Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden Terrace Alzheimer's Center Of Excellence during CMS and state inspections, most recent first.
The facility failed to protect two residents from physical abuse by a cognitively impaired, ambulatory resident with a documented history of restlessness, wandering, and escalating verbal and physical aggression toward staff and other residents. Despite care plan documentation that this resident could become agitated, refuse care, attempt to hit staff, throw objects, and place hands on other residents, intensive supervision was not consistently in place before or between two substantiated abuse incidents. In the first incident, the aggressive resident forcefully pushed another resident with dementia against exit doors and repeatedly hit her as she tried to walk away. In the second incident, the same aggressive resident entered a cognitively intact resident’s room, grabbed her blanket, and slapped her across the face, causing facial redness and pain. Staff interviews described the aggressive resident as impulsive, unpredictable, and difficult to redirect, and confirmed that the facility was unable to identify triggers or consistently prevent further resident-to-resident abuse.
A resident with severe dementia and a history of wandering and aggression was repeatedly found unsupervised in other residents' rooms and beds, while staff failed to monitor their whereabouts or engage them in meaningful activities as outlined in the care plan. Staff did not consistently document wandering incidents, focusing only on aggressive behaviors, and were often unaware of the resident's location until prompted. The lack of effective person-centered interventions and monitoring led to ongoing safety concerns and unaddressed behavioral issues.
Failure to Prevent Repeated Resident-to-Resident Physical Abuse by a Known Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident, despite documented patterns of aggressive behavior. Facility policy required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, including verbally and physically aggressive behavior and wandering into others’ rooms or space. Resident #8 had dementia with severe cognitive impairment and was independently ambulatory. Prior to the first substantiated abuse incident, multiple nursing and behavior notes documented that Resident #8 was restless, impulsive, wandered and interfered with other residents’ care, became irritated and agitated when redirected, and was verbally and physically aggressive toward staff. Specific episodes included pulling another resident in a wheelchair, hitting a CNA in the chest, attempting to throw a walker at a nurse, getting very close to other residents and preventing them from doing daily activities, and becoming verbally and physically aggressive when redirected. Resident #8’s behavior care plan, initiated in January and revised in February, identified depression, insomnia, agitation, anxiety about going home, refusal of care, verbal aggression, and physical aggression toward staff, including throwing objects and attempting to hit staff. Staff had also observed Resident #8 putting hands on other residents in a non-aggressive manner to direct them and noted that she could be difficult to redirect. The care plan included interventions such as one-on-one supervision, explaining procedures, allowing time to adjust to changes, intervening to protect the rights and safety of others, removing the resident from situations, taking her to alternate locations, observing for behavior episodes and underlying causes, and providing appropriate activities. However, one-on-one supervision was not in place prior to the first abuse incident and was only implemented after that event, even though Resident #8 had exhibited multiple aggressive behaviors toward staff and other residents in the weeks leading up to the incident. On 2/24/26, while Resident #8 was at the exit doors pushing on them, Resident #9, who had dementia with severe cognitive impairment, physical behaviors toward others, and wandering, approached the same area. Unprovoked, Resident #8 pushed Resident #9 forcefully against the exit doors, then followed her as she tried to walk away, hitting her back and upper arms multiple times and pulling a room door closed while stating, “If you are going to behave like a baby, you are going to stay there.” RN #1 witnessed the event as it was occurring and intervened, with a CNA responding to the commotion. Resident #9 was assessed and had no injuries or noted change in mood or behavior, and she was unable to recall the incident. The facility substantiated this as physical abuse. Despite this substantiated abuse and the prior documented aggressive behaviors, Resident #8 continued to exhibit problematic behaviors, including throwing water at another resident and touching other residents and staff. On 2/28/26, a second substantiated abuse incident occurred involving Resident #12, who had anxiety, dementia, a cognitive communication deficit, and was cognitively intact per MDS with verbal behaviors toward others. Resident #12 reported that she found Resident #8 in her room sitting on her bed and told her to leave, pointing to her name on the wall to show it was her room. Resident #8 became upset, grabbed Resident #12’s blanket, and slapped her on the left cheek. A nurse heard Resident #12 calling for help, entered the room, and observed Resident #8 holding the blanket while Resident #12 reported being slapped. Resident #8 admitted to slapping Resident #12, stating that she was “being a brat.” Resident #12 was found to have redness on her left cheek measuring 2.5 cm by 1 cm and reported that her cheek hurt for a couple of days. The facility substantiated this second incident as physical abuse. Staff interviews further described Resident #8 as impulsive, unpredictable, verbally and physically aggressive, challenging to redirect, and exhibiting exit-seeking behaviors. The social services director and CNA #3 both indicated difficulty identifying triggers for Resident #8’s behaviors, and CNA #3 reported being hit by Resident #8 while attempting to redirect her from entering another resident’s room. The DON and NHA confirmed that Resident #8 had been aggressive toward other residents, that she had been moved between units, and that the facility was still trying to identify her behavior triggers. Overall, the documented pattern of aggressive behavior, the care plan identifying risk to others, and the occurrence of two substantiated resident-to-resident abuse incidents demonstrate that the facility did not effectively implement and maintain interventions necessary to keep Resident #9 and Resident #12 free from abuse by Resident #8.
Failure to Implement Person-Centered Dementia Care and Monitor Wandering Behaviors
Penalty
Summary
The facility failed to ensure that a resident with severe dementia received appropriate person-centered care and interventions to maintain their highest practicable well-being. The resident, who was severely cognitively impaired and had a history of wandering, aggression, and behavioral disturbances, was repeatedly observed leaving their own room and entering other residents' rooms without staff awareness. On multiple occasions, the resident was found asleep in other residents' beds while the assigned staff were either unaware of their whereabouts or incorrectly assumed the resident was in their own room. Staff did not consistently monitor or engage the resident in meaningful activities to minimize wandering, despite care plan interventions that called for such engagement. Observations revealed that staff at the nurses' station and in the dining area were not attentive to the resident's movements, allowing the resident to wander unsupervised into other rooms. Staff only became aware of the resident's location after being prompted or when searching room by room. The care plan for the resident included interventions such as documenting wandering behavior, providing diversional activities, and encouraging participation in structured activities, but these were not effectively implemented. Staff interviews confirmed that the resident frequently wandered into other residents' rooms, sometimes becoming aggressive when redirected, and that staff were unable to prevent these behaviors. Documentation practices were also deficient, as staff primarily recorded aggressive behaviors but failed to document incidents of wandering, including entering other residents' rooms and sleeping in their beds. The social services director acknowledged that behavior tracking was not person-centered and that all behaviors, including wandering, should be documented. The director of nursing and other staff recognized that the lack of monitoring and documentation was unacceptable and that the resident's behaviors could lead to altercations with other residents.
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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) |
|---|---|---|---|---|
| Advanced Health Care Of Aurora | 0.3 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Aurora | 0.9 mi | ★★★★★ | 25 | 0 |
| The Springs At St. Andrews Village | 1.4 mi | ★★★★★ | 10 | 0 |
| Hampden Hills Post Acute | 2.5 mi | ★★★★★ | 0 | 0 |
| University Heights Care Center | 2.7 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 July 2026) and official state health department websites.