Aurora Health And Rehabilitation

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the FCSR, EDL, CNA verification, and any license verifications. The HR director said if potential new hires are not screened correctly then the facility could potentially hire someone who would harm a resident, and

the facility must protect the residents. The HR director said any pre-employment screenings completed prior to 6/1/25 the former HR director would have completed, and he/she would not know why they weren't completed correctly. During an interview on 10/22/25 at 2:42 P.M. the administrator said all new hires are to have their pre-employment screenings completed prior to the date of hire. The administrator said it is HR director is responsible to complete all new hire screenings. The administrator said the current HR director is

the third one the facility has had this year. The administrator said he/she was not aware the screenings weren't getting done correct and timely. The administrator said if a pre-employment screening is not completed correctly the facility runs the risk of having someone working here who could harm a resident and the facility must protect them. The administrator said it is critical to do these before the date of hire for everyone. Complaint #2659561; 2663004

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aurora Health and Rehabilitation

1200 McCutchen Road Rolla, MO 65401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609

time frame. Complaint #2659561; 2663004

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aurora Health and Rehabilitation

1200 McCutchen Road Rolla, MO 65401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the month. 11. During an interview on 10/21/25 at 1:48 P.M., Certified Medication Technician (CMT) N said there are not enough staff to ensure showers are done, assist with meals, toilet residents, and answer call lights timely. During an interview on 10/21/25 at 3:25 P.M., Certified Nurse Assistant (CNA) B said he/she is concerned for the residents of the facility due to staffing concerns. CNA B said there is usually one aide assigned to each hall and staff are not able to ensure residents get oral care, good hygiene, or showers completed. The CNA said he/she has not had time for showers in over a month because there is just not enough time. During an interview on 10/21/25 at 5:22 P.M., CNA C said he/she is lucky to check on the residents every two hours for toileting, so showers are just not getting done. He/She said he/she focuses on toileting to keep skin from breakdown, he/she doesn't have time for showers.During an interview on 10/21/25 at 6:33 P.M., CNA F said the shift is hectic, especially at the beginning of the shift, and there is not enough time to get showers done. Residents don't like to be woken up in the middle of the night for showers. Giving a shower would leave the hall unattended. He/She said he/she would feel gross if not able to get a shower.During an interview on 10/21/25 at 6:42 P.M., CNA D said he/she does not do showers because him/her on the floor. He/She said he/she wouldn't want to be woke in the middle of the night to get

a shower, so he/she doesn't do it to the residents. During an interview on 10/22/25 at 1:00 P.M., Licensed Practical Nurse (LPN) Y said the facility has a high acuity of residents and he/she knows showers do not get completed like they should. LPN Y said the aides are responsible to complete showers, but the charge nurse is responsible to oversee the aides and ensure the showers get completed. Showers are the things that gets pushed back and not done.During an interview on 10/22/25 at 1:33 P.M., the Director of Nursing (DON) said he/she is aware showers do not get completed twice a week. The DON said he/she started writing out the shower sheets daily himself/herself to ensure residents get showers, and if they do not get completed on that date they are moved to the following day. 2647073

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aurora Health and Rehabilitation

1200 McCutchen Road Rolla, MO 65401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

facility is really short staffed and sometimes he/she is responsible for up to 28 residents. He/She usually works the night shift and its always very hectic early in the shift with finishing supper, laying the residents down and toileting. By the time that is finished its going on ten o'clock and most of the residents don't want to take a shower then or would have to be woken back up for bathing. The CNA said that if a resident is a mechanical lift, then he/she would have to leave the hall unattended to go and get help which often takes time because the other aides are busy too. During an interview on 10/21/25 at 6:37 P.M., CNA Q said he/she wished the state surveyors were at the facility all the time because the aides get more help. CNA Q said the transporter and administration team normally leaves at 4:00 P.M. and he/she is only here this evening to assist with meals due to the state surveyors being at the facility. During an interview on 10/21/25 at 6:42 P.M., CNA D said he/she usually works the evening shift and works a hall that should have two staff

on it due to the amount of assist the residents need but is often by themselves. If he/she needs help he/she has to leave the hall unattended to get it. He/She said the nurses have their own jobs to do and the CMT's are busy until they leave after their medication pass. He/She said he/she does the best they can but goes home feeling like its just not good enough often neglecting to give oral care and good personal hygiene.

