Below 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 Manor Special Care Cent during CMS and state inspections, most recent first.
A cognitively intact but quadriplegic resident with MS, incontinence, and a history of behavioral symptoms was physically abused by a CNA during incontinence care. Video showed the CNA entering without knocking while the resident slept, roughly rolling him, striking his face and upper body multiple times, throwing and forcefully holding a pillow over his face, and continuing care in a rough manner. The next morning the resident reported being punched in the nose and handled "like a rag doll"; staff and police noted dried blood and nasal deviation, and hospital imaging confirmed multiple nasal fractures and a perforated nasal septum. The facility’s investigation, based on video review and interviews, substantiated that physical abuse had occurred.
A resident with MS, quadriplegia, depression risk, incontinence, and documented rejection-of-care behaviors was involved in an incident where video showed a CNA entering the room without knocking, roughly repositioning the resident during incontinence care, striking him multiple times, throwing and forcefully holding a pillow over his face, and continuing care while the resident appeared to react. The CNA later reported that the resident had been verbally aggressive and spitting at her during care, and an RN confirmed the resident became verbally aggressive and refused care later that night. Despite these reports and facility policies requiring assessment and monitoring of residents with behaviors that might lead to conflict or neglect, and immediate interventions when behaviors could harm others, the RN did not assess or formally report the resident’s aggressive behaviors, resulting in a failure to assess the resident following reported aggressive behaviors in the setting of a substantiated abuse incident.
A resident with dementia, chronic venous insufficiency, muscle weakness, and a prior pelvic fracture was identified as high fall risk and care-planned for non-skid socks and two-person assist for transfers, yet the fall/safety care plan was not updated after PT discharge and was inconsistently implemented. The resident sustained an unwitnessed fall in her room and was found on the floor barefoot, despite non-skid socks being a listed intervention, with no clear explanation in the fall investigation and no timely witness statement from the assigned CNA. Later the same day, a CNA transferred the resident alone from wheelchair to bed, contrary to the care plan, causing a severe skin tear when the resident’s leg scraped the wheelchair leg rest; the resident, on warfarin, required hospital care and was diagnosed with a pelvic fracture and multiple skin tears. Facility investigations lacked complete root cause analyses and did not reconcile MDS findings, therapy recommendations, and care-plan directives with the care actually provided.
A resident with multiple sclerosis, chronic respiratory failure with hypoxia, and a tracheostomy had provider orders and a care plan requiring oxygen via trach collar at 5 L/min, with oxygen tubing and disposable respiratory supplies to be changed weekly and equipment cleaned weekly. Facility policy also required weekly changes of oxygen tubing, masks, and cannulas with documentation in the EHR. During observation, the resident was in bed receiving oxygen via trach mask, and the oxygen tubing in use was dated several weeks earlier, which a CNA verified, showing the tubing had not been changed weekly as ordered and as required by facility policy.
A resident with severely impaired cognition and diagnoses including Alzheimer's disease and dementia had medications left at the bedside during the morning med pass. An agency LPN verified the cup of meds at the bedside and stated she was supposed to watch the resident take them, but instead asked if he had taken them; the resident said yes. The resident had no order for self-medication administration, and facility policy required staff not to leave meds unattended and to observe consumption.
A resident with cognitive impairment and total incontinence received incontinence care during which a CNA placed supplies on an uncleaned bedside table without a barrier and failed to perform hand hygiene after glove removal, contrary to facility policy.
The facility failed to ensure resident rooms were clean and sanitary, affecting five residents. Observations showed grimy floors, unswept areas, and unclean bathrooms. Residents reported that rooms were not cleaned daily, and the Housekeeping Manager confirmed staffing shortages. The facility's policy required daily cleaning, which was not consistently followed.
A resident was involved in a physical altercation with another resident, resulting in a bruise. Despite facility policy, the family was not notified of the incident. The event was not documented or reported to the administration until days later, leading to a deficiency in care.
Two residents in an LTC facility were involved in a physical altercation, resulting in one resident being punched and bruised. Despite the incident being witnessed by CNAs, it was not documented or reported to the Ohio Department of Health until ten days later. The facility's staff failed to follow the abuse policy, which required immediate reporting and investigation, leading to a deficiency in protecting residents from abuse.
