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Aurora Community Health

(715) 235-3707406 Technology Dr E, Suite B, Menomonie, WI 54751
CMS Certification Number 527261 · Proprietary · Medicare-certified since 09/19/1996
45deficiencies since 2018
5serious
3inspections
n/aCMS quality stars
Data from CMS inspection reports (Form 2567), 2018-01-02 to 2026-10-15, downloaded 2026-10-21; CMS agency list file dated 2026-09-21. What the labels mean

Inspection 2026-06-23

· Recertification · 2 deficiencies · CMS source report (PDF)
Serious Organization And Administration Of Services

The agency failed to ensure Home Health Agency federal and state regulations were followed in 1 of 1 Home Health Agency reviewed.

Source: CMS Form 2567, inspection 2026-06-23, tag G0940 · view on CMS
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Moderate Skilled Services Furnished

The agency failed to ensure skilled nursing services and at least one other therapeutic service were furnished for a total of 5 of 5 patients (Patients #1-#5).

Source: CMS Form 2567, inspection 2026-06-23, tag G0982 · view on CMS
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Inspection 2023-09-06

· Recertification · 4 deficiencies · CMS source report (PDF)
Moderate Plan Based On All Hazards Risk Assessment

The agency staff failed to document an all-hazards risk assessment as part of the Emergency Preparedness plan in 1 of 1 plan reviewed.

Source: CMS Form 2567, inspection 2023-09-06, tag E0006 · view on CMS
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Moderate Ep Training And Testing

This agency failed to maintain an emergency preparedness training and testing program, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2023-09-06, tag E0036 · view on CMS
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Moderate Performance Improvement Projects

This agency failed to implement performance improvement projects (PIP) in 1 of 1 QAPI (Quality Assessment and Performance Improvement) program.

Source: CMS Form 2567, inspection 2023-09-06, tag G0658 · view on CMS
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Moderate Infection Control

The agency failed to maintain an agency-wide program for the surveillance and identification of infectious and communicable diseases in 1 of 1 Infection Control Program.

Source: CMS Form 2567, inspection 2023-09-06, tag G0684 · view on CMS
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Inspection 2020-09-15

· Focused Infection Control, Other-Fed, Recertification · 39 deficiencies · CMS source report (PDF)
Serious Establishment Of The Emergency Program (Ep)

This agency failed to ensure there is a comprehensive Emergency Preparedness Program in 1 of 1 Emergency Plans.

Source: CMS Form 2567, inspection 2020-09-15, tag E0001 · view on CMS
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Serious Quality Assessment/Performance Improvement

This agency failed to develop, implement, evaluate and maintain an effective ongoing home health agency wide data driven QAPI (Quality Assessment and Performance Improvement) program in 1 of 1 QAPI programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0640 · view on CMS
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Serious Infection Prevention And Control

This agency failed to maintain and document an infection control program in 1 of 1 infection control programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0680 · view on CMS
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Serious Organization And Administration Of Services

This agency failed to maintain effective administration and organization of the agency functions and services provided.

Source: CMS Form 2567, inspection 2020-09-15, tag G0940 · view on CMS
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Moderate Develop Ep Plan, Review And Update Annually

This agency failed to establish an Emergency Preparedness program, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0004 · view on CMS
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Moderate Plan Based On All Hazards Risk Assessment

This agency failed to document a risk assessment in 1 of 1 Emergency Preparedness programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0006 · view on CMS
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Moderate Ep Program Patient Population

This agency failed to ensure there is a continuity of operations plan in the event of an emergency, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0007 · view on CMS
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Moderate Local, State, Tribal Collaboration Process

This agency failed to ensure there is documentation of local and/or regional personnel involved in developing the Emergency Preparedness program, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0009 · view on CMS
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Moderate Development Of Ep Policies And Procedures

This agency failed to ensure there Emergency Preparedness policies based on a risk assessment, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0013 · view on CMS
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Moderate Hha Comprehensive Assessment In Disaster

This agency failed to develop policies and procedure in the Emergency Preparedness plan to ensure all patients have an individualized plan in the event of an emergency, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0017 · view on CMS
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Moderate Homebound Hha/Hospice Inform Ep Officials

This agency failed to establish policy and procedure to inform State and Local Emergency Preparedness officials patients evacuation plan, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0019 · view on CMS
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Moderate Hha- Procedures For Follow Up Staff/Pts.

