Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hampden Hills Post Acute during CMS and state inspections, most recent first.
The facility failed to provide a clean and homelike environment by not supplying adequate clean washcloths and hand towels to residents. Observations showed many rooms lacked these items, and some towel holder bars were broken. Residents reported frequent shortages, especially on shower days, and staff interviews revealed a lack of awareness and communication about the issue.
The facility did not adhere to its menu and portion sizes, impacting residents' nutritional intake. During lunch, residents received one scoop of tortellini instead of two, and during dinner, milk was not offered as required. The dietary consultant confirmed these deviations from the menu, highlighting a failure to meet nutritional guidelines.
The facility failed to provide functional utensils to residents on the second floor, leading to difficulties in cutting and consuming meals. Residents were given plastic utensils due to an out-of-service elevator, resulting in some residents being unable to eat their meals properly. Staff struggled to assist with cutting food, and residents expressed dissatisfaction with the situation.
The facility failed to document and resolve resident grievances, particularly regarding food quality and missing packages. Despite policy requirements, grievances expressed during resident council meetings were not formally documented or addressed. Interviews revealed widespread dissatisfaction with food and unaddressed concerns about missing packages. Staff were unaware of grievances, and the grievance official admitted to not tracking concerns, highlighting systemic issues in grievance management.
The facility failed to provide adequate activity programs for three residents, impacting their well-being. One resident desired more mind-stimulating activities but was offered primarily coloring activities. Another resident, with minimal cognitive impairment, wanted more trivia-type games but found the options limited. A third resident, unable to attend group activities due to a non-functional elevator, was dependent on staff assistance, which was not provided. The care plans did not address these residents' preferences, leading to isolation and dissatisfaction.
The facility failed to maintain infection control and sanitation standards, as staff did not follow Enhanced Barrier Precautions for a resident with a nephrostomy tube, and pull cords in bathrooms were soiled. Additionally, resident rooms were not cleaned properly, and a resident's nebulizer was not cleaned or stored correctly.
The facility failed to ensure dining room tables were stable, leading to an unsafe and uncomfortable environment for residents. Observations showed unbalanced tables, and residents reported difficulty eating due to the instability. The maintenance director admitted to relying on verbal reports for repairs and was unaware of the issue, highlighting a lack of effective communication and documentation.
The facility failed to provide necessary assistance with ADLs for three residents, leading to deficiencies in personal hygiene and repositioning. One resident had severe cognitive impairment and was observed with poor oral and nail hygiene. Another resident with multiple sclerosis reported not having her teeth brushed and was not repositioned for nearly four hours. A third resident with a history of pressure ulcers was left in her wheelchair for extended periods without repositioning. Staff interviews and observations confirmed these deficiencies.
A resident with cognitive intactness and a history of anxiety disorder, hypothyroidism, and dysphagia requested to see an audiologist due to worsening hearing. Despite expressing this need, the facility did not arrange a hearing exam or provide education on the consent form required for hearing services. The social services assistant did not proceed with the request because the resident refused to sign the consent form and did not explore alternative consent options, resulting in the resident not receiving necessary hearing services.
The facility failed to provide timely dental services to two residents, one waiting seven months for dentures and another missing a lower denture since November. Despite the facility's policy requiring prompt assistance, there was no follow-up or documentation to address these issues, impacting the residents' ability to eat properly.
A facility failed to provide necessary speech therapy services for a resident with severe cognitive impairment and swallowing difficulties, despite a physician's order. The resident experienced significant weight loss and was left to eat meals without assistance, highlighting a lack of communication and follow-through in providing specialized rehabilitative services.
A resident with a left leg amputation was not provided a prosthetic device despite requests and a physician's order. The resident, who was cognitively intact and desired the prosthetic for independence, did not receive follow-up due to miscommunication among staff. The therapy department did not recommend a prosthetic as the resident did not express a desire to walk or transfer, leading to the resident's increased dependency.
A facility failed to accurately document a resident's PASRR Level II diagnosis in the MDS assessment. The resident, with a diagnosis of bipolar disorder, required specialized services as per the PASRR Level II Notice of Determination. However, the MDS assessment did not reflect this due to a communication gap between the social services department and MDS coordinators, leading to an oversight in the resident's assessment.
A facility failed to implement PASRR level II recommendations for a resident with Down's syndrome and major depressive disorder. The resident expressed interest in community activities, but the facility did not arrange the recommended specialized services, including community integration activities. Documentation and follow-up on referrals were lacking, as revealed in staff interviews.