Two residents with chronic conditions were involved in a physical altercation after a verbal dispute, resulting in a bruise on one resident's forehead. The incident was witnessed by CNAs but was not reported or documented until days later, leading to a deficiency due to the facility's failure to follow its abuse policy and protocol.
Two residents with chronic conditions were involved in a physical altercation, resulting in one resident sustaining a bruise. The incident was witnessed by CNAs but was not reported to the Ohio Department of Health until ten days later. The facility failed to document the incident, monitor behavior contracts, and follow the abuse policy, leading to a deficiency investigation.
Two residents were involved in a verbal and physical altercation, resulting in one resident being punched and bruised. Despite facility policy requiring immediate investigation of abuse allegations, the incident was not reported or investigated until several days later. Staff and resident interviews confirmed the altercation and the delay in response, leading to non-compliance.
A resident with multiple health issues did not have a stat Basic Metabolic Panel (BMP) completed as ordered by a Nurse Practitioner due to a hemolyzed specimen. The facility failed to reschedule the test, as confirmed by interviews with the NP and DON. This deficiency was identified during a complaint investigation.
An Administrator failed to treat a resident with dignity and respect, as evidenced by yelling and threatening behavior. The resident, who had no cognitive impairment and multiple health conditions, reported feeling inappropriately treated. Witnesses, including an LPN and a Regional RN, confirmed the Administrator's actions, which included yelling, gesturing, and threatening to evict the resident.
A resident with multiple health conditions reported that the Administrator yelled and threatened to evict her, which was witnessed by an LPN. The incident was reported to the former DON but not to the regional team, delaying the investigation. The facility's policy requires immediate reporting and investigation within five days, which was not followed, leading to non-compliance.
The facility failed to notify physicians when residents did not receive their prescribed insulin or have their blood sugar levels checked due to unavailability of medication or testing strips. This affected five residents with type II diabetes mellitus, and the lapses were confirmed by staff interviews.
The facility failed to administer insulin as ordered for five residents with type II diabetes mellitus due to the unavailability of glucometer strips needed to check blood sugar levels. This resulted in missed insulin doses on multiple occasions. Staff interviews and observations revealed that the strips were later found in the facility, indicating a failure in inventory management and communication.
A resident with a history of substance use disorder was not adequately assessed or provided with individualized care interventions to prevent a drug overdose. The resident was found unresponsive and later pronounced dead due to acute intoxication by Alprazolam, Fentanyl, and Gabapentin. The facility failed to implement increased monitoring or supervision to address the resident's substance abuse history, leading to a fatal outcome.
The facility failed to ensure that a resident's medications were administered as ordered. The resident, with diagnoses including anxiety disorder and multiple fractures, had physician orders for Lexapro, Ferrous Sulfate, and Lovenox. A review of the medication administration records revealed no evidence that these medications were administered as ordered. An LPN confirmed that the morning medications were not administered as required. This deficiency was investigated under Complaint Number OH00152414.
Physical abuse of dependent resident during incontinence care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact, totally dependent resident from physical abuse by a CNA during incontinence care. The resident had multiple sclerosis, quadriplegia, muscle weakness, dysphagia, incontinence of bowel and bladder, hearing loss, and a history of behavioral symptoms including rejection of care and use of profanity toward staff. His care plan required staff to face him when speaking, obtain his attention, speak clearly, explain all procedures before beginning care, approach in a calm and relaxed manner, re-direct when he was resistive, ensure he felt safe, and, if he became resistive, leave briefly and re-approach. He was dependent for all ADLs, including toileting and personal hygiene, and required staff assistance for incontinence care. On the night of the incident, facility video footage showed the CNA entering the resident’s room around 11:35 P.M. without knocking while the resident was asleep. The CNA lowered the bed, removed the sheets, lifted the resident’s gown, and opened his incontinence brief while he was still asleep. At approximately 11:37 P.M., she rolled him onto his left side toward the wall, placed a new brief, and then rolled him back onto his back in a rough manner, causing him to quickly fall onto the mattress. At about 11:38 P.M., the video showed the CNA making a swift, swinging motion with both hands toward the resident’s face, with enough force that the resident’s body and mattress shook. She then stood over him, pointed her finger at his face, appeared to touch his face with enough force to shake his body, and continued to hover over him while pointing and moving her mouth as if speaking. The video further showed the CNA slapping the resident with an open palm to his upper chest and/or face, again causing his body and pillow to shake, and then using a closed fist to hit his right upper shoulder, chest, and/or face while the wall partially blocked the view of his head. She threw a pillow at his upper chest and face, left it there, and then covered both his body and the pillow on his face with a sheet. She subsequently hit him in the chest with the pillow and held the pillow with force over his face for approximately two seconds before removing her hand but leaving the pillow on his face while raising the head of the bed. A nurse was later seen approaching and entering the room, and the CNA appeared to be wiping the resident’s face. The next morning, the resident reported to his family member and facility staff that a night-shift aide had been rough with him, had thrown him around “like a rag doll,” and had punched him in the nose after he asked her to take it easy. Staff and police observed dried blood under his right nostril and a deviation of his nose, and hospital imaging confirmed multiple nasal fractures and a perforated nasal septum. The facility’s investigation, including review of the video and interviews, substantiated that physical abuse by the CNA had occurred.
