residents. During interviews, the DON confirmed working the floor to provide resident care due to a nurse being out with a medical issue and the recent resignation of the Assistant Director of Nursing (ADON). The DON stated that regional support was assisting with DON tasks during these periods. The Administrator also acknowledged awareness that the DON was working the floor.
Failure to Provide Discharge Notice and Allow Resident Reentry After Hospitalization
Penalty
Summary
Facility staff failed to provide a required discharge notice for a resident who was sent to the emergency department for suicidal ideation. The resident's medical record did not contain a 30-day discharge notice or an emergency discharge notice, as required by facility policy. The Social Service Director, responsible for discharge planning, was unaware that the resident had been denied reentry to the facility and was not familiar with the rules regarding discharging a resident and denying reentry. The administrator confirmed that the resident had a history of suicidal ideations and, after the hospital attempted to discharge the resident back to the facility, the facility decided to deny reentry due to an inability to provide one-on-one care, which they determined was necessary for the resident's safety. The facility's policy requires that residents receive a transfer/discharge notice with specific information, including the reason for discharge, effective date, location, appeal rights, and contact information for advocacy agencies, at least 30 days prior to discharge unless it is an emergency. In this case, the required notice was not provided, and the facility did not follow the proper process for discharging the resident or for denying reentry after hospitalization. Both the Social Service Director and the administrator indicated a lack of awareness of the regulatory requirements for discharge and reentry, contributing to the deficiency.
Failure to Notify Physician and Family of Resident Change in Condition and Fall
Penalty
Summary
Facility staff failed to notify both the physician and the resident's family or representative in a timely manner following significant changes in a resident's condition. Specifically, a resident with cognitive impairment, a history of stroke, high blood pressure, and dementia was found on the floor in their room, but there was no documentation that the family was informed of this fall. Additionally, when the same resident experienced episodes of nausea, projectile vomiting, and a period of unresponsiveness, there was no documentation that the physician was notified of this change in condition. Interviews with facility staff, including the DON, administrator, and LPN, revealed uncertainty and lack of recall regarding whether appropriate notifications were made. The resident's guardian confirmed not being informed about either the fall or the medical episode, and stated that such information was important due to the resident's medical history and inability to communicate these events. The Nurse Practitioner reported being notified of the fall but not the subsequent medical episode, despite being present in the building at the time.
Failure to Maintain Safe and Functional Wheelchairs for Multiple Residents
Penalty
Summary
Facility staff failed to maintain wheelchairs in safe and functional condition for three residents, as observed during a survey. One resident with moderate cognitive impairment was seen using a wheelchair with both armrests torn. Another resident with severe cognitive impairment was observed in a wheelchair with worn armrests and missing vinyl. A third resident, who was cognitively intact, was found using a wheelchair with a bent metal piece connecting the chair to the leg rest, which had been temporarily secured with a medical bandage. Interviews with facility staff, including the maintenance director, RN, administrator, and DON, revealed that staff were expected to report and document wheelchair concerns in a maintenance log, but these issues had not been reported or addressed. The maintenance director was unaware of the problems and stated that repairs were not provided for personal wheelchairs, while the administrator and DON acknowledged that torn armrests and damaged wheelchairs could pose safety concerns, such as the potential for skin tears. The facility's policy required routine inspection and maintenance of resident care equipment, but this was not followed in these cases.
Failure to Provide Adequate Personal Hygiene Assistance
Penalty
Summary
Facility staff failed to provide adequate care to meet the hygiene needs of four residents who required assistance with activities of daily living (ADLs), specifically in the areas of nail care and facial hair grooming. Observations revealed that residents with severe or moderate cognitive impairment and physical limitations, who did not exhibit behaviors of rejecting care, were found with long and dirty nails, unbrushed or matted hair, unkempt facial hair, and clothing in poor condition. These residents were assessed as needing partial to maximum assistance with personal hygiene, yet their care plans and observed conditions indicated that their hygiene needs were not being met as required. Interviews with staff, including CNAs, RNs, the administrator, and the DON, confirmed that staff were responsible for providing nail care and facial hair grooming on shower days and as needed, as well as daily hair brushing and clothing changes. However, staff acknowledged that due to a shortage of shower aides, residents were only being showered once a week instead of the intended twice a week, which contributed to lapses in personal hygiene care. The facility's policy directed staff to assist residents with ADLs but lacked specific guidance on when and how to provide personal hygiene, further contributing to inconsistent care.