During an interview on 10/22/25 at 9:08 A.M., CMT H said with the number of residents staff are responsible for and have to give medications to, he/she is not always timely in giving out medications but does the best he/she can with the time he/she has. CMT H said he/she is too busy to help the CNA's on the floor with direct care. During an interview on 10/22/25 at 9:30 A.M., CNA C said the SSD does not assist with meals like he/she did today. CNA C said the SSD was only assisting due to the state surveyors being at the facility. During an interview on 10/22/25 at 9:32 A.M., CNA B said the SSD does not assist with meals like he/she did today. CNA B said the SSD was only assisting due to the state surveyors being at the facility and that is all for show. During an interview on 10/22/25 at 12:05 P.M., CNA C requested the state surveyors observe the lunch meal. CNA C we get help that way, and it's a nice break. During an interview

on 10/22/25 at 1:00 P.M., LPN Y said when the facility is short staff, they utilize the other staff to assist, such as the housekeeping supervisor, SSD, and activity director. LPN Y said the facility has a high acuity of residents and he/she knows showers do not get completed like they should. LPN Y said the aides are responsible to complete showers, but the charge nurse is responsible to oversee the aides and ensure the showers get completed. During an interview on 10/22/25 at 1:33 P.M., the DON said the facility staffing need is based on census, and facility assessment. The DON he/she works the floor as a charge nurse sometimes. The DON said he/she feels like the facility could always use more staff. The DON said he/she feels like some staff have poor time management which causes them to feel shorter staffed. The DON said he/she is aware showers do not get completed twice a week. The DON said he/she started writing out the shower sheets daily himself/herself to ensure residents get showers, and if they do not get completed on that date they are moved to the following day. During an interview on 10/22/25 at 2:42 P.M., the Administrator said he/she feels like the facility has enough staff to meet the resident needs, but he/she would be happy to have more staff. The Administrator said extra staff would make a difference between minimum care verses great care. The Administrator said he/she would not want the facility to have any less staff than they currently do. The Administrator said staffing needs are determined by the facility assessment, acuity of care, and the census. The Administrator said he/she does get complaints from residents and families regarding staffing. #2644893 and #2600355

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aurora Health and Rehabilitation

1200 McCutchen Road Rolla, MO 65401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on interview and record review, facility staff failed to ensure the Director of Nurses (DON) did not work as a charge nurse when the facility had an average daily occupancy of 60 or more residents. The census was 75.1.Review of the Facility Assessment, dated 10/09/25, showed: -Average daily census of 77;-The DON is identified as needed to care for the resident population;-The assessment does not indicate if the DON is a full-time staff member or how many hours are dedicated to the role of DON;-The assessment does not indicate if the DON is allocated to direct care. 2.Review of the facility's nursing schedule dated 09/01/25 through 9/30/25 showed the DON as charge nurse: - On 09/06/25, nightshift with census of 77;- On 09/07/25, nightshift with census of 77;- On 09/08/25, nightshift with census of 78;- On 09/10/25, nightshift with census of 78;- On 09/12/25, nightshift with census of 76;- On 09/15/25, nightshift with census of 78;- On 09/16/25, nightshift with census of 78;- On 09/19/25, nightshift with census of 77;On 09/20/25, nightshift with census of 77;- On 09/25/25, nightshift with census of 78;- On 09/30/25, nightshift with census of 78. Review of the facility's nursing schedule, dated 10/01/25 through 10/21/25, showed the following: - On 10/05/25, nightshift with census of 79;-On 10/13/25, nightshift with census of 81.

During an interview on 10/22/25 at 1:33 P.M., the DON said he/she works the floor to help provide resident care. He/She has a nurse who is out with a medical issue and have been covering for them where needed.

He/She said there is regional support to help with the DON tasks while he/she is working as a floor nurse.

He/She said the ADON was assisting as well, but they resigned a couple of weeks ago. The DON said he/she is aware of the regulation. During an interview on 10/22/25 at 2:00 P.M., the Administrator said he/she is aware the nursing director is working the floor. #2644893

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aurora Health and Rehabilitation

1200 McCutchen Road Rolla, MO 65401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Based on observation, interview and record review, facility staff failed to complete a thorough facility-wide assessment to include specific staffing needs for each resident unit in the facility. Facility census was 75.1.

Review of the facility's Facility Assessment policy, Review of the facility assessment, dated 10/09/25, showed: -Average daily census of 77 residents;-Dayshift to include: one-two Registered Nurse (RN)'s, zero-three Licensed Practical Nurse (LPN)'s, three-five Certified Nurse Aide (CNA)'s, and zero-two Certified Medication Technician (CMT)'s;-Nightshift to include: zero-one RN, zero-two LPN's, two-five CNA's.-Evening shift to include zero-two CMT's;-The assessment did not contain direction or guidance of shift times;-The assessment did not contain direction or guidance to include staffing needs for each resident unit. Observation on 10/21/25 at 10:30 A.M., showed the facility with 100, 200, 300, and 400 hall.

During an interview on 10/22/25 at 1:33 P.M., the Director of Nursing (DON) said he/she staffs the building based on census and the facility assessment. He/She said he/she has input into the assessment. The DON said he/she was not aware the assessment needed to include specific staffing needs for each unit. During

an interview on 10/22/25 at 2:15 P.M., the administrator said the facility assessment is completed with the interdisciplinary team to include the floor staff but the final say comes from the regional team. He/She was not aware the facility assessment needed to contain guidance for specific staffing needs for each resident unit. #2644893

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/19/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Aurora Health and Rehabilitation

1200 McCutchen Road Rolla, MO 65401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited AURORA HEALTH AND REHABILITATION in ROLLA, MO for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-11-19.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 7 deficiencies cited during this inspection of AURORA HEALTH AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-04.