Failure to Assess Resident After Reported Aggressive Behaviors in Context of Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident following reported aggressive behaviors, in the context of an abuse incident. The resident involved had multiple complex medical conditions, including multiple sclerosis, quadriplegia, muscle weakness, falls, failure to thrive, and dysphagia. His care plans documented hearing loss, risk for altered mood related to depression and medical diagnoses, incontinence of bowel and bladder, and self-care deficits requiring assistance with ADLs and mechanical lift transfers. A quarterly MDS assessment showed intact cognition, dependence for eating, toileting, bathing, and personal hygiene, incontinence of bowel and bladder, and behaviors that included rejection of care. On one evening, video footage showed a CNA entering the resident’s room without knocking while the resident was asleep, lowering the bed, removing sheets, and exposing and opening the resident’s incontinence brief while he remained asleep. The CNA was observed rolling the resident roughly, causing him to fall quickly onto the mattress, and then making a swift, swinging motion with both hands toward his face, with enough force that the resident’s body and mattress shook. The CNA then stood over the resident, pointed at him, appeared to touch his face with enough force to slightly shake his body, and continued to point at him while her mouth moved as if speaking. She slapped the resident with an open palm to his upper chest and/or face, again causing his body and pillow to shake, and used a closed fist to hit his right upper shoulder, chest, and/or face, though the exact area was obscured by the wall. The video further showed the CNA throwing a pillow at the resident’s upper chest and face, leaving it there while covering him and the pillow with a sheet, then striking him in the chest with the pillow and holding the pillow with force over his face for approximately two seconds before removing her hand but leaving the pillow on his face as she raised the head of the bed. Later, an RN approached and entered the room after the CNA had been seen wiping the resident’s face; the CNA pointed at or on the resident’s mouth and held up a cloth when it appeared the resident spit at her. The CNA’s written statement claimed she had provided routine care, denied treating the resident roughly or hitting him, and reported that the resident had used racial slurs, derogatory language, and spit at her during care at multiple times that night, including an instance when a nurse entered to help de-escalate and another when a nurse advised discontinuing care. The RN’s statement confirmed the resident was calm and cooperative earlier in the evening, and later verbally aggressive and refusing care, but documented that staff remained calm and professional. A progress note by the former DON documented that the resident had increased behaviors, including cursing at staff during care. In a subsequent telephone interview, the former DON stated that the RN should have assessed the resident for the aggressive behaviors reported by the CNA and should also have reported those behaviors accordingly. Facility policies on resident abuse and behavior management required assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect, including those with a history of aggressive behaviors, and required immediate implementation of keep-safe interventions and provider notification when residents present with behaviors that will harm others. Despite the CNA’s reports of escalating verbal aggression and spitting, there was no documented assessment of the resident’s aggressive behaviors by the RN as expected under these policies, which constituted the failure cited in this deficiency. The facility’s self-reported incident documented that the resident’s family reported the CNA had handled the resident roughly and that he had been hit in the nose during care. Upon assessment, the resident was found with a small amount of blood under his nostril and an apparently deviated nose, and he was transported to the hospital where he was admitted with multiple facial fractures. The facility’s investigation, including review of video footage, led to a determination that abuse had occurred. The deficiency specifically addresses that, in the context of these events and the resident’s documented behavioral issues, the facility failed to ensure the resident was assessed following reported aggressive behaviors, contrary to its own abuse prevention and behavior management policies. This deficiency was investigated under Complaint Number 2806407 and was based on interview, record review, policy review, and video camera footage. The cited non-compliance centers on the lack of appropriate assessment and reporting of the resident’s aggressive behaviors after they were reported by staff, in a resident with known behavioral symptoms and complex medical and psychosocial needs, as required by the facility’s policies for prevention and identification of abuse and for behavior management.
