Aurora Makarios Assisted Living

A recertification survey was completed on 9/3/25. A deficiency was cited. Based on observations, record review and interview, the agency failed to protect individuals' rights, based on the needs of the individual. The agency failed to ensure an individual' s rights to privacy, specifically his right to be free of devices that chimed or otherwise alerted others when the doors to the facility would open, affecting eight current members. Findings include: On 9/3/25 during an environmental tour of the facility, the three egress doors, the front door and two to the back yard, were observed to all be equipped with alarms and touch code pads. When opening the door to the back yard, a very loud alarm would go off and the members sitting in the living room were observed to be in distress from the loud alarm and were relieved when Staff #1 put in the code to stop the alarm. Staff #1 also stated they were not a locked facility. Record review revealed the resident agreement had no mention of the door alarms within the facility. On 9/3/25 at 8:10 a.m., Staff #1 stated the alarms were only activated at night in order to signal staff when the egress doors to the facility were opened. She stated it had a code that was written on the keypad for the residents to turn off on their own if they wanted. Staff #1 acknowledged the alarms were going off during the day. On 9/3/25 at 12:22 p.m., the alarms were observed to go off again when exiting the front door. Staff #1 had to come put in the code to turn them off. Members were observed complaining about the loud noise.On 9/3/25 at approximately 12:28 p.m., member #1 stated the alarms were extremely annoying and did not like them when they would go off, as the alarm was right outside her bedroom door. She stated it would sometimes startle her. On 9/3/25 at approximately 12:35 p.m., the administrator stated he did not know the alarms could be used as a restriction to the members. He stated he did not know he needed to have the alarms mentioned in the member agreement and to have the members acknowledge and or sign. He stated they use them just in case a member has a change in condition and..

A relicensure survey was completed on 9/3/25. A deficiency was cited. Based on observation, record review, and interview, the residence failed to prohibit a qualified medication administration person (QMAP) from assessing the need for oxygen use, affecting two of eight current residents (#1, #2).Resident #2 was admitted to the residence on 8/1/25 with a diagnosis of dementia. A written practitioner order, dated 8/20/25 directed the residence to administer oxygen via nasal cannula at two liters per minute, continuously per nasal cannula. Record review also revealed, staff were conducting vital sign checks and tracking Resident #2' s blood oxygen levels with the use of a pulse oximeter daily. On 9/3/25, during an environmental tour, an oxygen concentrator was observed in Resident #2' s room. Resident #2 was also observed on the sofa in the living room with staff assisting her with the nasal cannula multiple times throughout the day. Staff #1 and Staff #2 were observed turning the machine on and setting the litters per minute. The setting was observed to be set to three liters per minute. The care plan for Resident #2, dated 7/1/25 read in part, had no mention of oxygen use or the need for staff to check blood oxygen levels. On 9/3/25 at 10:10 a.m., Staff #1 stated Resident #2 was assisted with the use of oxygen at all times, day and night. She stated she would put the nasal cannula on resident #2, turn on the machine and place it at two liters per minute. On 9/3/25 at approximately 12:20 p.m., the residence care coordinator stated they were aware staff were assisting Resident #2 with the use of oxygen. She acknowledged the staff were using a pulse oximeter to determine the blood oxygen levels for resident #2. She mentioned the staff would then determine how many liters per minute Resident #2 would need, based on the results from the test and if the resident was struggling to breath. She stated she was advised by their nursing consultant to do so. On 9/3/25 at approximately 12:30 p.m, the administrator acknowledged the use of oxygen titration with the staff and Resident #2. He stated he r..

A licensure revisit was completed on 2/7/23 for all previous deficiencies cited on 8/2/22. The residence is in compliance with all regulations surveyed.