Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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 notify the LTC Ombudsman of non-emergent transfers and discharges on a monthly basis for 4 residents reviewed. One resident was discharged back to the community, one resident expired in the facility, and two residents were transferred or discharged to the hospital, but ombudsman notifications were delayed until surveyors requested proof. The Facility Ombudsman stated the expectation was monthly reporting, and the facility could not provide a policy for non-emergent transfer/discharge notification.
Failure to provide shaving assistance for a resident dependent on staff for ADLs. A resident with reduced mobility, chronic pain, and vascular dementia was observed over multiple days with facial mustache and chin hair, and she stated she wanted it shaved but could not do it herself. She reported asking staff and CNAs for help, but the shaving was not completed. Her MDS and care plan showed she was dependent on staff for personal hygiene, including shaving, and the DON stated CNAs are supposed to assist with shaving as part of hygiene and grooming.
A resident with severe cognitive impairment, left-sided flaccid paralysis, poor sitting balance, impulsivity, and high fall risk was left unattended on the toilet after staff assisted with the transfer. Staff later heard a loud thud and found the resident face down on the bathroom floor after an unwitnessed fall. The resident was taken to the hospital and later documented to have left eye injury with significant edema, ecchymosis, and subconjunctival hemorrhage while also receiving daily anticoagulant medication.
Failure to assess and address poor intake and weight loss: A resident with recent AKI, temporary HD, persistent hyperkalemia, hyponatremia, poor appetite, diarrhea, and significant wt loss had variable meal intake, refused meals, and was only offered a supplement once. The record showed no RD in-depth nutrition assessment, no documented weekly weights as ordered, and only limited nutrition documentation from the CDM despite the resident being identified as malnourished.
Unrelieved Pain Not Reassessed or Managed: A cognitively intact resident with ESRD on hemodialysis and recent hip surgery reported pain up to 7/10, said the medication was not helping, and remained uncomfortable during sitting and dialysis. The MAR showed Tylenol scheduled and Tramadol PRN, but the regimen lacked clear administration guidance, Tramadol was given only a few times, the pain care plan was incomplete and nonindividualized, and the RN/DON acknowledged the resident's pain was not adequately addressed or reported to the provider.
Controlled medication documentation, storage, and disposal were not followed for two residents. A nurse found an unopened box of morphine for a discharged resident stored in the med refrigerator, and staff had not accounted for it at shift changes. In another case, a nurse signed out hydrocodone-APAP on the controlled drug record even though the medication was not removed from the bingo card and was not administered, leaving the count and records mismatched.
Medication administration errors resulted in a 7.69% error rate after two errors were found during observation. An RN administered the wrong eye drop to a resident after checking only the bag label and not the bottle label, and another nurse withheld a scheduled hydralazine dose for a resident with a G-tube because she focused on the PRN SBP parameter instead of the full order that also required a scheduled dose. The DON and NP confirmed the orders and the need to follow them as written.
Improper medication storage and labeling led to two medication-related events. A controlled med was found exposed in a resident’s bingo card pocket during a cart inspection, and a nurse administered the wrong eye drop to another resident after it was stored in the resident’s eyedrop bag with the correct pharmacy label. The DON stated meds should not be left exposed and must be stored and administered according to MD orders.
Pureed pork portions were not served in the amounts listed on the approved menu for two residents on pureed diets. A cook initially plated smaller portions than the planned 2-#10 scoop serving, and the FSD reviewed the menu and directed a larger portion for the third plate. The facility’s spreadsheet, recipe, and policy all specified the same serving size.
Failure to Follow Contact Precautions and Medication Infection Control Practices: A resident on strict contact isolation for C-Diff had a meal tray delivered by the RGD without the required gown and gloves, and hand hygiene was done with alcohol-based sanitizer after leaving the room. In a separate event, an RN preparing meds for another resident touched the med cart with bare hands, dropped a medication on the cart, picked it up without hand hygiene, and administered it. The DON stated PPE was required for contact precautions and that dropped medication should not be given.
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.
