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 Aurora Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to Treat a Resident with Dignity and Respect: A CNA spoke rudely and in a disrespectful manner to a resident, including talking down to the resident and stating, “I told you that I was coming back to change you!” The resident’s family reported the incident, and the SSD and Administrator verified the CNA did not treat the resident with dignity and respect, contrary to facility policy requiring staff to treat residents with kindness, respect, and dignity.
A resident with aphasia, cognitive communication deficit, and severe cognitive impairment had an Advance Health Care Directive signed in his name and notarized by HR, making his mother the health care agent. HR stated the resident was not given an explanation or education about the directive, she did not check the chart for the RP, and she notarized the paperwork after the mother said it was needed for transfer to another facility.
Unlocked Medication Cart Left Unattended: Surveyors observed one of eight medication carts unlocked and unattended while an LPN was away from it. Facility policy required all drugs and biologicals to be stored in locked compartments, and the LPN confirmed he left his cart unlocked. He stated that leaving the cart unlocked and unattended could allow resident access to medications that could cause harm.
Unsanitary kitchen ductwork near food prep and storage areas. Surveyors observed a black mold-like substance on ventilation ductwork above the stove and in the dry storage room during kitchen tours, with dark discoloration along the seams and underside of the duct. The Dietary Mgr stated it had been present for several months, and the Plant Ops Mgr and Administrator confirmed the condition increased the risk for food contamination and foodborne illness.
Damaged wheelchair armrests left in use: A resident was observed seated in a wheelchair with both armrests split, torn vinyl hanging loose, exposed hard plastic, and a protruding screw on one side. The resident stated staff knew the wheelchair had been in that condition for a while. Facility policy required weekly checks for tears, cracks, and missing screws, and the DON/Administrator confirmed the armrests were broken and in poor condition. The resident had schizoaffective disorder, bipolar type, and DM with diabetic peripheral angiopathy, and was cognitively intact.
Failure to Apply Ordered Hand Splints: A resident with bilateral hand contractures, CVA-related hemiplegia, and severely impaired cognition was observed without her ordered hand splints in place. Records directed staff to apply bilateral hand splints for 8 hours daily, but a CNA said restorative was responsible, and the restorative nurse said she was unaware the resident was supposed to wear them. A family member reported staff no longer applied the splints, and only the right-hand splint was sometimes applied by family.
An unlocked and unattended med cart containing respiratory treatment medications was observed on a unit with residents wandering nearby. The RT confirmed the cart was left unsecured, and the Administrator confirmed med carts should be locked when not in active use.
Medication pass observations found that an LPN administered meds from pharmacy-prepared pouches that did not match the MAR for two residents. One resident received omeprazole from a pouch labeled 40 mg while the MAR ordered 20 mg tablets, and another resident received desmopressin from a pouch labeled 0.2 mg while the MAR ordered 0.1 mg tablets; the DON stated she was unaware of the discrepancies, and the LPNs confirmed the mismatches.
Care plans were not followed for a resident’s hand splints and for nail care for two residents. One resident with stroke-related deficits was repeatedly observed without ordered bilateral hand splints, and a restorative nurse confirmed they were not being applied as ordered. Two residents with ADL/functional deficits were observed with long, jagged, dirty fingernails despite care plans for personal hygiene; the DON and MDS staff acknowledged the nail care was part of the planned care and was not being implemented.
Failure to Provide Nail Hygiene for Two Residents: Two residents were observed with long, jagged, and dirty fingernails, with brown substance under the nails and stated preferences for trimming and cleaning. CNA staff said they were responsible for cleaning nails during morning care, and the DON confirmed CNAs were responsible for cleaning and nurses for ensuring nails were adequately trimmed. One resident had moderate cognitive impairment with diagnoses including a displaced ulna fracture and muscle weakness, and the other had metabolic encephalopathy with moderate cognitive impairment.
A resident with paraplegia and impaired sensation sustained a second-degree burn on the elbow after an LPN, despite knowing facility policy, set up a portable heater in the resident's room at the resident's request. The injury was discovered by another nurse and CNA, and subsequent infection required antibiotic treatment. Facility policy prohibits space heaters due to fire and burn risks.
A resident was incorrectly coded as using a trunk restraint in the MDS Quarterly assessment. Observations and interviews confirmed that the resident has never used a restraint, and there was no physician order for one. The MDS Nurse acknowledged the error, and the Administrator confirmed that incorrect coding could affect the resident's level of care.
A facility failed to prevent infection by improperly handling suction tubing during respiratory care for a resident. The tubing was placed in a trash can, picked up, and reused, contrary to infection control policies and physician's orders. Interviews confirmed the tubing should have been replaced to prevent contamination.
