Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 North Aurora Living & Rehab Ctr during CMS and state inspections, most recent first.
A facility failed to obtain medications from the pharmacy in a timely manner, causing missed ordered doses for 4 residents. One resident missed diclofenac multiple times and reported the facility had run out of medications before; other residents missed clonazepam, lorazepam, and Valbenzapine doses because the meds were awaiting delivery, reordered, or not yet delivered. The ADON and DON stated refill requests were sometimes denied without the facility being notified, leading residents to run out of meds.
Dish machine sanitizer testing showed the chlorine level remained white and read below the required ppm range while a dietary aide washed dishes and was unsure whether the unit was high-temp or low-temp. The aide said she had tested the machine before washing breakfast dishes, found the same result, and changed the detergent, rinse, and sanitizer containers, but had not yet reported it to the DM. Two dented cans were also observed in dry storage.
Water management program not implemented. The facility had no water flow schematics, no documented assessment of high-risk water areas, no risk assessments or control measures, and no plan to assess or monitor for Legionella or other waterborne pathogens. The ADM, Maintenance Director, Housekeeping Director, and ADON/Infection Prevention Nurse all stated they were unsure of key program components or could not provide the required documentation.
Failure to provide behavioral health services for residents with SMI. Four residents with diagnoses such as bipolar disorder, schizoaffective disorder, schizophrenia, and major depression had PASRR and psychosocial assessments identifying needs for psychotherapy, symptom management, daily living skills training, and socialization supports, but they largely stayed in their rooms, did not attend psychosocial groups, and had little or no documented one-on-one behavioral health intervention. Staff confirmed that several identified services were not being provided or were not available, and one resident only saw the psychologist twice before services stopped due to insurance issues.
A gap between the exterior wall and an air conditioner unit in a resident's room allowed cold air to enter, making the room uncomfortable. The issue went unreported for about a month, as neither staff nor maintenance were aware of it, and no maintenance request was submitted. The facility lacked a formal policy for reporting or requesting repairs, and staff had stopped using the maintenance request form.
A facility failed to ensure that two residents had a working bathroom toilet in their room. The toilet had been broken for weeks, did not flush properly, and a sign marked it out of order while the residents used other restrooms in the facility. Maintenance was aware of the issue from resident council, but the repair had not been completed.
A resident was not adequately prepared for a safe transfer or discharge, and the process did not meet the individual's needs or preferences.
Two residents with psychiatric and physical conditions became involved in a physical altercation after one entered a bathroom while the other was showering and ignored requests to leave. The situation escalated to physical aggression, including striking and the throwing of a urinal containing urine, resulting in a fall. Staff intervened after hearing yelling, but the altercation had already occurred, indicating a failure to prevent resident-to-resident physical abuse as required by facility policy.
A resident who was dependent on staff for transfers and required a mechanical lift fell during a transfer when the sling's worn strap ripped, resulting in multiple fractures. Two CNAs were involved in the transfer, and the sling had not been replaced since admission. The facility's policy lacked instructions for equipment checks before use, and the manufacturer's guidelines requiring inspection of sling attachments were not followed.
A resident who was dependent on staff and a mechanical lift for transfers experienced a fall when the sling's strap ripped during a transfer. Two CNAs reported the sling was old and worn out, and the DON confirmed the sling was not maintained or replaced according to manufacturer guidelines. The facility lacked a policy for lift sling maintenance, and the incident occurred due to the use of unsafe equipment.
A resident with a stress fracture of the left radius did not have a follow-up orthopedic appointment scheduled as required. The transportation scheduler, responsible for arranging appointments, was unaware of the need for a follow-up until receiving the after-visit summary late. The Program Director for ADAPT and a registered nurse were involved in handling the after-visit summary, which indicated the need for a follow-up appointment that was not scheduled.
A resident discharged with depression and cellulitis was unable to obtain complete medical records due to a transition from PCC to Sigma Care EHR system, leaving the facility without access to previous records. The resident sought her records to review treatment details, but the facility could only provide partial records, highlighting a deficiency in maintaining accurate and complete records post-discharge.
The facility failed to protect two residents from abuse by their peers, resulting in psychological harm. One resident was inappropriately touched by a female peer, while another was slapped by a male peer. Both incidents were reported, but the facility's abuse prevention policy was not effectively implemented, leaving the residents feeling scared and unprotected.
The facility did not report a physical altercation between two cognitively intact residents to local law enforcement, as required by their policy. The incident, which occurred in the TV lounge, involved one resident hitting another, leading to a mutual exchange of blows. The facility's policy mandates reporting such incidents, but the administrator failed to do so, and no investigation report or resident assessments were documented.
