Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Asbury Gardens Nsg & Rehab during CMS and state inspections, most recent first.
Two residents were left in a cool room with a nonfunctioning heating unit after one cognitively intact resident reported feeling cold and stated the heater had not worked for several days. Staff notified a maintenance assistant by phone, who assessed the unit, found it nonfunctional, left it unplugged, and did not enter a maintenance work order. The receptionist also failed to create a work order in the computer system, and the maintenance director was unaware of the issue until the survey, despite facility policy requiring maintenance of comfortable and safe temperature levels and properly operating heating units for resident comfort.
A dependent, cognitively impaired resident with severe dementia did not receive timely incontinence care as required by her care plan and facility policy. Surveyors observed the resident in bed with a strong foul urine odor persisting over an hour, a soiled urine-saturated brief, and dry urine-stained cloth pads beneath her. An RN acknowledged difficulty providing care due to the resident’s resistance and was unsure when incontinence care was last given, while a CNA reported last providing care several hours earlier. The DON later stated staff are expected to check for incontinence at least every two hours and that the resident should have received timely incontinence and hygiene care consistent with her assessed needs.
The facility failed to follow physician orders for CHF-related fluid management for three residents, including missing ordered daily weights and not applying prescribed compression stockings. One resident with CHF and bilateral lower extremity edema had orders and a care plan for daily weights with MD/NP notification for specific weight gains, yet several days lacked recorded weights. Another resident with chronic lower extremity edema related to CHF was repeatedly observed wearing regular socks and footwear instead of ordered compression stockings, despite being dependent on staff for their application. A third resident with CHF and generalized lower extremity edema also had orders and a care plan for daily weights with defined notification parameters, but multiple days showed no documented weights, contrary to facility policy on weight monitoring and fluid status assessment.
A resident with Parkinson’s disease, dementia, and moderate cognitive impairment stated he wanted unrestricted visits from his children, but staff followed a posted sign listing specific family members whose visitation was to be restricted per the POA. When a daughter arrived to visit, staff asked her name, informed her she was not allowed to see the resident based on the POA’s directive, and called the police when she refused to leave or provide ID; the police then told her she was trespassing. The Ombudsman reported that the POA was denying visitation and that there should not have been a barrier to the visit, while facility leadership acknowledged that the POA could not deny visitation and that the resident did want to see his daughter, yet the posted restriction and staff actions still prevented the visit.
A resident with hemiplegia and other complex medical conditions, who required substantial assistance for transfers, was moved from the toilet to a wheelchair by a CNA without the use of a gait belt as required by the care plan and facility policy. During the transfer, the resident's foot became caught, causing her contracted leg to strike the wheelchair frame and resulting in a laceration that required stitches. Staff interviews and documentation confirmed that proper transfer procedures were not followed.
The facility failed to assist residents with activities of daily living, including eating and personal hygiene. Several residents were observed with long facial hair and unkempt nails, and one resident's meal remained untouched until the DON intervened. The facility's policies on ADLs and nail care were not followed, leading to deficiencies in resident care.
The facility failed to properly puree maple glazed ham for eight residents on pureed diets. The cook blended pre-sliced ham with rind intact, resulting in a mixture with visible rind pieces, contrary to the required smooth, pudding-like consistency. This was identified by the Dining Director, highlighting a deviation from the facility's dietary policy.
A resident with medical conditions requiring assistance with hearing aid placement did not receive the necessary help from facility staff. Despite having a care plan indicating this need, the resident reported not receiving assistance and was observed without hearing aids, impacting her ability to hear. Staff members were either unaware of the resident's needs or had not been providing the required assistance, contrary to the care plan expectations.
A resident with spastic hemiplegia and contracture was not provided with a splint or positioning device to maintain ROM. Despite being moderately impaired and requiring assistance with ADLs, the resident was observed without necessary support. An OT recommended a hand roll and elbow orthosis, but these were not in place, highlighting a deficiency in care.
The facility failed to follow their policy for transferring a resident with severe cognitive impairment and multiple diagnoses. CNAs transferred the resident without using the mechanical lift and without the required assistance of a second staff member, contrary to the care plan.