Misappropriation of Narcotic Medications by LPN
Penalty
Summary
The facility staff failed to prevent the misappropriation of narcotic medications belonging to seven residents. An LPN was found to have taken these medications without authorization. The facility's Abuse, Neglect, and Exploitation Policy defines misappropriation as the wrongful use of a resident's belongings or money without permission. The facility's investigation revealed discrepancies in the narcotic counts, with the LPN inaccurately subtracting pills from the count for multiple residents. Despite the facility's conclusion that no pills were misappropriated, the police found empty narcotic cards with residents' names in the LPN's car. The investigation showed that the LPN had signed out medications but subtracted more pills than administered, and in some cases, wasted pills without a witness. The police report confirmed the presence of empty medication cards in the LPN's car, which were linked to the residents. The residents involved were cognitively intact and experienced occasional pain, receiving scheduled and as-needed pain medications. The facility's investigation was unable to substantiate the misappropriation despite the evidence found by the police. Interviews with the facility's administrator and DON indicated that they were aware of the allegations and had initiated an investigation. However, they concluded that the narcotic counts were correct and the investigation was unsubstantiated. The LPN did not cooperate with the investigation and did not return to the facility. The LPN claimed to have mistakenly taken narcotic log sheets and denied taking any medications from the facility, despite the evidence found in their car.
Failure to Report Alleged Misappropriation of Narcotics
Penalty
Summary
The facility staff failed to report an allegation of misappropriation of narcotics to the State Survey Agency within the required 24-hour timeframe, as per their policy and state law. This deficiency involved seven residents out of a sample of ten, with a facility census of 78. The facility's Abuse, Neglect, and Exploitation Policy mandates reporting alleged violations to the administrator, state agency, and other required agencies within specified timeframes. The issue arose when discrepancies in the narcotic count were noted, and medications were reportedly given outside the scheduled timeframe by an LPN. Despite attempts to interview the LPN, they did not return to the facility, and the Director of Nursing (DON) contacted the police after empty narcotic cards were found in the LPN's car. The facility did not report the alleged misappropriation to the Department of Health and Senior Services within the required timeframe. Interviews with the administrator, DON, and Assistant Director of Nursing (ADON) revealed that the corporate office advised against reporting the incident, as the investigation did not substantiate any misappropriation despite the discovery of empty narcotic cards. The DON and ADON expressed concerns about the narcotic counts and the inability to interview the LPN. The Regional Nurse Consultant also confirmed awareness of the situation but stated that without a proven allegation, it was not deemed reportable to the state.
Neglect in Resident Transportation Leads to Severe Injuries
Penalty
Summary
Facility staff failed to protect a resident from neglect during transportation in a facility vehicle. The incident occurred when the staff did not properly secure the resident with a shoulder strap while transporting them from a dialysis clinic. As a result, when the vehicle came to an abrupt stop, the resident fell over the lap belt and out of the wheelchair, leading to multiple fractures, including both femurs, thoracic spine, and an upper arm. The resident involved was cognitively intact but had impairments in both lower extremities and was dependent on staff for movement. The facility's investigation revealed that the van driver, identified as Driver A, did not secure the shoulder strap because the resident did not like it. The driver was not trained using the manufacturer's Device User Instructions Manual, and the training provided did not include the use of the shoulder strap. The administrator acknowledged that the facility did not monitor whether transport drivers were securing residents properly before transport. Additionally, the original training documentation for Driver A could not be located, indicating a lapse in ensuring that staff were adequately trained and compliant with safety protocols.