Failure to Notify Ombudsman of Transfers and Discharges
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman facility representative of non-emergent transfers and discharges monthly as requested, affecting 4 of 4 residents reviewed for discharge in the sample of 23. For one resident, the EMR showed admission to the facility and discharge back to a community senior living apartment; when surveyors asked for evidence of ombudsman notification, the SSA referred them to the Assistant Administrator, who stated the notification was sent by email and that the last prior notification had been submitted by the Administrator several days earlier. The Assistant Administrator also stated she was unsure how often the Ombudsman’s office is notified, but that the notification occurs by running a report through the EMR. For another resident, the EMR showed the resident expired in the facility, with the death certificate listing cardiorespiratory arrest as the cause of death, but the facility did not notify the ombudsman until surveyors requested to see the notification. Two additional residents were discharged or transferred to the hospital, and their ombudsman notifications also did not occur until surveyors requested evidence of discharge notification. The facility’s transfer/discharge report sent to the Ombudsman office contained 74 records with discharge dates ranging from February 13, 2026 through the later date listed in the report, and the Facility Ombudsman stated the expectation was for facilities to send notification of non-emergent discharges and transfers monthly; she also stated she had not received a report from the facility since February 9, 2026. The facility was unable to provide a policy addressing non-emergent notification of transfer/discharge to the Ombudsman office.
Failure to Provide Shaving Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide grooming and hygiene assistance for a resident who was unable to perform the task independently. R43 was observed in bed on May 11, 2026, with about 0.5 to 1 cm of facial mustache and chin hair and stated that she did not like facial hair and wanted it shaved, but could not do it by herself. On May 12, 2026, R43 was again in bed with the same facial hair and said she had asked for help but no one assisted her with shaving. On May 13, 2026, R43 remained in bed with the same facial hair and said she had asked a CNA to assist her with shaving, but it still had not been done. R43’s EMR listed diagnoses including reduced mobility, other fatigue, other chronic pain, and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, or anxiety. Her MDS showed mild cognitive impairment and dependence on staff for showering, bathing, and personal hygiene, including shaving. Her care plan, initiated August 14, 2023, identified ADL self-care deficit and impaired mobility due to impaired balance, weakness, and pain, and directed total staff assistance with personal hygiene care. The DON stated that CNAs are supposed to assist residents with shaving as part of hygiene and grooming and to support dignity. The facility policy stated it is the facility’s policy to provide care for every resident to meet their needs.
Failure to Supervise Toileting for High-Fall-Risk Resident
Penalty
Summary
The facility failed to provide necessary assistance and supervision during toileting for a resident with severe cognitive impairment, left-sided flaccid paralysis, poor sitting balance, impulsivity, poor safety awareness, and a high fall risk. The resident’s record showed dependence on staff for toileting, a care plan requiring staff participation of one for toileting, and fall interventions including keeping the call light within reach and responding promptly to requests. Occupational therapy documentation showed the resident had inability to right himself during self-care activities and was dependent on staff for toileting tasks. On the morning of the incident, the resident requested to use the bathroom while breakfast trays were being delivered. A CNA obtained help from another CNA to transfer the resident from bed to wheelchair and then from the wheelchair to the toilet, but both staff members left the room and the resident was left unattended on the toilet. Staff later heard a loud thud and found the resident lying face down on the bathroom floor after an unwitnessed fall. The resident was taken by ambulance to the hospital, and later physician documentation showed injury to the left eye with significant periorbital edema, ecchymosis, and severe subconjunctival hemorrhage. The resident was also receiving daily anticoagulant medication.