The facility failed to report two incidents of resident-to-resident physical abuse to the State Agency as required by their policy. In the first incident, a resident with multiple diagnoses, including schizoaffective disorder, was involved in an altercation with another resident, resulting in a reddened cheek. The second incident involved the same resident in a physical altercation with another resident, witnessed by a Restorative Aide. The Administrator admitted both incidents were not reported to the State Agency or local police.
The facility failed to investigate two incidents of resident-to-resident physical abuse as per policy. One incident involved a resident slapping another in the lounge, and another involved a physical altercation in the TV lounge. Despite acknowledgment by staff, no investigation reports were completed, violating the facility's abuse prevention policy.
The facility failed to follow proper procedures for administering eye drops and blood glucose monitoring. An LPN administered eye drops directly onto a resident's eyeball instead of into the lower eyelid pouch, causing the drops to fall onto the cheek. Another resident's blood glucose was checked incorrectly, as the LPN used an alcohol wipe to discard the first drop of blood, potentially altering the reading.
The facility failed to securely store medications and properly label insulin vials. An LPN did not label an insulin vial with an open date, and expired medications were found in a medication cart. Additionally, a pill was left unattended in a resident's room without authorization. Staff confirmed that medications should not be left at the bedside unless specifically ordered.
The facility failed to provide influenza and pneumonia vaccines to three residents, as identified during a survey. The DON was unable to explain why the vaccines were not administered, citing a lack of clarity about whether residents requested them or if the facility offered them. The residents had significant medical histories, making them vulnerable to complications, yet the facility's policy to offer vaccinations was not effectively implemented.
A resident with full code status did not receive CPR due to confusion over their code status, resulting in their death. The facility lacked a system to ensure timely completion and accessibility of advance directives, leading to a delay in emergency response. The nurse on duty assumed the resident was a DNR based on incorrect information, highlighting systemic issues in maintaining accurate records of residents' code statuses.
The facility failed to ensure timely completion and availability of Advance Directives, leading to inconsistencies in residents' code statuses. A resident, who expressed a desire not to live, remained a full code due to lack of coordination with hospice and the guardian. Additionally, a nurse under investigation for neglect was not removed from resident contact, contrary to facility policy.
A resident with a full code status was found unresponsive, but CPR was not initiated due to confusion over advanced directives. The nurse on duty did not perform CPR, instead searching for a DNR order and contacting hospice, leading to a delay in emergency response. The facility's records confirmed the resident was a full code, and the lack of CPR was deemed neglectful.
A facility failed to implement its abuse policy by not removing a nurse from resident contact during an active neglect investigation. The nurse continued to work despite the ongoing investigation into a resident's death. Additionally, the facility did not submit a timely final investigative report to the state agency, as required by their policy, and the report lacked a final investigative summary.
A facility failed to coordinate advanced directives with hospice and a guardian for a resident with Bipolar Disorder, Dementia, and Schizoaffective Disorder. Despite the resident expressing a desire not to live, the POLST form indicated a full code status, and there was no documentation of discussions with the state guardian. The resident was admitted to hospice, but the full code status was not addressed until the resident's condition worsened, highlighting a lack of timely communication and documentation.
A resident with severe cognitive impairment fell from a wheelchair due to the absence of footrests during transport, resulting in a forehead laceration. The CNA responsible admitted to not attaching the footrests, despite the care plan's instructions to use them. The DON confirmed the requirement for footrests during transport.
The facility failed to serve substitute menu items with similar nutritional content as the main entree. Five residents received meals that did not meet the nutritional standards of the main menu items, such as sandwiches with minimal protein content compared to the main entrees. The registered dietitian confirmed that substitute items should be equivalent to the main menu entree served.
The facility failed to notify two residents in advance and provide reasons for room changes or transfers. Both residents, who have multiple medical diagnoses, were transferred to new rooms without prior notice, causing distress. The facility's policy requiring advance notice was not followed.
Missed Medication Doses Due to Delayed Pharmacy Delivery
Penalty
Summary
The facility failed to ensure medications were obtained from the pharmacy in a timely manner, resulting in missed ordered doses for 4 of 4 residents reviewed for pharmacy services. R1, who was cognitively intact and had diagnoses including COPD, major depressive disorder, ADHD, and borderline personality disorder, missed diclofenac doses when the MAR documented the medication as awaiting delivery or pending delivery. R1 told surveyors the facility had run out of medications multiple times and said missing diclofenac made it difficult to ambulate. V3, the ADON, stated staff sometimes reordered medications too early, the pharmacy would not refill them, the facility was not notified when a refill request could not be fulfilled, and another request had to be sent without staff knowing the first request was denied. R2, who was cognitively intact and had diagnoses including schizoaffective disorder, depression, and anxiety disorder, missed a scheduled clonazepam dose because the medication was on order awaiting delivery. R3, who was cognitively intact and had diagnoses including paranoid schizophrenia, dementia, and atrial fibrillation, missed a scheduled lorazepam dose because it was reordered. R4, who was cognitively intact and had diagnoses including Parkinson's disease with dyskinesia, schizoaffective disorder, and drug induced subacute dyskinesia, missed scheduled doses of Valbenzapine because the pharmacy had not delivered the medication. The DON stated the facility was not being made aware by the pharmacy when refill requests were denied and residents were running out of medications, and said residents should not miss medication doses.