Failure to Implement and Update Individualized Fall and Transfer Safety Measures
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, effective, and individualized fall management program for a resident identified as high risk for falls. The resident was admitted with diagnoses including chronic venous insufficiency, osteoarthritis, dementia, muscle weakness, and a healing pubic fracture. A fall risk assessment identified the resident as high risk, and the care plan noted impaired safety awareness and deterioration in ADLs related to chronic venous stasis. Interventions included encouraging non-skid socks as tolerated and, later, providing two-person assistance for transfers and use of a manual wheelchair with one-person assist for mobility. The admission and subsequent MDS assessments documented severely impaired cognition and dependence or substantial/maximal assistance needs for transfers, toileting, and bed mobility. Despite these identified risks and documented needs, the facility did not update or consistently implement the resident’s fall and safety care plan in line with current functional status and therapy recommendations. A PT discharge summary indicated the resident generally required minimal assistance for functional tasks and safety cueing, and recommended limited assistance for safety due to high fall risk and cognitive deficits. However, no changes were made to the fall/safety plan of care after therapy discharge. Later MDS assessments continued to show the resident as dependent for transfers, but the care plan was not revised to reconcile these findings with therapy recommendations, and the DON confirmed the care plan had not been updated following PT discharge. On one night, the resident experienced an unwitnessed fall in her room. She was last seen in bed and later found on the floor, sitting on her buttocks, barefoot, with a left elbow skin tear. The fall investigation documented that all fall interventions were in place, yet also noted the resident was barefoot, without explaining why non-skid socks, which were a care-planned intervention, were not in use. No witness statement was obtained from the CNA assigned to the resident that shift, and the root cause analysis attributed the fall to the resident being old, confused, and unbalanced, without addressing the missing non-skid socks or other specific environmental or supervision factors. Later that same day, the resident sustained a severe skin tear during a transfer from wheelchair to bed. An incident investigation and CNA statement revealed that a CNA, working alone, transferred the resident and the resident’s leg scraped against the wheelchair leg rest, causing immediate and significant bleeding. The resident was on warfarin and required hospital evaluation, where she was diagnosed with a closed nondisplaced pelvic fracture and multiple skin tears. The DON confirmed that the care plan in place required two-person assistance for transfers, but only one CNA performed the transfer. The incident investigation for the skin tear did not include a root cause analysis. Interviews also showed inconsistencies in staff recall and documentation, including the assigned CNA not recalling the fall and the absence of timely, complete witness statements. These actions and omissions demonstrate the facility’s failure to implement and individualize fall and accident prevention measures as required by the resident’s assessed needs and care plan. Additional documentation and interviews highlighted further discrepancies between assessed needs, care plan directives, and actual care provided. The DON and MDS nurse confirmed that MDS data indicated the resident was dependent for transfers, which the MDS nurse equated with a two-person assist, while therapy had recommended minimal assistance with safety cueing. The care plan was not updated to reflect or reconcile these differing assessments, and the CNA who performed the transfer alone stated she believed she could transfer the resident by herself due to the resident’s weight, without referencing the care plan requirements. The facility’s fall prevention and management policy required assessment of fall risks, implementation of preventive measures, and review and investigation of all falls, but the investigations for both the fall and the transfer-related injury lacked complete root cause analyses and did not fully address why care-planned interventions, such as non-skid socks and two-person transfers, were not followed.
