Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Advanced Health Care Of Aurora during CMS and state inspections, most recent first.
Infection control practices were not maintained when housekeepers cleaned sink areas out of sequence and used the same rag on cleaner and dirtier surfaces, a water management program for Legionella was not in place and testing supplies were unavailable, and CNAs moved a vitals cart between residents without disinfecting the blood pressure cuff or machine between uses. The IP and DON stated that reusable equipment should be cleaned between residents.
The facility failed to follow medication orders for multiple residents. An LPN/RN administered an antihypertensive despite low BP parameters, gave Senna to residents with loose stools even though the orders said to hold it, and could not provide Eliquis and duloxetine during a med pass because the medications were not available. The DON and other staff acknowledged the orders and the missed or inappropriate administrations.
A resident with orders for Eliquis, duloxetine, and aspirin missed all three medications during a med pass because the RN could not find them in the cart. The RN said the meds had been requested from the pharmacy but had not yet been delivered, while the pharmacist and DON described the facility’s refill and delivery process and noted nurses should reorder before supply runs out.
A facility failed to provide food and fluids in accordance with physician orders for two residents. One resident with dysphagia and other neurologic conditions was served regular-texture meals instead of a soft and bite-sized diet, and staff observed the resident eating without consistent supervision. Another resident with a PEG tube and NPO orders was found with a meal tray and juice in the room, and nursing notes documented that liquids were given despite the NPO status.
A medication cart was left unlocked and unattended near the nurses' station while residents and housekeeping personnel were nearby. An RN was observed opening the cart, charting away from it, and leaving it unlocked for several minutes before returning to lock it. Staff stated medication carts should be locked when unattended, and the DON confirmed the facility policy was to keep medications locked at all times.
The facility failed to maintain effective infection control practices, as residents were not offered hand hygiene before meals, and an LPN used the same blood sugar testing supplies for multiple residents without changing them. Observations and interviews confirmed these lapses, highlighting a significant risk of cross-contamination and infection spread within the facility.
The facility failed to update comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. A resident's care plan did not reflect a new deep tissue injury or the use of a heel protector. Another resident's care plan was not updated after discontinuing a feeding tube and IV antibiotics, nor did it include fall prevention measures. A third resident's care plan failed to document a stage IV pressure injury and necessary treatment orders.
The facility failed to properly manage medication storage and temperature monitoring. Discontinued medications were not discarded, and loose pills were found in a medication cart. The medication refrigerator's temperature was inconsistently monitored, with missing documentation and recorded temperatures exceeding acceptable ranges without intervention. The DON confirmed the need for daily checks and immediate action on abnormalities.
Infection Control Failures in Housekeeping, Water Management, and Vital Sign Equipment Disinfection
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment on two of three units. During housekeeping observations, housekeepers cleaned resident sinks in a manner that did not follow a clean-to-dirty sequence. One housekeeper wiped the inside of a bedroom sink and then used the same rag to wipe the faucet, handles, and countertop. Another housekeeper wiped the inside of a bathroom sink and then used the same rag on the countertop and grab bar. Both housekeepers acknowledged that the inside of the sink could be dirtier than the outside surfaces and that a different rag should have been used after cleaning the sink bowl. The facility also failed to implement a water management plan. The maintenance director stated that the facility did not have a current water management plan, did not have a physical log or binder with Legionella tracking and testing information, and was out of Legionella testing supplies. The maintenance director said the facility had not tested the building’s water for Legionella for a couple of months because supplies were needed, and the previous maintenance director’s binder containing the water management plan and ordering information had not been passed on. The facility further failed to ensure vital sign machines were disinfected between residents. Surveyors observed CNAs moving a vital signs cart from one resident room to another without cleaning the equipment between uses. One CNA left a resident’s room with the vitals machine, retrieved a pulse oximeter from the nurses’ station, and entered another resident’s room without hand hygiene being performed between rooms. On another observation, a CNA used a blood pressure cuff on one resident and then took the vitals cart into another resident’s room without cleaning the cuff or machine in between resident uses. The infection preventionist and DON stated that vital sign equipment should be cleaned between residents.