Failure to Maintain Functional Room Heating and Comfortable Environment
Penalty
Summary
The deficiency involves the facility’s failure to maintain a comfortable environment by ensuring proper room heating for two residents sharing a room. One resident, who was cognitively intact per an MDS dated 12/08/2025, reported feeling cold and was observed wearing a shawl to keep warm. She stated that the room’s heating unit had not been working since 1/10/2026 and that she had reported this to staff on that date. She further reported that a maintenance assistant assessed the unit on 1/12/2026, determined it could not be fixed, left it unplugged, and did not return to reassess it. During the survey on 1/13/2026 at 10 AM, the room felt cool and the heating unit was unplugged. The cognitively intact resident’s roommate, who was documented as severely cognitively impaired and nonverbal on her MDS, was unable to be interviewed about the room temperature. Nursing staff notified the receptionist on 1/12/2026 at 3 PM that the heating unit was not working; the receptionist then notified the maintenance assistant by telephone but did not enter a work order into the computer system as required by the facility’s process. The maintenance assistant confirmed he assessed the unit, found it nonfunctional, left it unplugged, and did not complete a work order. The maintenance director stated he was unaware of the problem and confirmed there was no active maintenance order. Upon his assessment, the unit’s motor was not working and an outside vendor would be needed. He noted the room felt cool with a temperature around 71°F and acknowledged that residents’ rooms needed properly operating heating units so residents could adjust temperatures to their comfort level. The facility’s policy required maintaining comfortable and safe temperature levels within a specified range to minimize susceptibility to loss of body heat and to ensure resident comfort.
Failure to Provide Timely Incontinence Care to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and assistance with activities of daily living to a dependent resident with severe dementia. On 1/13/2026 at 10:10 AM, the resident was observed in bed wearing a gown, severely confused and fidgeting, with a strong foul urine odor in the room and incontinence products on the bedside table. At 11:00 AM, the resident remained in bed with the same strong foul urine smell. The RN (V14) stated that providing incontinence care was difficult because the resident tended to resist due to severe dementia. Upon assessing the resident’s incontinence brief, V14 found it soiled with urine and emitting a strong foul odor. The resident had two cloth pads underneath her, with the top pad soiled by a dark yellow stain that V14 said was dry, and V14 was unsure when the resident last received incontinence care. At 11:20 AM, two CNAs (V12 and V13) stated they were going to provide incontinence care to the resident. V12 reported that she had last provided incontinence care around 8:00 AM and, upon assessing the soiled cloth pad, believed it had not been present previously and was now dry. The resident’s care plan documented cognitive impairment and a need for assistance with ADLs, including toileting, with interventions directing staff to provide total incontinence and hygiene care. The DON (V2) stated that nursing staff were expected to check residents for incontinence at least every two hours and as needed, and that this resident should have received timely incontinence care, including premedication with PRN antianxiety medication if necessary to allow staff to meet basic toileting needs. The facility’s incontinence care policy dated 05/2025 stated that all incontinent residents would receive appropriate treatment and services based on their comprehensive assessment.
Failure to Follow CHF Fluid Management Orders and Daily Weight Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for CHF-related fluid management, including daily weights and use of compression stockings, for three residents. One resident with CHF and bilateral lower extremity non-pitting edema reported that nursing staff were supposed to obtain daily weights but that this had not been done recently. The RN confirmed that this resident’s CHF management required a fluid restriction and daily weights with MD/NP notification for specified weight gains. The resident’s orders and care plan included daily weights with parameters for provider notification, yet the January 2026 weight record showed missing daily weights on multiple dates. The DON stated that staff were expected to follow CHF orders, including daily weights and application of edema compression stockings. Another resident with chronic lower extremity edema related to CHF was repeatedly observed on different days wearing regular ankle socks with shoes or slippers instead of compression stockings. An RN stated this resident required compression stockings for edema management, was dependent on staff to apply them, and that nurses were expected to follow the physician’s order to apply compression stockings in the morning and remove them at night. A third resident with CHF and generalized lower extremity edema had an active order and care plan for daily weights with MD/NP notification for specified weight gains, but the January 2026 weight record showed multiple days without recorded daily weights. The facility’s weight monitoring policy required assessment of weight and fluid status and development of individualized care plans based on professional standards, but the documented omissions in daily weights and failure to apply ordered compression stockings demonstrate that these orders and care plan interventions were not consistently implemented.