Failure to Change and Date Oxygen Tubing Weekly for Tracheostomy Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and physician orders for weekly oxygen tubing changes for a resident receiving oxygen via tracheostomy. The resident had significant medical conditions including multiple sclerosis, chronic respiratory failure with hypoxia, tracheostomy status, encephalitis, and encephalomyelitis, and had orders for oxygen via tracheostomy collar at five liters per minute to maintain oxygen saturation above 90%. The orders and care plan specified that oxygen tubing and disposable respiratory supplies were to be changed weekly and that the oxygen concentrator and filter were to be cleaned weekly. The facility’s oxygen administration policy also required that tubing, masks, and cannulas be changed weekly and documented in the EHR. During an observation, the resident was seen in bed receiving oxygen via a tracheostomy mask, and the oxygen tubing in use was dated nearly four weeks earlier. A CNA confirmed the tubing date as 12/25/25 at the time of observation on 01/20/26, indicating that the tubing had not been changed according to the weekly schedule. This failure to change and date the oxygen tubing as required constituted non-compliance with the facility’s policy and the resident’s care plan and orders for equipment management and infection control.
Medications Left Unattended at Bedside
Penalty
Summary
The facility failed to ensure medications were not left unattended at the bedside of a resident with severely impaired cognition. Resident #55 was admitted with diagnoses including spinal stenosis, Alzheimer's disease with late onset, mild dementia with mood disturbance, hyperlipidemia, essential hypertension, major depressive disorder, and anxiety disorder. The quarterly MDS assessment indicated the resident needed setup/cleanup help for eating, toileting hygiene, bed mobility, and transfers, and had no behaviors. During observation in the resident’s room, medicine with a cup of medication was seen at the bedside. An agency LPN verified the medications at the bedside and identified them as blood pressure pills, aspirin, senna, and a multivitamin. The LPN stated she had brought the morning medications and asked the resident if he took them, and the resident said he did. She stated she was supposed to watch him take them, and the resident did not have an order for self-medication administration. The physician orders showed active morning medications including aspirin, Claritin, docusate sodium, losartan, memantine, bupropion HCl, and omeprazole. Facility policy stated staff should not leave medications unattended and should observe the resident's consumption of medications.
Infection Control Lapse During Incontinence Care
Penalty
Summary
During incontinence care for Resident #42, who had diagnoses including cerebral palsy, high blood pressure, Alzheimer's disease, and a history of falls, staff failed to follow infection control standards. The resident was cognitively impaired, fully dependent on staff for toileting, and always incontinent of bowel and bladder. Observation revealed that a Certified Nurse Aide (CNA) placed care supplies directly onto the bedside table without cleaning the surface or using a barrier. Additionally, after removing soiled gloves, the CNA retrieved additional supplies and donned new gloves without performing hand hygiene, contrary to the facility's hand hygiene policy, which requires hand hygiene immediately after glove removal. These findings were confirmed through staff interview and policy review.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms, affecting five out of eight residents reviewed for physical environment. Observations revealed significant cleanliness issues, including a black grimy buildup on the floor of one resident's room, unswept floors with dirt and paper in another, and a buildup of dust and dirt in a third resident's room. Additionally, one room had a plastic bag, paper towels, and an empty wipes container on the floor, with food and debris under the bed. Another room had dried food and drink on the floor, with a bathroom that had a brown wet liquid around the toilet base and a brown paper towel soaking up the wetness. Interviews with residents confirmed that their rooms were not cleaned daily, as required by the facility's housekeeping policy. The Housekeeping Manager acknowledged that resident rooms should be cleaned daily, including sweeping, mopping, and cleaning high-touch areas and bathrooms. However, it was revealed that only one housekeeper was working on the day of the observations, and there was no second shift housekeeper. The facility's policy outlined specific cleaning tasks, but these were not consistently performed, leading to the observed deficiencies.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the family of Resident #11 about a change in her condition after an incident of physical abuse. Resident #11, who was not responsible for herself and had her sister listed as her responsible party, was involved in an altercation with another resident, Resident #26, which resulted in a bruise above her left eyebrow. The incident occurred near the central nurse's station and was witnessed by two CNAs. Despite the facility's policy requiring notification of the family and physician in the event of a change in condition, Resident #11's family was not informed of the incident until much later. The incident was not documented or reported to the responsible party or the facility administration until several days after it occurred. Interviews with staff and the resident's sister confirmed that the family was not informed of the physical altercation and resulting injury. The facility's policy on notifying family members of changes in condition was not implemented, leading to a deficiency in the care provided to Resident #11.