Failure to Treat a Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when a CNA spoke rudely and in a disrespectful manner to Resident #2. The facility policy titled Resident Rights stated that employees shall treat all residents with kindness, respect, and dignity. A grievance report documented that the resident’s family reported the CNA talked down to the resident and was overheard saying, “I told you that I was coming back to change you!” The SSD stated he followed up after discharge and was told by the family that the CNA had talked down to the resident on the day of discharge, and he immediately reported the incident to the DON. The Administrator verified the facility investigated the report and found the CNA did not provide good customer service to the resident, which meant the resident was not treated with dignity and respect. Resident #2 was admitted with Acute Respiratory Failure and was later discharged home.
Failure to Provide Advance Directive Education Before Notarizing POA Paperwork
Penalty
Summary
The facility failed to ensure a resident was provided education and sufficient information regarding advance directives and the implications of assigning a Power of Attorney prior to obtaining the resident's agreement. Resident #1 was admitted with diagnoses including aphasia following cerebral infarction and cognitive communication deficit, and the admission record listed the resident's spouse as the responsible party. The MDS assessment with an ARD of 2/17/26 showed a BIMS score of 00, indicating severe cognitive impairment. The Advance Health Care Directive was signed with Resident #1's name and notarized by the facility's Human Resources personnel, making the resident's mother the health care agent. HR stated she was called to notarize paperwork after the mother said an advance directive was needed for transfer to another facility. HR said she asked the resident if it was okay for his mother to sign his name and he indicated that it was, but she did not provide any explanation or education about the details of the directive, did not check the medical record to determine who was listed as the responsible party, and later agreed she should not have notarized the form. The Administrator stated staff are not to notarize any forms for residents and/or visitors and expected HR would not have notarized the form.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure medications were stored in a safe and secure manner when one of eight medication carts was left unlocked and unattended. Facility policy titled Medication Storage stated that all drugs and biologicals would be stored in locked compartments, including medication carts. During an observation on 5/19/26 at 3:30 PM, surveyors found a medication cart located midway down the hall that was unlocked while LPN #1 was down the hall away from it. In an interview on 5/19/26 at 3:36 PM, LPN #1 confirmed the cart was his and stated he had left it unlocked, agreeing that he should have locked it before walking away. He also stated that leaving the cart unlocked and unattended could allow resident access to medications that could cause harm. The Administrator stated on 05/19/26 at 7:00 PM that it was her expectation that LPN #1 would have locked the cart before walking away.
Unsanitary Kitchen Ductwork Near Food Prep and Storage Areas
Penalty
Summary
The facility failed to maintain food service areas in a sanitary manner to prevent the potential for food contamination. During an initial kitchen tour on 1/20/2026 with the Dietary Manager, surveyors observed a black mold-like substance on the ventilation ductwork above the stove, with visible dark discoloration along the seams and underside of the duct, and a similar black mold-like substance on ductwork in the dry storage room extending along multiple sections of the duct. Both areas were located near food preparation and food storage locations. The Dietary Manager stated the substance had been present for several months. Later that day, the Plant Operations Manager confirmed the black mold-like substance was present on the ductwork above the stove and food preparation areas and in the dry storage room, and stated it increased the risk for food contamination. The Administrator also confirmed there was a risk for foodborne illness related to the substance above the stove and food preparation areas.
Damaged wheelchair armrests left in use
Penalty
Summary
The facility failed to ensure that Resident #12’s wheelchair was maintained in a safe manner. During observation, the resident was seated in the wheelchair with significant damage to both armrests: each armrest was split in half, the black vinyl covering was torn and hanging loosely, the hard gray plastic interior was exposed, and a protruding silver screw was visible on the right armrest. The resident’s arms were resting directly on the exposed plastic, and she stated that staff knew about the condition of the wheelchair and that it had been like that for a while. Facility policy required wheelchairs to be maintained in a safe and operable manner, with weekly preventative maintenance including checking seats, backs, armrests, and cushions for tears, cracks, or missing screws and replacing or repairing them if present. The Administrator stated that aides were responsible for reporting broken or damaged equipment in the maintenance log so repairs could be made, and confirmed that Resident #12’s wheelchair armrests were broken and in poor condition. Resident #12 was admitted with diagnoses including Schizoaffective Disorder, Bipolar Type, and Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy, and her MDS showed a BIMS score of 15, indicating she was cognitively intact.