The facility failed to administer Trulicity injections according to manufacturer's instructions and had inaccurate medication orders for two residents. An LPN did not follow proper injection technique, and the MARs contained incorrect or incomplete dosage information, leading to discrepancies in medication administration.
The facility failed to provide appropriate care for two residents with dementia, leading to deficiencies in their treatment. One resident exhibited wandering and aggressive behaviors, while another frequently yelled in Korean without effective staff intervention. The facility's care plans did not adequately address language barriers, and staff lacked training in dementia care and communication strategies.
A resident with dysphagia and hemiplegia was not provided with necessary adaptive drinking equipment, such as a spill-proof cup, leading to spills and inadequate assistance. The facility's policy required assessment and provision of adaptive equipment, but there was a lack of communication between departments, resulting in the resident not receiving the specified equipment.
Deficiency in Providing Clean Towels and Washcloths
Penalty
Summary
The facility failed to maintain a clean and sanitary homelike environment for its residents, specifically by not providing clean washcloths and hand towels. Observations conducted over several days revealed that numerous rooms lacked hand towels and washcloths, and some towel holder bars were broken. During a tour with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), it was noted that the Golden Gate unit had only 18 towels for approximately 65 residents, and the second-floor laundry room had no hand towels in the linen carts. Interviews with residents indicated dissatisfaction with the availability of clean towels and washcloths. Six alert and oriented residents reported that the facility frequently ran out of clean towels, especially on shower days. Individual interviews with residents further highlighted the issue, with some residents resorting to using paper towels due to the lack of linen hand towels. Staff interviews revealed a lack of awareness and communication regarding the deficiency. The DON stated that nursing staff were responsible for distributing towels and washcloths but was unaware of the shortage. The housekeeping supervisor mentioned that CNAs were supposed to bring towels to the linen closets, but observations contradicted this claim. The maintenance director was also unaware of the broken towel holder bars, as they were not reported by the nursing staff, indicating a breakdown in communication and reporting within the facility.
Failure to Follow Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to its established menus and portion sizes, which are crucial for meeting the nutritional needs of residents. During a lunch meal observation, it was noted that residents on a regular diet were served only one gray #8 scoop of tortellini instead of the prescribed two scoops. This deviation from the menu extensions indicates a failure to provide adequate nutrition as per the facility's guidelines. The dietary consultant confirmed that the incorrect portion was served, which could potentially impact the residents' nutritional intake. Additionally, during a dinner service observation, the facility did not follow the weekly menu, which specified that 2% milk should be served with the meal. Instead, dietary aides offered coffee and juice, neglecting to provide milk or a suitable dairy substitute. This oversight was acknowledged by the dietary consultant and registered dietitian, who stated that the calorie count for the day included all items on the menu, including milk. The failure to offer milk or an alternative beverage further demonstrates the facility's non-compliance with its nutritional policies.
Inadequate Utensils Provided to Residents
Penalty
Summary
The facility failed to reasonably accommodate the needs of residents on the second floor by providing them with functional utensils during meal times. Observations revealed that residents were served meals with plastic utensils and styrofoam cups, which were inadequate for cutting the chicken fried steak served for dinner. Staff members struggled to assist residents in cutting their food with the plastic knives, and in some cases, residents were unable to eat their meals properly. This issue was compounded by the fact that the elevator was out of service, leading to the use of disposable utensils as a temporary measure. Interviews with residents and staff highlighted ongoing difficulties with the use of plastic utensils. Residents expressed frustration with their inability to cut their food, leading to some residents not eating their meals. The dietary consultant confirmed that the use of disposable utensils was due to the elevator being out of service, and acknowledged that the management team had not discussed the potential difficulties residents might face with these utensils. The lack of proper utensils and the delay in assistance contributed to the residents' dissatisfaction and inability to enjoy their meals.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure prompt action was taken upon the filing of grievances expressed during resident council meetings. The facility's policy and procedure on grievances, revised in January 2025, mandates that grievances be documented and resolved promptly. However, multiple resident complaints, particularly regarding the quality and temperature of food, were not documented on grievance forms, nor were they resolved to the residents' satisfaction. This lack of documentation and resolution was evident despite the facility's policy requiring the grievance official to oversee the process and ensure grievances are addressed within three working days. Interviews with residents revealed widespread dissatisfaction with the food, with complaints about the taste, temperature, and portion sizes. Residents also expressed concerns about missing packages, which were reported but not formally documented or resolved. The social services assistant, who also served as the grievance official, admitted to not always filling out grievance forms for concerns raised during resident council meetings, indicating a systemic issue in tracking and resolving grievances. Staff interviews further highlighted the facility's failure to address grievances effectively. The social services assistant and director were unaware of any food-related grievances, despite multiple complaints documented in resident council minutes. The registered dietitian was only made aware of certain complaints during the survey process, and the dietary manager was unavailable for comment. The nursing home administrator acknowledged a lack of awareness regarding missing packages and admitted to not keeping track of reimbursements made to residents. This lack of communication and documentation contributed to the facility's failure to resolve resident grievances adequately.