Failure to Honor Resident’s Right to Receive Family Visitors
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of his choosing. The resident, who had Parkinson’s disease, unspecified dementia, and moderate cognitive impairment, reported that he had a blended family with three daughters and a stepson who served as his POA. He stated there had been internal family conflict, that his stepson did not get along with his daughters, and that the stepson had blocked his daughters from phone contact and visiting. The resident clearly stated there should not be any restrictions on any of his children visiting him. Despite this, a sign was posted at the nurse’s station stating that, per the resident and his wife/POA’s request, specific daughters and their spouses, as well as another family member, were to have their visitation restricted and that police could be contacted if they refused to leave. A daughter reported that she drove several hours to visit her father and, upon arrival, was told by staff she was on a list of people not allowed to visit per the POA; staff then called the police, who informed her she was trespassing and could not be there. The Ombudsman stated that the POA was denying visitation, that the facility believed there was to be no contact, and that there should not have been a barrier to the visit. Facility staff, including the receptionist and an RN, described following the posted note by asking visitors for their names, denying the daughter access, and calling the police when she refused to leave or provide identification. The RN stated the note restricting visitation was put up after a prior disturbance involving the daughter and that the POA had said to restrict visitation for these individuals. The Administrator and Director of Operations both acknowledged that the POA could not deny visitation and that visitation ultimately depended on the resident’s wishes, which were that he wanted to see his daughter, yet the posted restriction and staff actions continued to deny the daughter’s visit based on the POA’s request.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, epilepsy, aphasia, and cellulitis of the right lower limb required substantial to maximal assistance for toileting hygiene and transfers, as documented in the care plan and Minimum Data Set. The care plan specifically directed staff to use a gait belt for all transfers. Despite these instructions, a CNA transferred the resident from the toilet to a wheelchair without using a gait belt, instead holding onto the resident's brief during the transfer. During the transfer, the CNA did not notice that the resident's right foot was caught near the wheelchair's leg rest area. As the resident attempted to sit, her right leg, which was contracted due to her medical condition, swung forward and struck the frame of the wheelchair. This resulted in a laceration to the resident's right lower leg, which required emergency medical attention and stitches. The incident was confirmed by interviews with the resident, the CNA involved, and other facility staff, all of whom acknowledged that a gait belt should have been used according to facility policy and the resident's care plan. The facility's policy mandates the use of gait belts for residents who cannot independently ambulate or transfer, and staff receive training on this policy during orientation and annually. The failure to follow this policy and the resident's care plan directly led to the resident sustaining a significant injury during a transfer. The event was documented in the facility's final report and corroborated by medical records from the emergency room.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several residents, leading to deficiencies in personal hygiene and nutrition. One resident, identified as R50, who was cognitively intact and required assistance with eating and personal hygiene, was observed with long facial hair and unkempt fingernails. Despite being served a meal, the resident's food and drinks remained untouched until the Director of Nursing intervened to assist and cue the resident to eat. This lack of assistance was acknowledged by the Assistant Director of Nursing, who confirmed the resident's need for staff support in grooming and eating. Another resident, R51, who had multiple diagnoses including dementia and Parkinson's disease, also required maximum assistance with personal hygiene. Observations revealed that R51 had long facial hair and fingernails, despite expressing a desire for grooming. The Assistant Director of Nursing acknowledged the need for staff assistance in maintaining the resident's hygiene, which was not provided as per the care plan. Additional deficiencies were noted with residents R16 and R42. R16, who was severely cognitively impaired and dependent on staff for personal hygiene, was observed with long, unclean fingernails. Similarly, R42, who was admitted to hospice care and required substantial assistance with personal hygiene, was found with long nails and unkempt hair. The facility's policy on ADLs and nail care was not adhered to, as evidenced by the lack of documented nail care and grooming for these residents.