Dish Machine Sanitizer Level Out of Range
Penalty
Summary
The facility failed to sanitize dishes during the dishwashing procedure for all 99 residents who received meals prepared and served in the kitchen. During the initial kitchen tour, a dietary aide was observed washing dishes in the dish machine and stated she was unsure whether the machine was high temperature or low temperature, but that she checked sanitation using a test strip. When the sanitizer well was tested, the chlorine test strip remained white and read 10 on the strip scale, while the dietary aide stated the strip should read 100 ppm with a dark purple color. She also stated she had tested the machine before washing breakfast dishes, found the strip remained white, and then changed the three containers at the bottom of the machine, but had not yet reported the issue to the dietary manager. The report also noted two dented cans in dry storage among other cans: one containing marinara sauce and one containing cut waxed beans. Facility policy required damaged product to be identified and the vendor contacted immediately for pickup and credit. The facility’s ware-washing policy required dishes washed by the mechanical dishwasher to be cleaned and sanitized, and for a low-temperature dish machine the chlorine sanitizer level was to be 50-100 ppm before washing anything. The observed test results did not meet that range.
Water Management Program Not Implemented
Penalty
Summary
The facility failed to implement its water management program plan. During the survey, there was no documentation showing water flow schematics for the facility and no documentation of an assessment identifying high-risk water flow areas. The facility also did not have documented risk assessments or control measures established to address potential hazards, and it did not have a plan in place to assess, mitigate risk, and/or monitor for Legionella and other waterborne pathogens. On interview, the Administrator stated the water management program was maintained by the Maintenance Director and said he was unsure of the program’s components. The Maintenance Director stated he did not have a plan in place to assess or monitor for Legionella, was not aware of the documentation needed for the water management program, and could not provide documentation for the program. He also stated he did not have schematics describing the facility water system and did not have a facility water management plan that included the required risk assessment or established control measures. The Housekeeping Director and the Assisted DON/Infection Prevention Nurse also stated they were unsure of all components of the water management program or did not handle it.
Failure to Provide Behavioral Health Services for Residents with SMI
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for residents with serious mental illness, affecting 4 of 4 residents reviewed for behavioral health services. The report describes that R12, R85, R97, and R4 each had diagnoses and PASRR findings identifying serious mental illness and recommending behavioral health, psychosocial, rehabilitative, and symptom-management supports, yet the facility did not provide the documented services reflected in their assessments and histories. R12 had diagnoses including severe bipolar disorder with psychotic features, recurrent severe major depressive disorder, ADHD, and suicidal ideations. His PASRR and social service history identified needs for individual psychotherapy, group therapy, crisis intervention planning, daily living skills training, mental health education, money management, and consistent behavioral supports. R12 stated he did not attend psychosocial or behavioral health services in or outside the facility and wanted one-on-one support and groups to help him manage stress, behavior symptoms, and feelings. Facility records showed he was only seen twice by the psychologist, both times for 20 minutes, and no further visits occurred because of insurance issues. The social service director and case manager acknowledged there was no documentation of one-on-one intervention by social services to address his identified rehabilitation focus areas. R85 had diagnoses including schizoaffective disorder depressive type, major depressive disorder, and generalized anxiety disorder. Her PASRR and psychosocial history identified needs for daily living skills training, psychotherapy, substance abuse treatment, self-maintenance, symptom management, and one-on-one intervention related to coping, adjustment, and empowerment. During interviews, she stated she did not attend psychosocial or behavioral health services and spent her time napping, eating, and smoking. The social service staff confirmed she was not assigned to in-house group or one-on-one psychosocial services provided by an outside company, and there was no documentation of ongoing one-on-one intervention beyond a single discussion about adjustment to the facility. Although she attended one women’s psychosocial group, staff confirmed she did not receive the broader behavioral health services identified in her assessments. R97 had schizophrenia and his PASRR identified a short-term nursing facility stay with needs for one-on-one psychiatrist or social worker support, socialization groups, regular psychiatric follow-up, case management, symptom education, and medication management education. His psychosocial history also identified intensive skills training and supports focused on community integration, psychotherapy, symptom management, and medication education. Surveyors observed that he stayed in his room and only came out for meals. The social services director stated he did not go to groups, often stayed in his room, had delusions and hallucinations, and could benefit from symptom management education, but the facility’s symptom and medication management groups were still under development and not available to residents. R4 had diagnoses including major depressive disorder, hallucinations, insomnia, and hypertension. Her PASRR and psychosocial assessment identified needs for medication monitoring and education, structured social activities, daily living support, coping and adjustment, psychotherapy, symptom management, and medication management. She reported staying in her room, playing games on her phone, and not attending activities or psychosocial groups. Staff stated she had anxiety and self-care concerns, but no documentation of one-on-one intervention sessions was provided, and she was not participating in the available ADAPT program groups.
