Above 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 Avantara Aurora during CMS and state inspections, most recent first.
Leaking toilet plumbing and damaged bathroom flooring were observed in two resident rooms. In one room, the bathroom floor tiles around the toilet were warped and heavily stained, and the Maintenance Director said the leak from the toilet water pipe had been ongoing until it was repaired after a long delay. In another room, a resident with a fall history reported that toilet water leaked onto the bathroom floor every time it was flushed, and the ADON observed active leaks from the pipe during verification.
The facility failed to follow their planned menu, resulting in residents receiving inadequate protein portions during lunch. All 78 residents on various diets were affected, as they were served only 2 ounces of ham instead of the required 3 ounces. The Dietary Director acknowledged the lack of a slicer to accurately portion the meat, and the Dietician confirmed the importance of serving the correct portion size to meet nutritional needs.
The facility failed to secure medications for five residents, with medications found on bedside tables and nightstands without physician orders for self-administration or bedside storage. This included fish oil, turmeric, Calmoseptine ointment, TUMS Antacid, antifungal powder, and Docusate Sodium, contrary to facility policies requiring secure storage and physician orders.
The facility failed to implement proper infection control precautions for a resident with C-Diff and did not adhere to Enhanced Barrier Precautions for residents with wounds and medical devices. Staff were observed providing care without the required PPE, contrary to facility policy, posing a risk of infection spread.
The facility failed to maintain the dignity of two residents during care. A nurse stood over a resident while feeding her, and a CNA and a resident's daughter provided incontinence care without pulling the privacy curtain, leaving the resident exposed. The facility's policy requires privacy and dignity to be respected at all times.
A facility failed to prevent the re-opening of pressure ulcers for a resident with known skin issues on the right buttocks and coccyx. The resident was left in a wheelchair for too long, contrary to the care plan. The RN did not document the wounds or inform the physician, and the assistant director of nursing did not assess the wounds. The facility's wound care guidelines were not followed.
The facility failed to properly administer enteral feeding and maintain care for residents with gastrostomy tubes. One resident's feeding was connected to an unlabeled and outdated bottle, and the nurse did not follow proper procedures for tube placement and flushing. Another resident's feeding equipment was not labeled or changed as required, and a third resident's feeding bottle lacked proper labeling. The facility's policy on enteral feeding care was not followed, resulting in deficiencies.
A resident receiving IV antibiotics for a foot wound infection had a PICC line dressing that was not changed as ordered, remaining in place for eight days. The dressing was loose, and a nurse failed to assess its integrity before administering medication. Facility policy required dressing changes every seven days and as needed, but the scheduled change was missed, leading to a deficiency.
The facility failed to follow physician's orders and weigh residents weekly, resulting in significant weight loss for multiple residents. One resident with multiple diagnoses experienced a 6.02% weight loss, another resident with a right femur fracture and type 2 diabetes experienced a 13.57% weight loss, and a third resident with severe protein-calorie malnutrition did not receive their nutritional supplements as ordered.
The facility failed to follow their planned menu and recipes, resulting in lunch entrees with inadequate protein for 66 residents. The Chicken Alfredo dish was improperly prepared, leading to a significant discrepancy in the chicken portion size. The dietitian admitted to not closely monitoring the kitchen, contributing to this deficiency.
The facility failed to perform proper hand hygiene and implement Enhanced Barrier Precautions (EBP) for residents with implanted medical devices and during high-contact resident care. Staff did not wash hands or wear gloves before providing care, did not wear gowns during high-contact activities, and failed to post EBP signs on residents' doors. The Director of Nursing confirmed that these actions were necessary to prevent cross-contamination and maintain infection control.
The facility failed to assist three residents with personal hygiene, despite their care plans indicating the need for staff assistance. Residents were found with long facial hair and dirty fingernails, and their requests for help were not addressed by the staff.
The facility failed to maintain the kitchen floor in a condition that ensures cleanability, affecting all 70 residents receiving oral diets. Observations revealed loose, chipped, and crumbled floor debris, as well as food debris in various areas of the kitchen. The Maintenance Director was aware of the issue and in discussions for repairs.