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents, Resident #11 and Resident #26, from abuse, as evidenced by a physical altercation between them. Resident #11, who was alert and oriented with a BIMS score of 15, had a history of chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. She was dependent on staff for activities of daily living (ADLs) and had a care plan in place to monitor her mood and behaviors. Resident #26, with a BIMS score of 10 indicating cognitive impairment, had diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, and bipolar disorder. He also required staff assistance for ADLs and had a care plan to monitor his mood and behaviors. On the day of the incident, a verbal altercation between Resident #11 and Resident #26 escalated into a physical confrontation, resulting in Resident #26 punching Resident #11 in the head, causing bruising above her left eyebrow. The altercation was witnessed by CNAs #856 and #900, who reported differing accounts of the incident. Despite the altercation occurring on 11/04/24, it was not documented or reported to the Ohio Department of Health until 11/14/24. The facility's staff, including LPN #872 and ADON #849, failed to document or report the incident in a timely manner, and the investigation was not initiated immediately. The facility's policy required immediate reporting and investigation of all allegations of abuse, but this was not followed. The Administrator confirmed that the incident was reported late, and staff did not monitor the residents for compliance with their behavior contracts. The failure to document and report the incident promptly, as well as the lack of monitoring, contributed to the deficiency in protecting the residents from abuse.
Failure to Implement Abuse Policy in Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy for an incident involving two residents, resulting in a deficiency. Resident #11, who has chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder, and Resident #26, who has chronic obstructive pulmonary disease, cirrhosis of the liver, and bipolar disorder, were involved in a physical altercation. The incident occurred after a verbal altercation, where Resident #11 made hand gestures near Resident #26, leading to Resident #26 physically contacting Resident #11's face, causing a bruise above her left eyebrow. The incident was witnessed by two CNAs, but it was not reported or documented until several days later. The facility's failure to report and document the incident promptly, as well as to monitor the residents for compliance with behavior contracts, contributed to the deficiency. The Administrator was not informed of the incident until ten days after it occurred, resulting in a late self-reported incident to the Ohio Department of Health. The facility's abuse policy, which requires immediate investigation and reporting of all allegations and incidents of abuse, was not followed, leading to non-compliance with the policy and protocol.
Failure to Report Resident Abuse Timely
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency, affecting two residents. Resident #11, who had chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder, was involved in a physical altercation with Resident #26, who had chronic obstructive pulmonary disease, cirrhosis of the liver, and bipolar disorder. The incident occurred on 11/04/24, when Resident #11 and Resident #26 had a verbal altercation that escalated into physical violence, resulting in Resident #11 sustaining a bruise above her left eyebrow. Certified Nursing Assistants (CNAs) #856 and #900 witnessed the altercation, with Resident #26 punching Resident #11 in the head. Despite the severity of the incident, the facility did not report the altercation to the Ohio Department of Health until 11/14/24, ten days after it occurred. The Administrator confirmed that staff failed to document the incident, monitor the residents for compliance with behavior contracts, and follow the abuse policy and protocol. The facility's Ohio Resident Abuse Policy, revised in July 2024, mandates the immediate reporting of all allegations and incidents of abuse, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00159817.
Delayed Investigation of Resident Altercation
Penalty
Summary
The facility failed to ensure a timely and thorough investigation of an abuse allegation involving two residents. Resident #11, who was alert and oriented, was involved in a verbal and physical altercation with Resident #26, who had cognitive impairment. The incident occurred on 11/04/24, but the investigation was not initiated until 11/18/24, after the facility's administration was informed on 11/14/24. This delay in response was contrary to the facility's policy, which mandates immediate investigation of all abuse allegations. Resident #11 was admitted with diagnoses including chronic diastolic congestive heart failure and dysthymic disorder, and was dependent on staff for activities of daily living. She had a behavioral contract to avoid Resident #26. On the day of the incident, Resident #11 was observed with bruising above her left eye and scapula area. The altercation reportedly involved Resident #11 making hand gestures and contact with Resident #26, who then punched her, resulting in a bruise above her left eyebrow. Witnesses, including CNAs, confirmed the physical altercation. Resident #26, admitted with chronic obstructive pulmonary disease and bipolar disorder, had a care plan that included checks to prevent harm to others. Despite this, the incident log did not reflect the physical abuse incident until 11/15/24, and the Self-Reported Incident was dated 11/14/24. Interviews with staff and residents confirmed the altercation and the delay in reporting and investigating the incident. The facility's policy required immediate investigation, which was not adhered to, leading to non-compliance under Complaint Number OH00159817.