Medication Orders Not Followed for Blood Pressure, Loose Stools, and Missing Medications
Penalty
Summary
The facility failed to ensure residents received medications according to physician orders and failed to hold medications when ordered parameters were met. For Resident #42, who had diagnoses including hypertension, atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, and kidney failure, the record showed an order to hold antihypertensive medication when systolic blood pressure was below 100 mmHg or diastolic blood pressure was below 50 mmHg. Despite documented blood pressures below that threshold on multiple occasions, nebivolol was still documented as administered, and the record did not show that the physician was notified about the low blood pressure during those administrations. For Resident #63, who had severe cognitive impairment and diagnoses including a displaced left femur fracture, hypertensive chronic kidney disease, type 2 diabetes, and vascular dementia with anxiety, the physician ordered Senna to be held for loose stools. The bowel movement record documented loose or liquid stools on several days, yet Senna was still marked as administered each day during that period. The resident’s representative reported concern that the resident had diarrhea while receiving the laxative, and the record did not show documentation that the physician was contacted about the loose stools. For Resident #50, who was cognitively intact and had diagnoses including chronic pancreatitis, generalized muscle weakness, polyneuropathy, anemia, and atrial fibrillation, the record showed repeated loose or liquid stools while Senna remained ordered to be held for loose stools. The resident also had orders for Eliquis and duloxetine, but during medication administration the nurse could not find either medication and the resident did not receive them at that time. The nurse stated the medications had not yet been delivered by the pharmacy, and the DON stated nurses should reorder medications before supply ran out so residents would not go without them.
Medication Administration Errors Due to Unavailable Ordered Medications
Penalty
Summary
Medication administration errors occurred when the facility failed to prevent a medication error rate of 8.1%, based on three errors out of 37 opportunities for error. During a medication pass for a resident with orders for Eliquis 2.5 mg twice daily for clot prophylaxis, duloxetine 30 mg daily for neuropathy, and aspirin 81 mg daily for clot prophylaxis, the RN preparing the medications was unable to find any of the three medications. As a result, the resident did not receive the medications during the medication pass. Interviews showed the RN said the medications had been requested from the pharmacy but had not yet been delivered. The pharmacist stated the facility normally requested refills by fax, phone, or electronically and that delivery occurred within one business day, with three deliveries per day to the facility. The DON stated nurses should reorder medications 72 hours before supply ran out, and said if medications were not available in the cart, nurses should check resources and emergency supplies, notify the provider and family, and inform her so she could contact the pharmacy.
Incorrect Diet Texture and NPO Order Not Followed
Penalty
Summary
The facility failed to ensure that two residents received food and fluids prepared in a form consistent with their physician orders. One resident had orders for a mechanically altered diet, but was observed being served regular-texture meals, including whole or long pasta noodles, peas, bread, cake, and other items that were not consistent with a soft and bite-sized diet. The resident’s record showed diagnoses including Parkinson’s disease, metabolic encephalopathy, and convulsions, and speech therapy had documented moderate oropharyngeal dysphagia with a recommendation for mechanical soft textures and close supervision while eating. During meal observations, the resident was seen eating alone without consistent, meaningful supervision from staff. The meal tickets at the time of observation reflected a regular diet, regular texture, even though the physician order in the record indicated a Level 6 soft and bite-sized diet with thin liquids and specific cut-up instructions for some meats. Interviews with nursing, dietary, and therapy staff showed conflicting understanding of the resident’s diet order and how it should be implemented, and the resident’s representative stated the resident had been receiving regular-looking trays and had not been contacted about liberalizing the diet. A second resident was admitted with diagnoses including encephalopathy, intracerebral hemorrhage, pneumonitis due to inhalation of food or vomit, and dysphagia, and had a PEG tube in place. Hospital discharge information documented that the resident was NPO with limited ice chips only under supervision, and the facility’s physician order also reflected NPO with tube feedings. Despite this, staff found an intact meal tray with food and juice in the resident’s room, and nursing notes documented that the resident had been given liquids. The tray was removed after discovery, the physician was notified, and the resident later developed fever, low oxygen saturation, and elevated pulse before being sent to the hospital.