Failure to Assess and Address Poor Intake and Weight Loss
Penalty
Summary
The facility failed to perform a nutrition assessment and implement interventions for a resident with poor appetite and oral intake, hyperkalemia, and significant weight loss. The resident had intact cognition, had recently returned from the hospital after treatment for hyponatremia, volume overload with edema, high blood potassium, and acute kidney injury, and had required temporary hemodialysis. The resident reported no appetite, not feeling like eating, and stated she had not spoken with a dietitian at the facility about her poor oral intake. During observation, the resident repeatedly refused meals or ate very little. She stated she was not hungry, had not eaten breakfast, and said the oral supplement offered that morning was the first time she had been offered a supplement at the facility. She also reported that when she did not eat at home she would drink two oral nutritional supplements to prevent weight loss. Staff later learned the resident preferred foods such as hot dogs, lunch meat, and chili; after a CNA offered a hot dog, the resident accepted and ate 100% of it. Review of the record showed multiple notes of poor appetite, poor oral intake, and diarrhea, along with persistent hyperkalemia and hyponatremia and repeated orders for Lokelma. The resident’s weights showed significant loss, including 230.6 pounds on April 10, 2026, 191.4 pounds on May 1, 2026, and 214.2 pounds on May 12, 2026. The record did not show weekly weights as ordered by the physician, and the DON confirmed there were no weekly weights documented. Meal intake records showed the resident ate less than 75% of meals 29 of 54 times and refused meals 7 times. The only nutrition documentation in the record was a note by the CDM identifying the resident as malnourished and recommending double protein and a no added salt diet, but there was no evidence that a dietitian completed an in-depth nutrition assessment of the resident’s clinical condition. The dietitian stated the resident should have been referred because she was high nutritional risk and that critical lab values should have been referred for follow-up, but no further interventions were recommended.
Unrelieved Pain Not Reassessed or Managed
Penalty
Summary
Safe, appropriate pain management was not provided for one resident who had multiple diagnoses including end stage renal disease with dependence on hemodialysis, aftercare following a right hip replacement, diabetes type 2, and Barrett's esophagus disease. The resident was cognitively intact and reported discomfort when sitting up in a chair and while in dialysis. On May 14, 2026, the resident stated she had pain rated 7 out of 10 and said the medication was not helping and she wished someone would do something about it. An RN was informed that the resident had received Tramadol 25 mg about an hour earlier and stated that Tramadol 25 mg might not be enough for the resident. The resident's pain assessment dated May 7, 2026, showed no pain, although the admission pain score was documented as 3 later that day. Pain scores documented from May 7 through May 14 ranged from 0 to 7. The MAR showed Tylenol 500 mg, 2 tablets three times daily, and Tramadol 25 mg every 6 hours as needed for pain, with Tramadol administered only 4 times since admission as of May 14, 2026. There was also an as-needed Tylenol order, but no indication of when either Tylenol or Tramadol should be administered. The pain care plan initiated on May 7, 2026, was not individualized and had blank spaces for medication name, type of pain, and reason for pain, and it did not include a pain score goal. The DON stated that if an initial pain score is documented as 3, the initial pain assessment should reflect that score, and if a resident's pain is not relieved, the physician or healthcare provider should be contacted. The facility policy required residents to be assessed for pain in situations where pain is possible and stated that if pain remains unrelieved despite pharmacological and nursing measures, the physician will be called and informed.
Controlled Medication Documentation, Storage, and Disposal Failures
Penalty
Summary
The facility failed to follow its policy for controlled medication documentation, storage, and disposal for two residents. During inspection of the medication storage room, a clear locked box in the medication refrigerator contained an unopened box of morphine labeled for a resident who had been discharged from the facility on December 23, 2025. The nurse present stated she was new to the facility and was not aware that any controlled medication was stored in the refrigerator, and she said the controlled medication had not been accounted for at the beginning or end of shifts. During medication cart inspection, a resident’s controlled medication count did not match the medication remaining in the bingo card. The bingo card showed 18 tablets of hydrocodone-APAP 10-325 mg remaining, while the controlled drug administration record showed one tablet signed out at 10:30 AM by a nurse. The nurse stated the resident requested the medication but then went to therapy, so she did not administer it, and the MAR also showed the medication not administered. The DON stated nurses must account for all controlled medications before and after each shift, that the discharged resident’s narcotic should have been disposed of after discharge, and that the facility’s practice was to document on the controlled drug administration record only when a medication had been removed from the bingo card.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered, resulting in 2 medication errors out of 26 opportunities and a 7.69% medication error rate. The findings involved 2 of 6 residents observed for medication administration. During observation on May 12, 2026, V17 checked the EMAR for Difluprednate ophthalmic emulsion 0.05 percent, ordered as one drop in the right eye four times a day for post-cataract surgery, and removed an eye drop medication from the cart with a bag label that matched the order. V17 administered one drop to R29's right eye, but the bottle inside the bag was labeled brinzolamide suspension one percent ophthalmic. V17 stated she only checked the bag label and did not check the bottle label, and she realized the wrong eye drop had been administered. V17 also stated the brinzolamide bottle was the only eye drop bottle R29 had in the medication cart. The report also identified an error involving hydralazine HCl Oral Tablet 25 mg for R29, who had diagnoses including gastrostomy status, hypertensive heart disease without heart failure, and paraplegia unspecified. R29's physician order summary included hydralazine 25 mg via G-tube every 8 hours as needed for HTN for SBP greater than 160 and also one tablet via G-tube four times a day for HTN. When V16 prepared the noon G-tube medication, she read the EMAR and said she would not administer the noon hydralazine because R29's SBP was less than 160, focusing on the PRN instruction and not administering the scheduled dose. The DON stated nurses must check medication orders to ensure correct medications, dosages, frequencies, and times are administered, and the NP confirmed the order clearly stated both the PRN and scheduled directions. The facility policy titled Medication Pass stated the facility adheres to Federal and State regulations with medication pass procedures.