Failure to Complete and Report Ordered Laboratory Services
Penalty
Summary
The facility failed to ensure that a resident's physician-ordered laboratory services were completed and reported as required. The resident, who had diagnoses including cirrhosis of the liver, obesity, chronic pain, heart failure, and pulmonary edema, was seen by a Nurse Practitioner due to congestion and not feeling well. The Nurse Practitioner ordered a stat Basic Metabolic Panel (BMP) and a chest x-ray. However, the BMP specimen collected was hemolyzed, rendering it unusable, and the facility did not reschedule the test. Interviews with the Nurse Practitioner and the Director of Nursing confirmed that the facility should have followed up on the stat BMP and rescheduled the test after the initial specimen was found to be inadequate. The facility's policy on Resident Change in Condition required the nurse to address emergency care and gather the most recent labs for the physician, which was not adhered to in this case. This deficiency was identified during the investigation of a complaint.
Administrator's Inappropriate Conduct Towards Resident
Penalty
Summary
The facility Administrator failed to treat a resident in a dignified and respectful manner, as evidenced by multiple accounts of inappropriate behavior. The resident, who had no cognitive impairment and was diagnosed with anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus, reported that the Administrator yelled at her and argued with her. This incident was corroborated by a Licensed Practical Nurse (LPN) who witnessed the Administrator yelling and gesturing at the resident near the nurses' station. Further interviews and signed statements confirmed the Administrator's inappropriate conduct. A Regional Registered Nurse (RN) stated that the Administrator was verbally inappropriate and threatened to evict the resident from the facility. The resident's signed statement indicated that the Administrator asserted her authority and threatened eviction. The LPN's signed statement also confirmed the Administrator's actions and described them as a bad choice of words and uncalled for. This deficiency was investigated under Complaint Number OH00155871.
Failure to Timely Report Alleged Abuse by Administrator
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation involving Resident #21, who had diagnoses including anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus. The incident involved the Administrator allegedly yelling at and threatening Resident #21, which was witnessed by an LPN. The LPN reported the incident to the former Director of Nursing, but it was not communicated to the regional team, resulting in a delay in the investigation. The facility's policy requires immediate reporting of abuse allegations and completion of investigations within five working days. However, the incident involving the Administrator was not reported in a timely manner, leading to non-compliance with the facility's abuse policy. The deficiency was identified during a complaint investigation, affecting one resident out of the 56 in the facility census.
Failure to Notify Physician of Missed Insulin Administration
Penalty
Summary
The facility failed to notify the physician of residents not receiving medications as ordered, specifically insulin for diabetes management. This deficiency affected five residents who did not receive their insulin or have their blood sugar levels checked as prescribed. The medical records for these residents showed missed doses and lack of blood sugar monitoring, with reasons such as 'drug/item unavailable' and 'no testing strips available' noted in the medication administration records (MAR). However, there was no documentation that the physicians were informed of these missed medications and checks. Resident #1, diagnosed with type II diabetes mellitus and end-stage renal failure, did not receive insulin or have his blood sugar checked on a specific date due to the unavailability of the drug/item. Similarly, Resident #3, who also has type II diabetes mellitus, missed multiple doses of insulin and blood sugar checks over two days due to the unavailability of testing strips. In both cases, the physician was not notified of these lapses in care. Other residents, including Resident #8, Resident #24, and Resident #55, also experienced similar issues where their insulin was not administered, and blood sugar levels were not checked as ordered. The reasons for these lapses included the unavailability of testing strips and other unspecified reasons. Interviews with the Regional Nurse and an LPN confirmed that the physicians were not notified about these missed medications and checks, highlighting a systemic issue in the facility's communication and medication administration processes.