Failure to Provide Adequate Activity Programs for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs and interests of three residents, impacting their physical, medical, and psychosocial well-being. Resident #23, who had no cognitive impairments, expressed a desire for more mind-stimulating activities such as trivia and word games. However, the facility's activities were primarily geared towards residents with cognitive impairments, resulting in activities like coloring pictures. The resident's care plan did not address her preference for thought-provoking activities, leading to her spending more time in her room. Resident #34, with minimal cognitive impairment, also expressed a preference for cognitively challenging activities. Despite attending activities regularly, she found the options limited and desired more trivia-type games. Her care plan similarly failed to address her interest in such activities, and she reported not receiving new reading materials from the activity department for some time. The activity director claimed that both residents attended activities without complaints, but the residents' interviews contradicted this assertion. Resident #21, who was cognitively intact but required maximum assistance with ADLs, was unable to participate in group activities due to a non-functional elevator. This resident expressed a desire to get out of bed more often and participate in activities, but was dependent on staff assistance, which was not provided. The resident's care plan indicated she structured her own day with independent activities, but the lack of staff support and the elevator issue prevented her from attending group activities, further isolating her from social engagement.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain and follow infection prevention and control programs, leading to several deficiencies. Staff did not adhere to Enhanced Barrier Precautions (EBP) for a resident with a nephrostomy tube, as they did not wear the required personal protective equipment (PPE) such as gowns and masks during high-contact care activities. Despite the presence of a sign indicating EBP and available PPE, staff members were observed providing care without the necessary protective measures. Interviews with the resident and staff confirmed the lack of compliance with EBP protocols, despite previous training sessions on infection control measures. Additionally, the facility did not ensure that pull cords in resident bathrooms and shower rooms were clean. Observations revealed that call light strings in multiple locations were soiled with a brown substance, indicating a failure in maintaining sanitary conditions. Interviews with the housekeeping staff revealed that the material of the pull cords was difficult to clean, and there was no immediate plan to address this issue. The facility also failed to ensure that resident rooms were cleaned appropriately. A housekeeper was observed using the same towel to clean both bathroom and resident table surfaces, and high-touch areas such as light switches and door knobs were not cleaned. Furthermore, a resident's nebulizer was not cleaned or stored properly, as it was found lying on a cluttered nightstand with dried water stains and without a protective covering. Interviews with staff indicated a lack of adherence to proper cleaning and storage procedures for the nebulizer, despite the availability of resources to do so.
Unstable Dining Tables Compromise Safety and Comfort
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the dining area, as evidenced by unstable dining room tables. Observations revealed that five tables were unbalanced, causing the surface to move unsteadily when residents leaned on them. During an evening meal, multiple tables were noted to be unbalanced, affecting residents' ability to eat comfortably. Interviews with residents confirmed the issue, with one resident resorting to using folded paper towels under the table legs to stabilize them, although this solution was temporary and required frequent adjustments. The maintenance director (MTD) acknowledged that the maintenance team relied on nursing staff to report repair needs, but the facility's electronic report database was not utilized. Instead, maintenance requests were communicated verbally or through written notes, and the MTD used a legal pad to track repairs, discarding the list once tasks were completed. The MTD was unaware of the unbalanced tables despite checking them a few times weekly, indicating a lack of effective communication and documentation regarding maintenance issues.
Deficiencies in ADL Assistance and Repositioning
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal hygiene and repositioning. Resident #35, who had severe cognitive impairment and was dependent on staff for most ADLs, was observed with a heavy buildup of whitish matter on his teeth and long, dirty nails. Despite being assessed as needing maximal assistance for oral hygiene, the resident's care plan lacked a focus on nail care, and staff interviews revealed inconsistencies in the provision of care. Resident #34, diagnosed with multiple sclerosis and requiring partial assistance with oral hygiene and total assistance with repositioning, reported not having her teeth brushed for some time, resulting in foul-smelling breath and visible white substance on her teeth. Observations confirmed that the resident was not repositioned for nearly four hours while in her wheelchair, despite her care plan indicating a need for frequent repositioning due to a history of pressure injuries. Staff interviews corroborated the lack of adherence to the care plan's interventions. Resident #25, with a history of pressure ulcers and quadriplegia, was left in her wheelchair for extended periods without repositioning, despite her care plan's emphasis on frequent repositioning to promote healing of pressure ulcers. Observations showed the resident remained in the same position for over four hours, and staff interviews highlighted a failure to provide the necessary repositioning assistance. The facility's documentation did not indicate any refusal of repositioning by the resident, further underscoring the deficiency in care provided.
