Advanced Health Care Of Aurora

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards in one out of three medication carts.

Specifically, the facility failed to ensure the medication cart was locked when not in the direct line of sight of a nurse.

Findings include:I.

Facility policy and procedureThe Medication storage policy, revised September 2022, was provided by the director of nursing (DON) on 11/20/25 at 2:40 p.m. It read in pertinent part, Only licensed nurses and pharmacy personnel are allowed access to medications.

Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. II.

ObservationsMedication cart #5 was observed on 11/19/25 at 1:26 p.m. with registered nurse (RN) #2. RN #2 walked up to the medication cart by the nurses' station and tugged on the top drawer which opened.

She pushed the drawer back and pushed the lock in with her hand locking the cart.

She said the cart was not locked correctly and the cart should be locked at all times.

Medication cart #5 was observed on 11/19/25 at 2:18 p.m.

The cart was unlocked and unattended.

There were residents and housekeeping personnel around the medication cart.

The medication cart was by the nurses' station.

There was one unidentified staff member sitting at the station facing a computer screen. He was sitting with his back to the cart. At 2:21 p.m. RN #3 walked up to the cart. RN #3 opened and closed a drawer then he charted on the screen.

After charting, he walked across the nurses' station leaving the cart unlocked. He returned to the cart at 2:27 p.m. when he locked the cart by pushing the locking mechanism in. III.

Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 11/19/25 at 2:54 p.m. LPN #2 said medication carts should be locked when unattended for the safety of others.

She said it was a crucial part of the job to keep medication locked.

She said it was important since there was heavy traffic in the hallway from visitors, residents, and staff members She said the staff were trained quarterly on safe medication storage. RN #3 was interviewed on 11/20/25 at 1:21 p.m. RN #3 said he always made sure that the cart was locked. He said he made sure that the lock on the medication cart was pressed in so it was locked. He said he would tug on the drawers to make sure that the cart was locked. He said that the medication cart should have not been left unlocked.The DON was interviewed on 11/20/25 at 1:45 p.m.

She said medication carts should not be left unlocked and unattended.

She said it was the facility`s policy to keep the medications locked at all times.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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