Improper Preparation of Pureed Diets
Penalty
Summary
The facility failed to properly prepare pureed maple glazed ham for eight residents on pureed diets, as observed during a meal preparation on November 13, 2024. The cook, identified as V9, was responsible for preparing the meal and was observed placing pre-sliced ham with rind intact into a blender, adding glaze for flavor, and pureeing the mixture. Despite blending the ham for about two minutes, the resulting product contained small pieces of rind that were visible and not fully pureed, posing a risk to residents who require a smooth, pudding-like consistency for safe consumption. The issue was identified when the Dining Director, V10, was informed that the pureed ham was unsafe due to the presence of rind pieces. The facility's 'Diet Type Report' confirmed that the eight residents were on pureed diets, and the facility's policy for pureed diets specified that the texture should be smooth, similar to mashed potatoes or pudding. The failure to achieve the required consistency for the pureed ham indicates a deviation from the facility's policy and the dietary needs of the residents.
Failure to Assist Resident with Hearing Aid Placement
Penalty
Summary
The facility failed to provide necessary assistance with hearing aid placement for a resident, identified as R31, who required such assistance. R31, a female resident with medical conditions including Carpal Tunnel Syndrome, Torticollis, Neuropathy, and Poly-osteoarthritis, was admitted to the facility with a care plan indicating a need for assistance with personal care, including the placement of hearing aids. Despite this documented need, R31 reported that staff did not assist her with her hearing aids, leading her to stop asking for help. During a resident council interview, R31 was observed without her hearing aids and expressed difficulty hearing, confirming that she had not received assistance from staff. Further investigation revealed that the staff, including a registered nurse (V15) and a certified nursing assistant (V16), were either unaware of R31's need for hearing aids or had not been assisting her with them. V15 acknowledged seeing R31 with hearing aids occasionally but stated that R31 had never requested assistance. V16 admitted to not helping R31 with her hearing aids and noted it had been a while since she had seen R31 wearing them. The Assistant Director of Nursing (V3) confirmed that residents requiring assistance with hearing aids should have such orders in their care plans and expected staff to follow these plans. Despite this expectation, R31 remained without her hearing aids throughout the day, highlighting a lapse in care and adherence to the resident's care plan by the facility staff.
Failure to Provide Splint for Resident with Contracture
Penalty
Summary
The facility failed to assess and provide appropriate care for a resident, identified as R38, to maintain and/or improve range of motion (ROM). R38 was admitted with multiple diagnoses, including spastic hemiplegia affecting the left dominant side, mild dementia, and contracture of the left hand muscle. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and functional limitations in ROM on one side of both upper and lower extremities, requiring maximum to total assistance with activities of daily living (ADLs). Despite these needs, observations on two separate occasions revealed that R38 had left hand weakness and contracture without any splint or positioning device in place. The Assistant Director of Nursing (V3) acknowledged the contracture and was prompted to have the therapy department screen R38. The Occupational Therapist (V11) conducted a screening and confirmed the presence of contractures in the left hand and elbow, which were partially stretchable. V11 recommended the use of a left hand roll and a left elbow orthosis to prevent further contracture, stiffness, deformity, and skin breakdown. However, these recommendations were not implemented prior to the surveyor's observations, indicating a deficiency in the facility's care for maintaining and improving the resident's ROM.
Failure to Follow Transfer Policy
Penalty
Summary
The facility failed to follow their policy to transfer a resident according to the resident's care plan. The resident, who had multiple diagnoses including Parkinson's disease, heart failure, dementia, anxiety, and falls, required extensive assistance from two facility staff for transfers between surfaces as per their care plan. However, on multiple occasions, CNAs transferred the resident without using the mechanical lift and without the assistance of a second staff member. One CNA admitted to transferring the resident manually by himself, while another CNA used the mechanical lift but did so alone, contrary to the care plan requirements. The Director of Nursing confirmed that the CNAs should have used the mechanical lift with two staff members present for the transfers. The facility documentation corroborated the CNAs' admissions, showing that they did not follow the prescribed transfer procedures. This failure to adhere to the care plan and facility policy resulted in improper nursing care for the resident, who had severe cognitive impairment and was non-ambulatory, requiring total staff assistance for transfers.
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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 North Aurora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Aurora | 0.7 mi | ★★★★★ | 1 | 0 |
| North Aurora Living & Rehab Ctr | 1.3 mi | ★★★★★ | 1 | 0 |
| Grove Of Fox Valley,the | 2.3 mi | ★★★★★ | 12 | 0 |
| La Bella Of Aurora | 2.6 mi | ★★★★★ | 3 | 0 |
| Jennings Terrace | 3.3 mi | ★★★★★ | 0 | 0 |
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