Failure to Provide Hearing Services Due to Consent Issues
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for a resident. The resident, who was cognitively intact and had a history of anxiety disorder, hypothyroidism, and dysphagia, expressed a need to see an audiologist due to worsening hearing and a desire to obtain hearing aids. Despite the resident's requests and documentation of poor hearing in a progress note, the facility did not arrange for a hearing exam or provide education regarding the consent form necessary for hearing services. The social services assistant acknowledged that the resident had requested to see an audiologist but did not proceed with the request because the resident refused to sign the consent form for treatment. The assistant was unsure if the resident understood the consent form and did not explore alternative consent options, such as verbal consent with a witness. This inaction resulted in the resident not receiving the necessary hearing services, as there was no documentation of an audiologist appointment or education provided to the resident about the consent process.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to assist two residents in obtaining necessary dental services, as required by their policy. Resident #60, a 78-year-old with dementia, anxiety, and depression, had been waiting for new dentures for seven months without any follow-up from the facility. Despite a social services referral for denture replacements being made in March 2024, there was no documentation or action taken to ensure the dentures were received. Interviews with the resident revealed significant difficulty in eating due to the lack of dentures, and staff interviews indicated a lack of awareness and follow-up on the issue. Resident #23, a 73-year-old with unspecified protein-calorie malnutrition and type 2 diabetes, was missing a lower denture, which affected her ability to eat. Although the resident was aware of the issue, there was no documentation in her electronic medical record indicating a referral to a dentist for the missing denture. Staff interviews revealed that the resident's dentures had been lost and found several times, but the lower denture had been missing since November 2024. The resident was only placed on the dentist list on the day of the surveyor's visit. The facility's dental policy requires prompt assistance in obtaining dental care, defined as within three business days of identifying the need. However, both residents experienced significant delays in receiving necessary dental services, with no documented extenuating circumstances to justify the delays. The lack of timely follow-up and documentation indicates a failure to adhere to the facility's policy and ensure residents' dental needs are met.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services to maintain the highest practicable level of functioning for a resident diagnosed with stroke, polyneuropathy, and adult failure to thrive. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, was observed to have difficulty swallowing and experienced significant weight loss. Despite a physician's order for a speech therapy evaluation due to pocketing food and intermittent coughing when swallowing, the evaluation was not completed, and the resident did not receive the necessary speech therapy services. The resident's care plan did not adequately address the degree of eating assistance required, and there was no speech therapy care plan focus related to the resident's swallowing difficulties. Staff interviews revealed a lack of communication and follow-through regarding the speech therapy order, with the Director of Rehabilitation and the Speech Therapist unable to explain why the evaluation was not conducted. The resident was left to eat meals without assistance, despite needing cueing to swallow food safely, highlighting a significant oversight in the provision of necessary rehabilitative services.
Failure to Provide Prosthetic Device for Resident
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing a left leg prosthetic, which the resident had prior to admission. The resident, who is under 65 and has a diagnosis of bipolar disorder and an acquired absence of the left leg above the knee, was cognitively intact and expressed a desire for a prosthetic to regain independence. Despite the resident's request and a physician's order for a prosthetic fitting, there was no documentation of follow-up in the resident's electronic medical record. Interviews with staff revealed a lack of communication and responsibility regarding the resident's request. The Social Services Director was unaware of the referral status, and the Nursing Home Administrator indicated that the therapy department was responsible for the assessment and referral. However, the Physical Therapy Assistant stated that the resident did not express a desire to walk or transfer, which was a criterion for providing a prosthetic. This miscommunication and lack of follow-up led to the resident feeling dependent on others for mobility, contrary to his expressed wishes.
Inaccurate MDS Assessment Due to PASRR Information Omission
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding the Preadmission Screening and Resident Review (PASRR) Level II qualifying diagnosis. The resident, an 84-year-old individual with a diagnosis of bipolar disorder, was admitted to the facility and had a PASRR Level II Notice of Determination indicating a condition that required specialized services such as psychiatry case consultation and additional one-to-one engagement support. However, the MDS assessment conducted on a later date did not document the resident's PASRR Level II diagnosis, which was a critical oversight. Interviews with facility staff revealed that the social services department was responsible for reviewing PASRRs and providing Level II determination information to the MDS coordinators. The MDS coordinators relied on this information to complete the MDS assessments accurately. In this case, the MDS coordinators were not aware of the resident's PASRR Level II determination due to a lack of updated information from social services. This communication gap led to the inaccurate documentation in the MDS assessment, highlighting a deficiency in the facility's process for ensuring accurate resident assessments.