Significant Medication Errors Due to Unavailability of Glucometer Strips
Penalty
Summary
The facility failed to administer medications as ordered by physicians, resulting in significant medication errors for five residents diagnosed with type II diabetes mellitus. These residents did not receive their prescribed insulin due to the unavailability of glucometer strips needed to check their blood sugar levels. This issue was observed on multiple occasions, affecting the residents' ability to manage their diabetes effectively. For instance, Resident #1 did not receive insulin on 05/05/24 at 9:30 P.M. because their blood sugar was not checked, and the medication administration record (MAR) noted that the drug was unavailable. Similar issues were noted for Residents #3, #8, #24, and #55, who also missed their insulin doses due to the same reason. Interviews with staff confirmed these lapses in medication administration, and it was revealed that glucometer strips were later found in the facility, indicating a failure in proper inventory management and communication among staff members. Resident #3's medical record showed that they missed their insulin doses on 05/05/24 at 9:00 P.M. and 05/06/24 at 7:30 A.M. due to the unavailability of testing strips. Resident #8 also did not receive their insulin at bedtime on 05/05/24 for the same reason. Resident #24 missed four insulin doses between 05/04/24 and 05/06/24 because their blood sugar was not checked, and no insulin was administered. Resident #55 did not have their blood sugar checked and missed insulin doses at dinner and bedtime on 05/05/24. Observations on 05/09/24 revealed that the medication storage room and medication carts had sufficient supplies of insulin needles and glucometer strips, suggesting that the issue was not a lack of supplies but rather a failure in locating and utilizing them. Interviews with the facility's staff, including the Regional Nurse and the Administrator, highlighted communication breakdowns and inadequate inventory management as contributing factors to the medication errors. The Administrator confirmed that LPN #306 had reported the unavailability of glucometer strips and had attempted to contact management without success. The Administrator instructed LPN #306 to check the central supply and medication room, but the nurse was unable to find the strips. This deficiency represents non-compliance investigated under Complaint Number OH00153676.
Failure to Prevent Drug Overdose in Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that a resident with a history of substance use disorder was adequately assessed and provided with comprehensive and individualized care interventions to prevent a drug overdose. Resident #65, who had a history of substance abuse, was admitted to the facility for short-term placement following a motor vehicle accident. Despite the resident's history of substance abuse, the facility did not include increased monitoring or supervision in the resident's care plan to address the risk of relapse or overdose. The resident's medical record and care plans lacked interventions to address substance abuse history, and there was no evidence of increased supervision of visitors who might provide drugs to the resident. On the day of the incident, the resident was found unresponsive in their room and later pronounced dead due to acute intoxication by Alprazolam, Fentanyl, and Gabapentin. The resident had not received their morning medications, and the nurse on duty had not assessed the resident until finding them unresponsive. The coroner's report and police investigation revealed evidence of drug use in the resident's room, including a white powdery substance and drug paraphernalia. Interviews with facility staff confirmed that the resident's substance abuse history was known, but no specific interventions were implemented to prevent a potential overdose. The facility's failure to assess and implement appropriate interventions for Resident #65's substance use disorder resulted in the resident's death due to a drug overdose. The facility did not provide adequate supervision or monitoring to prevent the resident from obtaining and using drugs, leading to a fatal outcome. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with ensuring resident safety and preventing accidents related to substance abuse.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #65's medications were administered as ordered. Resident #65, who was admitted with diagnoses including anxiety disorder, other psychoactive substance abuse, and multiple fractures, had physician orders for Lexapro, Ferrous Sulfate, and Lovenox. A review of the medication administration records (MARS) from 08/01/23 to 08/21/23 revealed no evidence that these medications were administered as ordered. An interview with LPN #813 confirmed that the morning medications were not administered as required. The facility's General Dose Preparation and Medication Administration policy, revised on 01/01/13, mandates that staff verify the correct medication, dose, route, rate, time, and resident each time a medication is administered. This deficiency was investigated under Complaint Number OH00152414.
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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 Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenue At Aurora | 0.9 mi | ★★★★★ | 7 | 0 |
| Kensington At Anna Maria | 2.2 mi | ★★★★★ | 9 | 0 |
| Anna Maria Of Aurora | 2.2 mi | ★★★★★ | 12 | 0 |
| Twinsburg Post Acute | 4.2 mi | ★★★★★ | 19 | 0 |
| Canterbury Of Twinsburg | 4.4 mi | ★★★★★ | 0 | 0 |
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