Leaking Toilet Plumbing and Damaged Bathroom Flooring
Penalty
Summary
The facility failed to maintain the building environment and plumbing equipment in good repair by allowing water pipes connected to resident toilets to remain leaking and unrepaired. During an environmental tour of one resident room, the bathroom floor tiles around the toilet were severely warped and had heavy dark brown staining. The Assistant Director of Nursing could not explain the condition, and the Maintenance Director stated the warped tiles and staining were caused by an ongoing leak from the water pipe tubing connected to the toilet that leaked every time the toilet was flushed. He also stated the leak had only been repaired that morning, even though the replacement parts had been ordered, shipped, and delivered to the facility more than a month earlier, and the family member had reported the leak to administration more than a month earlier. In another resident room, a resident who reported a history of falls and a prior fall with a forehead laceration stated that the toilet pipes leaked every time the toilet was flushed and that water ran onto the bathroom floor and became slippery. The resident said he used a cane for ambulation and frequently used the private bathroom. When the Assistant Director of Nursing flushed the toilet to verify the concern, active water leaks were observed pooling downward from both the top and middle sections of the water pipe connected to the toilet structure. The facility policy required the maintenance department to address and repair building environment issues as soon as possible.
Inadequate Protein Portions Served to Residents
Penalty
Summary
The facility failed to adhere to their planned menu, resulting in residents receiving inadequate protein during lunch. This deficiency affected all 78 residents on various diets, including General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft. The facility's Daily Spreadsheet indicated that residents were to receive a 3-ounce portion of ham, but observations revealed that only one slice of ham was served, which weighed 2 ounces. This discrepancy was confirmed by the Dietary Director, who acknowledged the lack of a slicer to accurately portion the meat. The Dietician confirmed that the ham should be served at a 3-ounce weight to meet the residents' nutritional needs. The failure to provide the correct portion size could lead to inadequate protein intake, potentially causing malnourishment or hindering wound healing. The facility's kitchen policy, revised in August 2024, mandates that all menu items and recipes be followed, highlighting the deviation from established procedures.
Failure to Secure Resident Medications
Penalty
Summary
The facility failed to properly secure resident medications, as observed during a survey. Medications were found unsecured in the rooms of five residents. For instance, a medication cup with fish oil and turmeric capsules was left on a resident's bedside table without a physician's order for self-administration or for the medication to remain at the bedside. The resident reported taking the medication when she felt better, indicating a lack of proper medication management and oversight by the nursing staff. Additionally, other residents were found with various unlabeled medications and ointments on their nightstands or drawers, such as Calmoseptine ointment, TUMS Antacid, antifungal powder, and Docusate Sodium. None of these medications had corresponding physician orders for self-administration or to be kept at the bedside. The facility's policies require medications to be stored securely and only allow bedside storage with a physician's order, which was not adhered to in these cases.
Failure to Implement Infection Control Precautions
Penalty
Summary
The facility failed to implement transmission-based precautions for a resident with an acute contagious gastrointestinal infection, specifically Clostridioides difficile (C-Diff). Resident R183, who had been experiencing diarrhea for several days, was not placed under proper isolation precautions. Despite a physician's order for strict contact isolation and a stool sample being obtained for C-Diff testing, there was no isolation sign on the door of the shared room with another resident, R184. The facility's infection control policy mandates such precautions, but they were not followed, leading to potential exposure of other residents. Additionally, the facility did not adhere to Enhanced Barrier Precautions (EBP) for residents with open wounds or indwelling medical devices. Multiple staff members, including CNAs and RNs, were observed providing care to residents with wounds, PICC lines, and gastrostomy tubes without wearing the required gowns, only using gloves and masks. This was contrary to the facility's policy, which requires gowns and gloves to prevent the spread of multi-drug resistant organisms during high-contact care activities. The facility's failure to implement these precautions was observed in several instances, affecting multiple residents. The Director of Nursing and the Infection Preventionist acknowledged the expectations for PPE use during high-contact care activities, yet staff did not comply with these protocols. This lack of adherence to infection control measures posed a risk of cross-contamination and infection spread among residents.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to uphold the dignity of two residents during care, as observed by surveyors. A nurse was seen standing over a resident while feeding her, which was acknowledged as a dignity issue by both the nurse and the Director of Nursing. Additionally, a Certified Nurse's Assistant and a resident's daughter provided incontinence care to another resident without pulling the privacy curtain, leaving the resident exposed and visible from the hallway. The resident, who is cognitively intact, expressed a preference for the curtain and door to be closed during care. The facility's policy mandates that privacy and dignity be respected at all times, including drawing privacy curtains during care that requires privacy.