Improper Medication Storage and Wrong Eye Drop Administration
Penalty
Summary
The facility failed to follow its policy for proper medication storage and labeling. During a medication cart inspection with the DON, R43’s controlled medication, hydrocodone-APAP 5-325 mg tablets, was found in a bingo card pocket with three pockets popped open and the tablet exposed; the DON stated medications should not be left exposed and should have been disposed of by two nurses for infection control and to prevent diversion. In a separate event during medication administration, a wrong eye drop medication not ordered for R29 was stored in R29’s eyedrop medication bag with the correct pharmacy label, and V17 administered Brinzolamide Suspension 1% ophthalmic into R29’s right eye even though R29’s order and label were for Difluprednate Ophthalmic Emulsion 0.05%. The DON stated nurses must administer medications according to the doctor’s orders and store medications in the correct containers to avoid medication errors.
Pureed Diet Portions Not Served as Planned
Penalty
Summary
The facility failed to serve portions of pureed pork in the amounts indicated on the planned and approved facility menus for two residents with physician orders for pureed diets, R73 and R99. During lunch service, the cook served one #8 scoop of pureed pork to each of the first two pureed diet plates, while the Food Service Director reviewed the diet spreadsheet and stated the planned serving size was 2-#10 scoops, or approximately 7 fluid ounces total. The Food Service Director then instructed the cook to provide the third pureed plate with 2-#8 scoops, and after that plate was served, the cook retrieved approximately 6 fluid ounces of pureed pork from the steamtable pan. The facility’s daily spreadsheet for the week showed pureed diets were to be served two #10 scoops of pureed breaded pork cutlet, and the standardized recipe for pureed breaded pork cutlet also specified one serving as two #10 scoops. The facility policy stated food shall be served in portions indicated on the cycle menu and standardized recipes.
Failure to Follow Contact Precautions and Medication Infection Control Practices
Penalty
Summary
The facility failed to follow its infection prevention and control policy for contact isolation precautions during care of a resident with C-Diff. R93 had an active order for Strict Contact Isolation for positive C-Diff and an order for oral Vancomycin. Although a contact precautions sign was posted on the resident’s door stating that staff and providers must clean their hands, wear gloves before entry, and wear a gown before room entry, V18, the Regional Guest Relations Director, entered R93’s room to deliver a meal tray without wearing a gown or gloves. After leaving the room, V18 performed hand hygiene with alcohol-based hand sanitizer. V18 stated she did not need PPE because she was only delivering a meal tray and had already sanitized her hands after leaving the room. The facility also failed to follow infection prevention practices during medication administration for another resident. While preparing medications for R83, V17, a nurse, touched different surfaces on the medication cart with bare hands, popped a medication from the bingo card, dropped it on the cart, and then picked it up with bare hands without performing hand hygiene before administering it to the resident. The DON stated that if medication is dropped on the med cart, nurses are not to administer it to residents to prevent spread of infection from potential contamination of the medication cart surface. The facility’s infection prevention policy stated that contact precautions are intended to prevent transmission of infectious agents spread by direct or indirect contact and that gown and glove use is necessary prior to room entry.
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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What surveyors actually found near you
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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 | ★★★★★ | 6 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.