Dishwasher Temperature Non-Compliance
Penalty
Summary
The facility staff failed to maintain the mechanical dishwasher in good repair, resulting in ineffective washing and sanitizing of dishes, which could lead to cross-contamination affecting all residents. Observations revealed that the dishwasher's water temperature was consistently below the required 120 degrees Fahrenheit, with readings of 102, 110, 106, and 108 degrees Fahrenheit during various wash and rinse cycles. The facility's Dishwasher Temperature policy mandates that the water temperature for low-temperature dishwashers with chemical sanitation should be 120 degrees Fahrenheit, and temperatures should be recorded prior to each meal or after the dishwasher is emptied or refilled. However, the facility did not have a temperature log for June 2024, indicating a lack of compliance with their own policy. Interviews with the dietary staff and supervisor revealed a lack of awareness and adherence to the required temperature standards. Dietary Aide F admitted to not checking the dishwasher temperature on the day of observation and was unsure if others had done so. Dietary Aide G incorrectly believed that any temperature over 100 degrees was acceptable, while the Dietary Supervisor acknowledged that the dishwasher usually required three cycles to reach the correct temperature but was unaware of the missing temperature log for June 2024. The administrator also expressed a lack of awareness regarding the correct dishwasher temperature and any existing issues prior to the survey, indicating a systemic failure in monitoring and maintaining kitchen equipment.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility staff failed to protect the personal and medical information of residents, as evidenced by several observations and interviews. On multiple occasions, electronic medical records (EMR) were left open and unattended on a tablet at the nurses' desk, making resident information visible to visitors, residents, and staff. Interviews with various staff members, including a CNA, LPN, and the Director of Nursing, confirmed that the protocol was to close or clear the screen when unattended to ensure privacy, but this was not adhered to. Additionally, resident information was publicly displayed in the facility, compromising confidentiality. Observations revealed that care instructions, adaptive equipment lists, and dietary orders were posted in public areas, such as the CNA station and on an ice chest, making them visible to anyone passing by. Interviews with the facility's staff, including the Corporate Quality Assurance representative and the administrator, acknowledged that such information should not be publicly accessible and should be kept private to protect resident privacy and dignity. The facility also failed to provide personal privacy for residents, as observed in the cases of two residents who were exposed in their rooms with doors open to the hallway. Staff walked by without assisting or ensuring privacy by closing doors or using privacy curtains. Interviews with CNAs, LPNs, and the Director of Nursing indicated that staff were expected to provide privacy by covering residents or using privacy curtains, but this was not done. The administrator admitted to being unaware of the lack of privacy curtains and acknowledged the expectation for residents to have privacy curtains around their beds.
Deficiencies in Documentation and Adherence to Physician Orders
Penalty
Summary
The facility failed to maintain professional standards of care by not documenting follow-up neurological assessments after falls for four residents. These residents experienced unwitnessed falls, and the facility's policy required neurological checks to be conducted and documented. However, the medical records for these residents did not contain the necessary documentation of neurological checks, which is a critical step in assessing potential brain injuries following a fall. Additionally, the facility did not adhere to physician orders for two residents who required tube feedings and skin assessments. One resident did not receive documented tube feedings and flushes as ordered, and another resident did not have weekly skin assessments documented as required. Furthermore, the facility failed to complete weekly weights for a newly admitted resident, which is essential for monitoring the resident's nutritional status and overall health. The facility also failed to clarify a medication order and obtain necessary lab values for a resident receiving Lithium, a medication that requires regular blood level monitoring to prevent toxicity. The resident's physician order sheet did not include an order for lithium level monitoring, and staff interviews revealed a lack of awareness and follow-through on this critical aspect of care. These deficiencies highlight significant lapses in following established protocols and physician orders, potentially compromising resident safety and care quality.
Inadequate Bathing and Hygiene Care for Residents
Penalty
Summary
The facility staff failed to provide adequate bathing and personal hygiene for six out of twelve sampled dependent residents, leading to a deficiency in care. The facility's policy requires that residents receive showers as per request or schedule, with CNAs responsible for assessing skin changes during bathing. However, observations and interviews revealed that several residents had greasy, disheveled hair, strong body odor, and expressed dissatisfaction with the infrequency of showers. For instance, Resident #9, with moderate cognitive impairment and Alzheimer's, was observed with greasy hair and a strong odor of urine, despite the care plan indicating a need for extensive assistance with bathing twice weekly. Resident #17, also with moderate cognitive impairment, reported not having received a shower in over two weeks, contrary to the care plan's directive for showers twice weekly. Similarly, Resident #21, who is cognitively intact but requires maximal assistance with showering, was observed with greasy hair and body odor, having received only one shower in the documented period. Other residents, such as Resident #32, #46, and #47, also exhibited signs of inadequate personal hygiene, with observations noting greasy hair and skin, and residents expressing concerns about the lack of regular showers. Interviews with facility staff, including CNAs, an LPN, the Director of Nursing, and the Administrator, highlighted staffing issues as a contributing factor to the deficiency. Staff acknowledged that showers were not being completed as per policy due to insufficient personnel, with only one shower aide available when two were needed. The Director of Nursing and Administrator noted that showers should be documented in the residents' electronic health records, but there was a discrepancy between the documentation and the actual provision of care, leading to residents not receiving the necessary hygiene assistance.