Failure to Prevent and Document Pressure Ulcer Care
Penalty
Summary
The facility failed to implement measures to prevent the re-opening of pressure ulcers for a resident with known skin alterations on the right buttocks and coccyx. During an observation, it was noted that the resident had a wound dressing on the right buttock but none on the coccyx, where multiple open areas were observed. The wounds were described as red with yellow and whitish tissue. The resident, who is frail and dependent on staff for mobility and care, was left sitting in a wheelchair for an extended period, contrary to the care plan that limits wheelchair time to two hours with a pressure-relieving cushion. The registered nurse (RN) failed to document the wound findings in the electronic health record (EHR) and did not inform the physician or obtain new treatment orders. The assistant director of nursing was informed but did not assess the wounds or notify the physician. The nurse practitioner had previously noted moisture-associated skin damage but did not measure it. The director of nursing expects immediate physician notification and documentation for any skin breakdown, which was not followed. The facility's wound care guidelines require timely documentation and treatment initiation, which were not adhered to in this case.
Deficiencies in Enteral Feeding Administration and Care
Penalty
Summary
The facility failed to properly administer enteral feeding and maintain the necessary care for residents with gastrostomy tubes. For one resident, the gastrostomy tube pump was connected to an unlabeled and outdated bottle of Jevity 1.5, and the feeding tubing tip was uncovered. The nurse administering the feeding did not prime the tubing initially, failed to check for tube placement, and did not flush the tube with water before or after the feeding. Additionally, the resident's gastrostomy tube site was not dressed, despite the resident reporting discomfort and leakage. The resident's order summary indicated specific instructions for feeding and site care, which were not followed. Another resident's gastrostomy tube pump was also connected to an unlabeled and outdated bottle of Jevity 1.5, with the tubing tip uncovered. The order summary for this resident did not include instructions for changing the enteral feeding equipment or providing care to the gastrostomy tube site. A third resident had an open feeding bottle without an open time, and the registered dietician confirmed that feeding bottles should be labeled with specific information and that feeding sets and tubing should be changed daily. The facility's policy outlined these requirements, but they were not adhered to, leading to deficiencies in the care provided to these residents.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to change a resident's PICC line dressing as ordered, which was observed during a survey. A resident, identified as R51, was receiving IV antibiotic infusions for a right foot wound infection and had a central catheter in the left upper arm. On March 11, 2025, it was noted that the transparent dressing on R51's PICC line was dated March 3, 2025, indicating it had not been changed for eight days. Additionally, the dressing was loose and not fully adherent to the skin. Despite this, a registered nurse, V9, initiated the resident's scheduled IV antibiotic infusion without assessing the integrity of the dressing. Further investigation revealed that the facility's policy required central catheter dressings to be changed every seven days and as needed for infection control. The Assistant Director of Nursing, V3, confirmed that nurses should assess PICC line dressings every shift and change them if compromised. However, R51's electronic treatment administration record showed that the scheduled dressing change was not completed on March 9, 2025, as per the order summary report. This oversight in following the facility's intravenous therapy policy led to the deficiency identified during the survey.
Failure to Follow Physician's Orders and Implement Nutritional Interventions
Penalty
Summary
The facility failed to follow physician's orders and weigh a resident weekly, resulting in significant weight loss for multiple residents. For instance, one resident with multiple diagnoses, including stroke and type 2 diabetes, was not weighed weekly as ordered, leading to a 6.02% weight loss. The Assistant Director of Nursing and a Certified Nursing Assistant confirmed the weight loss, and the physician stated that the weight loss could have been prevented if the resident had been weighed weekly as ordered. The Registered Dietician also noted that the resident should have been weighed weekly but was not, and no interventions were put in place to prevent the weight loss. Another resident with diagnoses including a right femur fracture and type 2 diabetes experienced a 13.57% weight loss. The Registered Dietician recommended weekly weights for four weeks, but the facility did not document any weights after the initial recommendation. The resident's significant weight loss was noted, but no follow-up weights were recorded, and the dietician confirmed that the facility did not obtain the weekly weights as ordered. A third resident with severe protein-calorie malnutrition and dysphagia did not receive their nutritional supplements as ordered due to the supplements being unavailable. The Registered Nurse confirmed that the supplements were sometimes out of stock, but the supply room was found to be stocked with multiple nutritional supplements. The dietician stated that the resident should have received an equivalent nutritional supplement if the ordered one was unavailable. The facility did not have a policy regarding addressing residents at nutrition risk or the frequency of dietitian assessments for residents with tube feedings.