Failure to Apply Ordered Hand Splints
Penalty
Summary
The facility failed to ensure prescribed splinting devices were applied as ordered for a resident with bilateral hand contractures. The resident had diagnoses including cerebral infarction due to embolism of the left middle cerebral artery and hemiplegia and hemiparesis affecting the right dominant side, and her MDS indicated severely impaired cognitive skills for daily decision making. Facility records showed a restorative care referral to apply bilateral hand splints for 8 hours daily, and the Kardex directed staff to wash and dry both hands, provide PROM, and apply bilateral hand splints for 8 hours daily. During observation, the resident was found in bed with no hand splints in place, and a soft hand roll was in her left hand. A family member stated therapy had previously applied hand splints to both hands, but staff no longer applied them, and the family member only applied the right-hand splint for about an hour a day. Staff interviews confirmed the splints were not being applied as ordered: a CNA stated restorative was responsible, while the restorative nurse stated the facility did not have a restorative program at the time and she was not aware the resident was supposed to wear the splints. The rehabilitation director confirmed the resident last received OT for contractures and splinting in February 2024 and stated that if the splints were not applied, the contractures could worsen.
Unsecured Medication Cart
Penalty
Summary
The facility failed to ensure medications were secured properly to prevent unauthorized access. Review of a Med Pass check-off list showed no date and included a statement that medications were locked within the cart when the cart was out of direct line of vision, with signature lines for both the learner and observer. During an observation on 1/20/2026 at 8:14 AM, an unlocked and unattended medication cart was found on the 200 unit with residents wandering in the immediate area. The cart contained various respiratory treatment medications used by the Respiratory Therapist. During an interview at 8:15 AM, the Respiratory Therapist confirmed the cart was left unlocked and unattended and stated residents were wandering while it remained unsecured. During an interview at 10:30 AM, the Administrator confirmed medication carts should be locked at all times unless in active use, particularly when left unattended.
Medication Labels Did Not Match Physician Orders
Penalty
Summary
The facility failed to ensure medications were accurately labeled and matched the physician's orders for two residents observed during medication pass. During observation, an LPN retrieved pharmacy-prepared multi-dose pouches and administered medications to both residents even though the MARs did not match the medication labels on hand. The pharmacy policy reviewed stated that strip packaging is provided for efficient and accurate medication administration and accountability of routine oral solid medications and reminded staff to always check the MAR prior to administering medications. For one resident, the January 2026 MAR showed an order for omeprazole delayed release 20 mg, two tablets by mouth daily for GERD, while the pouch was labeled omeprazole delayed release 40 mg, one tablet daily for GERD. For the other resident, the MAR showed desmopressin acetate 0.1 mg, two tablets via PEG tube three times a day for diabetes insipidus, while the pouch was labeled desmopressin acetate 0.2 mg, one tablet three times a day; the same pouch also contained baclofen 10 mg, 0.5 tablet twice daily. The LPNs confirmed the discrepancies, and the DON stated she was unaware of them. One resident was cognitively intact with a BIMS of 15, and the other had a history of intracranial injury and persistent vegetative state with staff-assessed severe impairment in decision making.
Care Plans Not Followed for Nail Care and Hand Splints
Penalty
Summary
The facility failed to implement a comprehensive care plan related to hand splint use for Resident #61 and nail care for Resident #66 and Resident #89. The facility policy stated that each resident’s comprehensive person-centered care plan must include measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. Review of three residents’ care plans and observations showed that the planned care was not being carried out as documented. Resident #66’s care plan identified an ADL self-care performance deficit related to increased weakness and limited mobility, with interventions for personal hygiene and oral care requiring set-up and clean-up assistance from one staff member. During observation and interview, the resident stated a preference for nails kept short and smooth and requested trimming. The resident’s nails were observed to be about 1/4 inch from the nail bed, jagged and rough in multiple areas, with a brown substance under several nails. The DON acknowledged the nails were long, dirty, and jagged and confirmed the facility failed to maintain the resident’s nails at an appropriate and safe length and in clean condition. The RN MDS Coordinator also acknowledged that nail care was part of personal hygiene and that the care plan for personal hygiene and nail care had been developed but not implemented. Resident #89’s care plan identified a functional abilities deficit related to impaired balance and musculoskeletal impairment, with an intervention stating she was dependent on two assistants to maintain personal hygiene. Observations showed her fingernails were approximately one inch long, jagged, and had a brown substance underneath them, and the resident stated she wanted them trimmed and cleaned. CNA #1 stated staff were responsible for cleaning fingernails during morning care and that the wound treatment nurse cut nails if residents were diabetic, while the DON confirmed CNAs were responsible for cleaning fingernails and nurses were responsible for ensuring nails were adequately trimmed. For Resident #61, the care plan directed staff to wash and dry both hands, provide PROM, apply bilateral hand splints, and have the resident wear the splints for 8 hours daily. However, observations on multiple occasions showed the resident without hand splints, with one splint found on the bedside dresser, and the restorative nurse confirmed the splints were not being applied as ordered. The MDS Nurse stated there was a break in communication and confirmed the care plan was not followed for the splints.