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards in one of three medication carts. The facility policy stated that only licensed nurses and pharmacy personnel were allowed access to medications and that medication rooms, carts, and medication supplies were to be locked or attended by persons with authorized access. On observation, medication cart #5 was found unlocked when not in the direct line of sight of a nurse. One RN was observed tugging on the top drawer of the cart, which opened, and then pushing the lock in with his hand to secure it. Later, the same cart was observed unlocked and unattended near the nurses' station while residents and housekeeping personnel were nearby. An RN opened and closed a drawer, charted at the nurses' station, walked away from the cart leaving it unlocked, and returned several minutes later to lock it. Staff interviews confirmed that medication carts should be locked when unattended and that the cart should not have been left unlocked.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the lack of hand hygiene offered to residents before meals. Observations revealed that residents in the dining room, including those in wheelchairs, were not provided with hand hygiene opportunities before eating. Additionally, meal trays delivered to resident rooms did not include hand sanitizing packets, and staff did not encourage or assist residents with hand hygiene. Interviews with residents confirmed that they were not offered hand hygiene before meals, and staff interviews corroborated the lack of adherence to hand hygiene protocols. The facility also failed to ensure that point of care (POC) testing supplies were not contaminated between residents. An LPN was observed using a disposable plastic cup containing blood sugar testing supplies for multiple residents without changing the supplies between uses. The same cup and supplies were used in different resident rooms and then stored in the medication cart, posing a risk of cross-contamination. The LPN acknowledged the inappropriate practice during an interview, and the DON confirmed that supplies should not be shared among residents. These deficiencies highlight a significant lapse in the facility's infection prevention and control measures, as they did not adhere to established guidelines and policies. The lack of hand hygiene before meals and the improper handling of POC testing supplies could contribute to the spread of infectious diseases within the facility, compromising the safety and well-being of the residents.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which led to deficiencies in addressing their specific medical needs. Resident #4, who was admitted with a pressure ulcer, did not have her care plan updated to reflect a new deep tissue injury on her right heel. Additionally, the intervention of using a soft heel protecting boot was not included in her care plan, despite being used as a protective measure. Interviews with staff, including the infection preventionist, confirmed that the pressure injury and the use of the heel protector should have been documented in the care plan. Resident #11 experienced significant changes in her medical condition, including the discontinuation of a feeding tube and IV antibiotics, and a transition to oral feeding. However, her care plan was not updated to reflect these changes, nor did it include interventions following a fall she experienced at the facility. Interviews with the registered dietitian and the director of nursing revealed that the care plan should have been revised to include the new diet orders and fall prevention measures. Resident #26, who had severe cognitive impairments, was admitted with a pressure injury on the sacrum. The comprehensive care plan failed to document the presence of a stage IV pressure injury and did not include the wound physician's treatment orders or recommendations for turning the resident. The director of nursing acknowledged that the care plan should have been updated to reflect these changes in the resident's condition.
Medication Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications, as observed in the medication storage room and one of the medication carts. Specifically, medications that had been discontinued were not discarded from the medication cart, and loose pills were found in a drawer of the cart, with the LPN unable to identify them. Additionally, the medication refrigerator's temperature was not consistently monitored or documented, with several days missing records and instances of recorded temperatures exceeding the acceptable range without any documented interventions. The facility's policy requires medications to be stored securely and under proper temperature controls, with refrigerator temperatures monitored and recorded twice daily. However, the August, September, and October logs showed numerous days without temperature documentation, and abnormal temperatures were recorded without any corrective actions. The DON confirmed that medications should be removed from the cart on the day they are discontinued and that refrigerator temperatures should be checked daily, with any abnormalities reported and addressed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Terrace Alzheimer's Center Of Excellence | 0.3 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Aurora | 0.6 mi | ★★★★★ | 26 | 0 |
| The Springs At St. Andrews Village | 1 mi | ★★★★★ | 10 | 0 |
| Hampden Hills Post Acute | 2.2 mi | ★★★★★ | 3 | 0 |
| University Heights Care Center | 3.1 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.