Failure to Follow Planned Menu and Recipes
Penalty
Summary
The facility failed to follow their planned menu and recipes, resulting in lunch entrees being served to residents with inadequate protein. Specifically, the Chicken Alfredo dish was not prepared according to the recipe, which required the chicken and noodles to be served separately. Instead, the chicken, mushrooms, sauce, and noodles were mixed together and served using a six fluid ounce spoodle. Upon inspection, it was found that the chicken portion in the mixture weighed only 0.75 ounces, significantly less than the required two ounces per serving. This deficiency affected all 66 residents receiving General, Low Concentrated Sweets, No Added Salt, Pureed, and Mechanical Soft diets at the facility. The dietitian admitted to not closely monitoring the menus and food production in the kitchen, only performing walk-throughs during visits. The facility's kitchen policy mandates that all food items in the menu and recipe be followed, and any changes must be approved by the dietitian. The failure to adhere to the planned menu and recipes led to residents receiving inadequate protein in their meals, as evidenced by the discrepancy in the chicken portion size. This issue was observed during lunch service and confirmed through interviews and record reviews.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to perform proper hand hygiene and implement Enhanced Barrier Precautions (EBP) for residents with implanted medical devices and during high-contact resident care. Specifically, an LPN did not wash hands or wear gloves before adjusting a resident's nasal cannula, despite the resident being on EBP due to end-stage renal disease and hemodialysis. The Director of Nursing confirmed that the LPN should have followed EBP protocols to prevent cross-contamination and maintain infection control. Another incident involved a resident with multiple diagnoses, including a nontraumatic intracerebral hemorrhage, who required wound treatment. The LPN did not perform hand hygiene before putting on gloves to provide perineal care and did not wear a gown during the treatment of the resident's sacral wound. The Assistant Director of Nursing and the Director of Nursing confirmed that the LPN and CNA should have worn gowns and performed hand hygiene to prevent cross-contamination. Additional deficiencies were observed with residents who had gastrostomy tubes and dialysis catheters. Staff failed to post EBP signs on the residents' doors and did not wear gowns during high-contact activities such as transferring residents from bed to wheelchair. The Director of Nursing acknowledged that EBP signs should have been posted and that staff should have followed EBP protocols, including wearing gowns and performing hand hygiene before and after direct resident contact.
Failure to Assist Residents with Personal Hygiene
Penalty
Summary
The facility failed to assist residents identified as needing assistance with personal hygiene. This deficiency was observed in three residents (R12, R60, and R61) who required staff assistance for activities of daily living (ADLs). R12, diagnosed with Parkinson's disease and altered mental status, was found with long facial hair and stated that he needed assistance to shave and trim his mustache. Despite his care plan indicating the need for assistance with personal hygiene, this was not provided. Similarly, R60, who required maximum assistance for personal hygiene, had long, jagged fingernails with black substances underneath. R60 expressed the need for staff to trim and clean her fingernails, which was not done. R61, with hemiplegia and hemiparesis, also had long facial hair and dirty fingernails. He stated it had been two weeks since he was last shaved and requested assistance, which was not provided despite his care plan indicating dependency on staff for ADLs. The observations were made during a survey on April 8, 2024, and the staff, including LPNs and CNAs, were informed of the residents' requests. The Director of Nursing (DON) confirmed that the nursing staff is expected to assist residents with personal hygiene, especially those needing help with ADLs. However, the facility failed to meet these expectations, leading to the deficiency noted in the report.
Failure to Maintain Kitchen Floor Cleanability
Penalty
Summary
The facility failed to maintain the kitchen floor in a condition that ensures cleanability, affecting all 70 residents receiving oral diets. During an initial kitchen tour, it was observed that the kitchen floor under the dish machine, in the janitor area, under the cooking hood and cooking equipment, and near the cooler was in poor repair with loose, chipped, and crumbled floor debris, as well as food debris. The Maintenance Director acknowledged awareness of the issue and mentioned ongoing discussions with the corporate office regarding repairs. The facility's policy on maintenance, reviewed in July 2023, mandates the upkeep of equipment and the building environment.
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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) |
|---|---|---|---|---|
| Asbury Gardens Nsg & Rehab | 0.7 mi | ★★★★★ | 5 | 0 |
| North Aurora Living & Rehab Ctr | 1.9 mi | ★★★★★ | 1 | 0 |
| La Bella Of Aurora | 2 mi | ★★★★★ | 3 | 0 |
| Grove Of Fox Valley,the | 2.2 mi | ★★★★★ | 12 | 0 |
| Jennings Terrace | 2.6 mi | ★★★★★ | 0 | 0 |
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