Failure to Implement PASRR Recommendations for Resident
Penalty
Summary
The facility failed to incorporate recommendations from the PASRR level II determination and evaluation for a resident with serious mental illness or a related condition. Specifically, the facility did not arrange or incorporate the recommended specialized services for a resident diagnosed with Down's syndrome and major depressive disorder. The resident, who was cognitively intact, expressed interest in community activities and making friends, but the facility's social services department had not set up any community activities or services for her. The PASRR level II evaluation recommended supported community connections, case management, psychiatric case consultation, individual therapy, transportation to behavioral management, and pastoral care. However, the resident's care plan did not include community integration activities, and there was no documentation in the progress notes or electronic medical record indicating efforts to meet these recommendations. Interviews with the social services director and consultant revealed that referrals for services had not been adequately pursued or documented, and no follow-up had been conducted since December 2024.
Deficiency in Trulicity Administration and Documentation
Penalty
Summary
The facility failed to ensure that the administration of Trulicity injections for two residents met professional standards of quality. Specifically, an LPN administered a Trulicity injection to a resident by pinching the skin and not following the manufacturer's instructions to hold the pen flat against the skin and wait for two clicks. Additionally, the medication administration record (MAR) for this resident contained an incorrect dosage order, which did not match the physician's order or the dosage administered. Furthermore, another resident's MAR documented a Trulicity order without specifying the milligram dose, leading to potential confusion in administration. The discrepancies in medication orders and administration instructions were identified during a review, revealing that the orders for residents on Trulicity were contradictory and not accurately documented in the MARs.
Deficiencies in Dementia Care and Communication for Non-English Speaking Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with dementia, leading to deficiencies in their care. Resident #72, an 85-year-old with severe cognitive impairments, exhibited behaviors such as wandering, aggression, and interference with other residents' privacy and safety. Despite having a care plan that included interventions like structured activities and communication strategies, the facility did not effectively implement these measures. The resident's non-English speaking status further complicated communication, and the care plan did not adequately address this language barrier. Resident #80, also diagnosed with dementia, experienced severe cognitive impairments and was unable to communicate effectively in English. The resident frequently yelled in Korean, expressing delusions and fears, but the staff did not utilize translation tools or person-centered interventions to address these behaviors. Observations revealed that staff often left the resident alone until the yelling ceased, without attempting to understand or alleviate the underlying distress. Interviews with staff indicated a lack of knowledge and training in dementia care and communication strategies for non-English speaking residents. The facility's reliance on family members for translation was insufficient, as they were not always available. Additionally, the facility's psychotropic drug meetings did not adequately address the challenging behaviors exhibited by these residents, and there was a lack of documentation and follow-up on non-pharmacological interventions discussed during these meetings.
Failure to Provide Adaptive Drinking Equipment
Penalty
Summary
The facility failed to provide adaptive drinking equipment for a resident with significant medical conditions, including dysphagia following a cerebral infarction, cerebral vascular disease, hemiplegia, and hemiparesis. The resident, who was dependent on staff for most activities of daily living, was observed on multiple occasions without the necessary adaptive equipment, such as a spill-proof cup designed to be used with a straw. This resulted in visible spills on the resident's clothing, indicating a lack of appropriate assistance and equipment provision. The facility's policy required that residents be assessed for adaptive equipment needs upon admission and reassessed quarterly. However, the resident's care plan, which included the provision of an adaptive cup, was not followed. Interviews with the Director of Nursing and the Assistant Director of Nursing revealed a lack of communication between the dietary and therapy departments regarding updates to care plans. The dietary consultant confirmed that the resident's dietary meal ticket specified the need for a spill-proof cup, which was not provided, highlighting a breakdown in the implementation of the comprehensive plan of care.
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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) |
|---|---|---|---|---|
| The Springs At St. Andrews Village | 1.2 mi | ★★★★★ | 10 | 0 |
| Life Care Center Of Aurora | 1.7 mi | ★★★★★ | 25 | 0 |
| Beth Israel At Shalom Park | 2.1 mi | ★★★★★ | 10 | 0 |
| Advanced Health Care Of Aurora | 2.2 mi | ★★★★★ | 1 | 0 |
| Garden Terrace Alzheimer's Center Of Excellence | 2.5 mi | ★★★★★ | 2 | 0 |
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