Failure to Provide Nail Hygiene for Two Residents
Penalty
Summary
The facility failed to provide personal hygiene, including nail care, for two sampled residents. Facility policy titled, Resident Hygiene Care of Fingernails/Toenails, stated nail care includes cleaning and trimming as needed to keep nails trimmed and prevent infections. For Resident #89, an observation and interview on 1/20/2026 showed fingernails approximately one inch long, jagged, and with a brown substance under them, and the resident stated she wanted them trimmed and cleaned. A later observation on 1/21/2026 found the fingernails remained long, jagged, and dirty. CNA #1 stated staff were responsible for cleaning fingernails during morning care and that the wound treatment nurse cut nails for diabetic residents, while the DON confirmed CNAs were responsible for cleaning fingernails and nurses for ensuring nails were adequately trimmed. Resident #66 was observed with nails approximately 1/4 inch from the nail bed, with a brown substance under several nails and nails that were jagged and rough in multiple areas. The resident stated he liked his nails kept short and smooth and wanted them trimmed. During interview and observation, the DON acknowledged Resident #66's nails were long, dirty, and jagged with sharp areas. Record review showed Resident #89 had diagnoses including a displaced oblique fracture of the shaft of the right ulna and muscle weakness, with a BIMS score of 8 indicating moderate cognitive impairment. Resident #66 was admitted with a diagnosis of metabolic encephalopathy and had a BIMS score of 12 indicating moderate cognitive impairment.
Resident Burned After Unauthorized Use of Space Heater
Penalty
Summary
A deficiency occurred when a portable space heater was used in a resident's room, resulting in a burn injury. The resident, who had a history of traumatic subarachnoid hemorrhage, paraplegia, and autonomic dysreflexia, requested the use of a heater brought by his family due to his tendency to feel cold and sweat excessively. Despite being aware that heaters were not permitted in the facility due to fire and burn risks, an LPN set up the heater approximately three feet from the resident at his request. The resident, who was cognitively intact but had impaired sensation due to his spinal injury, was later found with redness and blisters on his right elbow by another nurse and CNA during their rounds. The resident was unaware of the injury due to his lack of sensation in the affected area. Medical documentation confirmed a diagnosis of a second-degree burn on the resident's right elbow, which subsequently became infected with Enterococcus Faecalis and MRSA, requiring multiple courses of antibiotics. Facility policy review indicated that space heaters were prohibited due to safety concerns, and staff interviews confirmed that the heater was used against established protocols. The incident was identified as a failure to maintain a safe, hazard-free environment, as required by facility policy and regulatory standards.
Incorrect MDS Coding for Restraint
Penalty
Summary
The facility failed to properly code a resident for a restraint on the Minimum Data Set (MDS) for one of the 21 residents' MDS assessments reviewed during the survey. Specifically, Resident #56 was incorrectly marked as using a trunk restraint less than daily in the MDS Quarterly assessment. However, observations and interviews with the resident, a registered nurse, and a certified nursing assistant confirmed that Resident #56 has never used a restraint. Additionally, a review of the resident's physician orders revealed no order for a restraint. The MDS Nurse acknowledged that the trunk restraint was marked by mistake and confirmed that Resident #56 has never had a restraint. The MDS Nurse also emphasized that the purpose of the MDS is to gather accurate information about the resident to guide their care and determine payment for services. The Administrator confirmed that incorrect MDS coding could result in the resident receiving the wrong level of care. Resident #56 was admitted to the facility on the date specified in the report.
Improper Handling of Suction Tubing
Penalty
Summary
The facility failed to prevent the possibility of an infection as evidenced by improper handling of suction connecting tubing during respiratory care for a resident. During an observation, the Respiratory Therapist (RT) performed suctioning and trachea care on the resident. After suctioning, the RT placed the suction connecting tubing in the trash, allowing it to come into contact with the side of a trash can that was full of trash. The RT then picked up the tubing, suctioned sterile water through it, and wrapped it for future use, despite acknowledging that the tubing should have been changed due to contamination. Interviews with the RT, Infection Preventionist, and Director of Nurses (DON) confirmed that the suction tubing should have been replaced after touching the trash can to prevent potential infection. The facility's policy on infection control and the resident's physician's order for proper storage and handling of respiratory equipment were not followed. The resident involved had a medical history that included Cerebral Infarction and Tracheostomy Status.
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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 Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Healthcare Center | 1 mi | ★★★★★ | 2 | 0 |
| The Windsor Place | 1 mi | ★★★★★ | 0 | 0 |
| Vineyard Court Nursing Center | 3.9 mi | ★★★★★ | 3 | 0 |
| Baptist Memorial Hospital Gt | 4.1 mi | — | 0 | 0 |
| West Point Community Living Center | 17.5 mi | ★★★★★ | 0 | 0 |
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