This agency failed to establish procedures to inform state and local officials of any on-duty staff or patients unable to contact, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0021 · view on CMS
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Moderate Policies/Procedures For Medical Documentation

This agency failed to ensure there is a policy on securing and making medical records available in an emergency, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0023 · view on CMS
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Moderate Development Of Communication Plan

This agency failed to ensure there is a communication plan, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0029 · view on CMS
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Moderate Names And Contact Information

This agency failed to ensure there is documentation of emergency contact information, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0030 · view on CMS
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Moderate Emergency Officials Contact Information

This agency failed to ensure there is documentation of official emergency contacts, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0031 · view on CMS
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Moderate Primary/Alternate Means For Communication

This agency failed to ensure there are multiple means of communication with emergency contacts and officials in the event of an emergency, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0032 · view on CMS
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Moderate Methods For Sharing Information

This agency failed to ensure there is a policy on sharing medical records in the event of an emergency, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0033 · view on CMS
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Moderate Ep Training And Testing

This agency failed to develop and maintain an emergency preparedness training and testing program, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0036 · view on CMS
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Moderate Ep Training Program

This agency failed to ensure there is a policy for training in emergency preparedness, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0037 · view on CMS
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Moderate Ep Testing Requirements

This agency failed to ensure the emergency plan was tested at least annually, in 1 of 1 Emergency Programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag E0039 · view on CMS
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Moderate Program Scope

This agency failed to implement a QAPI (Quality Assessment and Performance Improvement) program that showed measurable improvements in quality indicators for patient safety and quality of care in 1 of 1 QAPI program.

Source: CMS Form 2567, inspection 2020-09-15, tag G0642 · view on CMS
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Moderate Program Data

This agency failed to implement a QAPI (Quality Assessment and Performance Improvement) program that utilized program data in 1 of 1 QAPI program.

Source: CMS Form 2567, inspection 2020-09-15, tag G0644 · view on CMS
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Moderate Program Activities

This agency failed to implement a QAPI (Quality Assessment and Performance Improvement) program that included performance improvement activities in 1 of 1 QAPI program.

Source: CMS Form 2567, inspection 2020-09-15, tag G0646 · view on CMS
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Moderate Track Adverse Patient Events

This agency failed to develop a QAPI (Quality Assessment and Performance Improvement) program that track adverse events, analyze causes implement preventative actions in 1 of 1 QAPI program reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0654 · view on CMS
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Moderate Performance Improvement Projects

This agency failed to implement a QAPI (Quality Assessment and Performance Improvement) program that conducted performance improvement projects in 1 of 1 QAPI program.

Source: CMS Form 2567, inspection 2020-09-15, tag G0658 · view on CMS
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Moderate Executive Responsibilities For Qapi

This agency failed to implement a QAPI (Quality Assessment and Performance Improvement) program that had continued oversight by the Governing Body in 1 of 1 QAPI program.

Source: CMS Form 2567, inspection 2020-09-15, tag G0660 · view on CMS
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Moderate Infection Control

The agency failed to maintain an agency-wide program for the surveillance and identification of infectious and communicable diseases in 1 of 1 Infection Control Program.

Source: CMS Form 2567, inspection 2020-09-15, tag G0684 · view on CMS
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Moderate Governing Body

This agency's governing body failed to maintain oversight of the agency to ensure they followed current regulations in 3 of 3 programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0942 · view on CMS
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Moderate Administrator Must:

This agency's administrator failed to ensure the agency followed current regulations in 2 of 2 programs reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0944 · view on CMS
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Minor Written Notice Of Patient'S Rights

The agency failed to notify patients of their right to receive the patient rights form in the individual's preferred language, free of charge, with the use of interpreter, in 1 of 1 Patient Rights forms reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0412 · view on CMS
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Minor Be Free From Abuse

The agency failed to inform patients of their right to be free from verbal, mental, sexual, and physical abuse including injuries of unknown source, neglect and misappropriation of property in 1 of 1 Patient Rights forms reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0430 · view on CMS
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Minor Receive All Services In Plan Of Care

The agency failed to notify patients of their right to receive all services outlined in the plan of care in 1 of 1 Patient Rights forms reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0436 · view on CMS
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Minor Contact Info Federal/State-Funded Entities

The agency failed to inform patients of their right to names of federally funded entities (agency on aging, center for independent living, protection and advocacy agency, aging and disability resource center and quality improvement organization) and their contact information for the area in which…

Source: CMS Form 2567, inspection 2020-09-15, tag G0446 · view on CMS
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Minor Access To Auxiliary Aids And Language Service

The agency failed to notify patients of the right to receive notice of the patient's rights and responsibilities in the individual's preferred language, free of charge with the use of a competent interpreter, as needed and no later than the completion of the second visit from a skilled professional…

Source: CMS Form 2567, inspection 2020-09-15, tag G0450 · view on CMS
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Minor High Risk, High Volume, Or Problem-Prone Area

This agency failed to develop a QAPI (Quality Assessment and Performance Improvement) program that was based on high risk, high volume, or problem-prone areas in 1 of 1 QAPI program reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0648 · view on CMS
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Minor Incidence, Prevalence, Severity Of Problems

This agency failed to develop a QAPI (Quality Assessment and Performance Improvement) program that measure incidence, prevalence, and severity of problems in 1 of 1 QAPI program reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0650 · view on CMS
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Minor Activities Lead To An Immediate Correction

This agency failed to develop a QAPI (Quality Assessment and Performance Improvement) program that leads to immediate correction in 1 of 1 QAPI program reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0652 · view on CMS
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Minor Improvements Are Sustained

This agency failed to develop a QAPI (Quality Assessment and Performance Improvement) program that track performance to ensure improvements are sustained in 1 of 1 QAPI program reviewed.

Source: CMS Form 2567, inspection 2020-09-15, tag G0656 · view on CMS
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