Failure to Ensure Safe Environment and Medication Self-Administration
Penalty
Summary
The facility staff failed to ensure a safe environment free from accident hazards by not removing chemicals from the dining room during meal service. Observations revealed a container of sanitizing wipes on a dining room table where five residents were seated. Interviews with staff, including a CNA, RN, and Corporate Quality Control staff, confirmed that chemicals should not be stored within residents' reach, especially for those with dementia, as it poses a safety risk. The facility lacked a policy for chemical storage or safety, contributing to this oversight. Additionally, the facility did not assess the safety of self-administration of medications for two residents who had medications within reach in their rooms. One resident, diagnosed with COPD, had an inhaler from home without a self-medication assessment or care plan direction for its use. The resident was unaware of any order for self-administration but used the inhaler as needed. Another resident, diagnosed with Gastrointestinal Reflux Disease, had antacids at the bedside without a self-medication assessment or care plan direction. The resident reported taking antacids for heartburn, provided by staff, without a formal order for self-administration. Interviews with facility staff, including a CMT, RN, and the administrator, revealed a lack of awareness and adherence to the facility's policy on self-administration of medications. Staff were not aware of any residents authorized to keep medications at the bedside, and there was no documentation of assessments or orders for self-administration in the medical records. The facility's policy requires an interdisciplinary team assessment and documentation for residents to self-administer medications, which was not followed in these cases.
Failure to Ensure Appropriate Diagnosis and Duration for Psychotropic Medications
Penalty
Summary
The facility staff failed to ensure that medication regimens were free from unnecessary medications, as evidenced by the lack of appropriate diagnoses for the use of psychotropic medications in three residents. Specifically, Resident #20 was prescribed Clonazepam without a corresponding diagnosis, Resident #32 was prescribed Buspirone without a diagnosis of anxiety, and Resident #45 had an order for Vraylar with a diagnosis simply listed as antipsychotic, which did not correlate with a specific condition. Interviews with various staff members, including a Registered Nurse, Licensed Practical Nurse, Certified Medication Technician, Director of Nursing, and Corporate Quality Assurance representative, revealed a lack of adherence to the policy that requires a diagnosis to match each prescribed medication. Additionally, the facility failed to limit as-needed psychotropic medication orders to 14 days for Resident #60, who had severe cognitive impairment and diagnoses of schizophrenia, anxiety, and depression. The resident's orders for Buspirone and Lorazepam did not include a 14-day stop date, contrary to the facility's policy. Interviews with the Director of Nursing and Corporate Quality Assurance representative confirmed that there should be a 14-day stop date for such medications, and a mock survey had previously identified this issue as a problem with physician orders.
Deficiencies in Catheter Care and Documentation
Penalty
Summary
The facility staff failed to obtain a reason for the use of a urinary catheter for two residents, and did not obtain orders for the catheter size or update a care plan for one resident. Additionally, the staff did not appropriately document catheter care for another resident. The facility's Catheter Care policy, dated September 2021, lacked direction for catheter orders, care planning, documentation, or indication for use. Resident #46 was assessed as cognitively intact and intermittently catheterized, but the care plan was not updated to reflect the change from indwelling to intermittent catheterization. The physician order for this resident did not include an indication of use or size of the catheter. Resident #281 was admitted with an order for an indwelling catheter, but the order did not contain an indication for use. The Treatment Administration Record showed that staff failed to document catheter care on several shifts. Interviews with staff revealed a lack of clarity and consistency in catheter care orders and documentation. The Registered Nurse acknowledged that catheter orders should include specific details and be part of a care plan, while the Corporate Quality Control staff noted that documentation was an issue, partly due to challenges with the electronic health record system. The administrator deferred clinical questions to the nursing staff and mentioned that management staff meet to discuss catheter-related risks and infections.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff responsible for resident care per shift. The facility's policy, dated 09/01/21, mandates that staffing information be made readily available in a readable format to residents and visitors at any given time. This information should include the facility name, current date, resident census, and the total and actual hours worked by Registered Nurses, Licensed Practical Nurses/Licensed Vocational Nurses, and Certified Nurse Aides. The policy also requires that the staffing sheet be updated to reflect staff absences due to callouts and illness and that it be posted at the beginning of each shift in a prominent place accessible to residents and visitors. Observations on three consecutive days showed that the staff postings did not include the required information in an easily accessible manner. Interviews revealed a lack of awareness and responsibility for this task. A regional staff member indicated that the night shift nurse was responsible for posting the information, with follow-up by the Human Resource person. However, the administrator acknowledged that the Human Resource position was vacant, and the task had been overlooked. The administrator stated that the posting was done on the day of the interview and would remain their responsibility until a new Human Resource person was hired.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility staff failed to ensure residents were allowed to make choices about aspects of their lives in the facility, specifically regarding their right to smoke. Four residents, who were their own responsible persons, were not allowed to smoke due to an ongoing investigation. The facility's Resident Rights Policy states that residents have the right to self-determination and to make choices about significant aspects of their lives. However, the facility suspended smoking breaks for all residents following an incident where one resident went outside to smoke independently. This decision affected residents with varying levels of cognitive impairment, none of whom exhibited behaviors that would justify such a restriction. Interviews with the residents and staff revealed that the suspension of smoking breaks was a direct response to the incident involving one resident. The Administrator, Director of Nursing, and other staff members confirmed that smoking was put on hold for all residents pending the investigation. Residents were informed of this decision and offered nicotine patches as an alternative. The facility is also considering turning into a non-smoking facility. This action was taken without considering the individual rights and preferences of the residents, leading to a deficiency in promoting and facilitating resident self-determination.
