Accura Healthcare of Aurelia, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the clinical record, facility policy, and staff interviews, the facility failed to notify the physician when a resident with a history of cardiac and pulmonary conditions and oxygen dependence stopped using a Bilevel Positive Airway Pressure (BiPAP) machine at night for 1 of 12 residents reviewed. The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of congestive heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and centrilobular emphysema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Clinical Physician Orders dated 9/3/25 for Resident #2 showed the following:BiPAP on at bed time and off in the morningOxygen 3 liter per nasal cannula COPD and centrilobular emphysemaDuo Neb breathing treatments twice a day for COPDFluticase-Salmeterol inhaler twice a day for COPDPrednisone tablet daily for COPDTorsmide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and staff interview, the facility failed to refer 1 resident with a negative Level I result for the Preadmission Screening and Resident Review (PASRR), who was later identified with newly evident or possible serious mental disorder, intellectual disability, or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination for 1 out of 2 residents (Resident #27) reviewed for PASRR requirements. The facility reported a census of 35 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #27 documented diagnoses of dementia, Anxiety Disorder, adjustment disorder with depressed mood, depression and suicidal ideations. The MDS included a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The Medical Diagnosis list for Resident #27 revealed the following diagnoses:General Anxiety Disorder, dated 5/27/25Major depressive disorder, dated 6/12/2Suicidal ideation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews and facility policy review the facility failed to accurately document Bilevel Positive Airway Pressure (BiPAP) machine usage for 1 of 12 residents (Residents #2). The facility reported a census of 34 residents.Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #2 documented diagnoses of congestive heart failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and centrilobular emphysema. The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. The Clinical Physician Orders dated 9/3/25 for Resident #2 showed an order for a BiPAP on at bedtime and off in the morning. During an interview on 1/27/26 at 2:25 PM, Resident #2 reported the pulmonologist ordered her to wear a BiPAP at night related to CHF, COPD, and emphysema. When asked about the BiPAP location, the resident reported placing the device on a shelf due to personal preference not to use the machine because the mask fit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene before and after catheter care for 1 of 2 residents reviewed (Resident #31). The facility reported a census of 34 residents.Findings include:During an observation on 1/28/26 at 1:08 PM, Staff A, Certified Nursing Assistant (CNA), failed to perform hand hygiene prior to donning personal protective equipment (PPE) and emptying urine from the catheter bag, per policy. Staff A then doffed PPE, failed to perform hand hygiene, and proceeded to arrange the catheter bag, privacy bag, and the resident's blanket before exiting the room.The Hand Hygiene Policy last updated on 11/13/24 identified hand hygiene is required immediately before donning and doffing gloves. During an interview on 1/27/26 at 2:47 PM, the Director of Nursing (DON), reported she expected staff to perform hand hygiene immediately before applying gloves and when staff removed gloves. During an interview on 1/27/26 at 3:31 PM, the Infection Preventionist indicated staff are expected to perform hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that all residents were free from verbal abuse for 1 of 5 residents reviewed (Resident #2.) Staff reported that on several occasions, a Certified Nurse Aide (CNA) addressed Resident #2 in a disrespectful and derogatory manner. The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff for toileting, dressing, rolling and transfers. She was always incontinent of urine and bowel, and was impaired on both sides of her upper and lower extremities. Diagnoses for Resident #2 included: heart failure, renal insufficiency and quadriplegia.The Care Plan for Resident #2, dated 4/15/25, showed that she was dependent on staff for activities of daily living related to unspecified intellectual disabilities. Staff were to converse while providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and policy review the facility failed to report allegations of abuse in a timely manner for 1 of 1 residents reviewed. On 5/1/25, several staff members reported that Staff F was rude and verbally abusive to Resident #2. They did not have dates and times as to when these incidences occurred. The facility reported a census of 34 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #2 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits.) The resident was totally dependent on staff for toileting, dressing, rolling and transfers. She was always incontinent of urine and bowel, and was impaired on both sides of her upper and lower extremities. Diagnoses for Resident #2 included: heart failure, renal insufficiency and quadriplegia.The Care Plan for Resident #2 dated 4/15/25, showed that she was dependent on staff for activities of daily living related to unspecified intellectual disabilities. Staff were to converse while providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure that staff interacted with residents with dignity and respect for 1 of 13 residents reviewed, (Resident#9). The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14 (intact cognitive ability.) She was dependent on staff for toileting, showering and lower body dressing and required substantial assistance with toilet and sit to stand transferring. Diagnoses for Resident #9 included; anemia, hypertension, peripheral vascular disease, diabetes mellitus, osteoporosis, bipolar disorder, and fracture of the right pubis A Care Plan revised on 2/12/25, showed that Resident #9 was occasionally dependent on staff and others for meeting her emotional, intellectual, physical and social needs, and staff were to converse with the resident while providing care. Staff were to provide resident with cues, reorientation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure staff followed physicians' orders for 2 of 13 residents reviewed, (Resident #17 and #9). Resident #17 had an order for International Normalized Ratio (INR) blood test to be conducted on 2/13/25, staff failed to complete the blood draw. Staff were directed to report to the doctor if/when the Blood Glucose (BG) levels were out of parameters for Resident #9. The facility failed to follow through according to physician's orders. The facility reported a census of 32 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability.) He required partial assistance with toileting hygiene, showering, dressing and transfers. Resident #17 was using anticoagulant medications and his diagnoses included: atrial fibrillation, heart failure, anxiety and depression. The Care Plan updated on 2/23/25, showed that Resident #17 was at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure safe transfer techniques with the use of a Gait Belt (GB) for 1 of 3 residents reviewed, (Resident #17). The facility reported a census of 32 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intake cognitive ability). He required partial assistance with toileting hygiene, showering, dressing and transfers. Resident #17 had diagnoses that included: atrial fibrillation, heart failure, anxiety and depression. The Care Plan updated on 2/23/25 showed that Resident #17 was at risk for falls and staff were to have the Gait Belt in place for all transfers and to ensure the resident was wearing the appropriate footwear. Limited physical mobility related to morbid obesity. On 3/3/25 at 1:01 PM, Resident #17 was sitting in a wheel chair that did not fit well and he seemed to be sliding down. The resident said that he could stand and pivot…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, facility policy, 2022 Food Code, and staff interview, the facility failed to store kitchenware and utensils in a manner to prevent contamination; failed to store a measuring scoop in a clean manner; bulk foods did not have an open date labeled; provide covered trash cans; cover food stored in a freezer. The facility reported a census of 36 residents. Findings include: Observation on 2/05/24 at 9:13 AM of dry storage room revealed: 1. Two muffin baking pans turned right side up. 2. A powdered drink mix canister with scoop inside. Observation on 2/05/24 at 9:13 AM of main area of kitchen revealed: 1. Two boxes of disposable silverware not closed. 2. Two containers of silverware without eating end of the utensil covered. 3. Shelf storing cutting boards not laying vertically. 4. Reusable and disposable dishware stored right side up and not covered. 5. Two uncovered trash cans. 6. No open date on bulk storage of sugar, flour, and breadcrumbs. 7. Utensils for food preparation and serving stored uncovered on hooks on the wall. Observation on 2/05/24 at 9:16 AM of 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, facility policy, and staff interview, the facility failed to develop care plans to reflect side effects of high risk medications insulin and melatonin or an Urinary Tract Infection (UTI) for 2 of 12 residents reviewed (Residents #23 and #32). The facility reported a census of 36 residents. Findings include: 1. The MDS dated [DATE] for Resident #23 revealed a BIMS of 14 which indicated intact cognition. The MDS revealed the resident had diagnoses of diabetes mellitus, insomnia, and generalized muscle weakness. The Order Summary Report signed by a physician on 1/16/24 revealed an order for melatonin, 3 milligrams (mg) given one time per day. In a Nurses Note on 1/11/24 at 8:00 PM, Staff E, Licensed Practical Nurse (LPN) reported, in pertinent part, new order for ATB (antibiotic) for UTI. The Doctor's Orders and Progress Notes signed by an Advanced Practice Registered Nurse (ARNP on 1/11/24 revealed an order for nitrofurantoin (antibiotic) 100 mg BID (twice per day) for 5 days. The Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview and record review, the facility failed to update the resident's care plan to accurately reflect interventions ordered by the physician and accurately list residents current assistance level for 2 of 12 residents reviewed (Residents #23 and #32). The facility reported a census of 36 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 documented diagnoses of myositis (a group of rare conditions that can cause muscles to become weak, tired and painful), generalized muscle weakness and radiculopathy (pinched nerve or injury or damage to nerve roots in the area where they leave the spine). The MDS showed the Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. The MDS revealed Resident #32 has a pressure ulcer or injury and has one or more unhealed pressure ulcers or injuries. The MDS revealed resident was dependent on staff for bed mobility and transfers to and from bed to chair, and chair to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record, facility policy, and staff interview, the facility failed to provide a restorative exercise program for 1 of 1 resident reviewed (Resident #20). The facility reported a census of 36 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #20 revealed a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS revealed the resident had diagnoses of osteoarthritis to his left knee, osteoporosis (loss of bone strength), and muscle weakness. In an interview on 2/05/24 at 10:40 AM, the resident reported that his physical therapy (PT) ended last week and that he was waiting for someone to come to his room this week to show him the exercises he is supposed to do on his own. The resident reported that he goes to a group exercise held in the facility, but that he would like individual assistance with an exercise program to maintain the progress he made in PT. The PT Discharge Summary signed by a PT on 2/1/24 directed, in pertinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.