Failure to Develop Comprehensive Care Plans for Residents Who Smoke
Penalty
Summary
Facility staff failed to develop a comprehensive person-centered care plan for residents who smoke cigarettes. The facility's smoking policy requires staff to ask about tobacco use during the admission process and during each quarterly or comprehensive Minimum Data Set (MDS) assessment. However, the facility did not have a policy for the development of comprehensive care plans. Review of the care plans for four residents who smoke showed that none contained interventions for supervision, assessment, or safety risks related to smoking. These residents had varying levels of cognitive impairment and no exhibited behaviors, yet their care plans lacked necessary smoking-related interventions. Interviews with facility staff, including an LPN, the Director of Nursing, the administrator, and the MDS coordinator, revealed a lack of awareness and responsibility regarding the inclusion of smoking in care plans. The MDS coordinator admitted that without a completed smoking assessment, it was difficult to know what interventions to add to the care plans. The Director of Nursing and the administrator both believed that smoking should be included in the care plans and that it was the MDS coordinator's responsibility to ensure this. The deficiency was identified during a survey, highlighting the facility's failure to meet the residents' medical and nursing needs related to smoking.
Failure to Notify Guardian of Abuse Allegation and Injury
Penalty
Summary
Facility staff failed to notify the guardian of a resident in a timely manner regarding an allegation of abuse and an injury of unknown source. The facility's policy requires notifying the resident, family, or representative of any changes in condition, including health deterioration or injuries. The resident involved was assessed as severely cognitively impaired, and the incident was documented in the facility's investigation. However, there was no documentation indicating that the resident's guardian was informed of the situation. Interviews revealed a breakdown in communication among staff members. The administrator assumed the guardian had been notified, but it was not done. RN B claimed to have instructed LPN C to contact the guardian, but LPN C stated they were not given such instructions and only completed a skin assessment and statement. The guardian was eventually informed of the incident several days later, which was not in accordance with the facility's policy or the guardian's preference for timely notification.
Delayed Investigation of Abuse Allegation
Penalty
Summary
The facility staff failed to conduct a thorough investigation following an allegation made by a resident who reported being held down by a staff member. The facility's policy on abuse and neglect mandates an immediate investigation, including interviews with all involved parties, such as the alleged victim, perpetrator, witnesses, and others who might have knowledge of the incident. However, the investigation was delayed, and interviews with potential witnesses, including the resident's roommate and visitors, were not conducted until 11 days after the initial report. The resident involved was assessed as severely cognitively impaired, which may have impacted their ability to recall or articulate the incident. The investigation was initiated after a Certified Nursing Assistant reported a large bruise on the resident's chest to a Registered Nurse. Despite this, the facility administrator misunderstood the requirement for a comprehensive investigation, believing the report to the state was merely informational. This misunderstanding led to a significant delay in gathering crucial information from other residents and potential witnesses.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rolla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolla Presbyterian Manor | 0.4 mi | ★★★★★ | 0 | 0 |
| Cedar Pointe | 1.9 mi | ★★★★★ | 0 | 0 |
| Phelps Health | 2.1 mi | ★★★★★ | 0 | 0 |
| Silverstone Place | 2.2 mi | ★★★★★ | 1 | 0 |
| St James Living Center | 8.3 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Aurora Health And Rehabilitation.
100% money-back within 48 hours.
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.