Failure to Repair Exterior Wall Gap and Lack of Maintenance Reporting System
Penalty
Summary
A gap was observed between the exterior wall and the air conditioner unit in a resident's room, allowing cold air to flow directly into the room and making the space chilly. The gap was large enough that the parking lot was visible through it. The resident, who was cognitively intact and had multiple diagnoses including schizophrenia, alcohol-induced psychosis, anxiety disorder, and nicotine dependence, reported that the gap had been present for about a month. The resident's roommate was also observed fully dressed and lying under blankets, indicating discomfort due to the cold. Staff members, including the housekeeper assigned to the room and the housekeeping supervisor, were unaware of the gap until it was pointed out during the survey. The maintenance director also stated he was unaware of the issue prior to being informed by staff. There was no record of a maintenance request form being completed for the gap, and the last maintenance request received by the maintenance director was dated nearly two months prior. The facility did not have a policy regarding the reporting of maintenance issues or requesting repairs, and staff had stopped using the maintenance request form for unknown reasons. The administrator confirmed that there was no formal policy in place and that staff were expected to request repairs using the form, but could not explain why this process was not being followed.
Non-Functioning Resident Bathroom Toilet
Penalty
Summary
The facility failed to ensure that a resident bathroom had a clean and working toilet for two residents, R78 and R91, who were both observed alert and oriented in their room on December 1, 2025. A sign on the bathroom door stated, "Temporarily Out of Order." R78 reported that the toilet had not been working for a few weeks, did not flush properly, and that waste would remain in the bowl before sometimes going down later. R78 also stated the sign had been placed on the door the prior week by maintenance staff who said they would fix it. R91 stated the toilet had been broken for about three weeks and that maintenance had been informed again at the resident council meeting on November 25, 2025. R91 said the residents had been using different restrooms throughout the facility for the past few weeks.
Failure to Ensure Safe and Appropriate Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report identifies a deficiency related to the lack of proper planning and preparation for the resident's transition, which is necessary to ensure continuity of care and resident well-being. No additional details about the specific resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent physical abuse between two residents, both of whom were cognitively intact and had significant psychiatric and physical diagnoses. The incident occurred when one resident was taking a shower and another entered the bathroom, ignoring requests to leave. The situation escalated when the second resident bumped the first resident's shower chair and continued to harass him. The first resident, after drying off and attempting to leave, was confronted again by the second resident, who threw a urinal full of urine at him. In response, the first resident struck the second resident on the back of the head. The altercation continued in the hallway, with further physical aggression and the first resident slipping on urine and falling. Staff became aware of the incident after hearing yelling and observed the residents in a physical altercation. Despite staff attempts to intervene, the situation escalated, with one resident dumping urine on the other and a wheelchair being flipped. Both residents were assessed and found to have no injuries. The facility's abuse prevention policy prohibits any form of abuse, including physical or mental injury inflicted by non-accidental means. The events described demonstrate a failure to prevent resident-to-resident physical abuse as required by facility policy.
Failure to Inspect and Replace Worn Mechanical Lift Sling Results in Resident Fall and Fractures
Penalty
Summary
A resident with multiple diagnoses, including impaired mobility and generalized weakness, was dependent on staff for transfers and required the use of a mechanical lift. The resident's care plan specified the need for a mechanical lift and two-person assistance for transfers. On the day of the incident, two CNAs attempted to transfer the resident from bed to wheelchair using a mechanical lift. One CNA secured the resident's sling to the lift, while the other stood behind the wheelchair but was not within close reach of the resident. As the lift was being maneuvered, the sling's lower left strap ripped, causing the resident to fall to the floor. Both CNAs reported that the sling appeared worn out and had not been replaced since the resident's admission. The Director of Nursing confirmed that the sling's lower left and right straps were completely ripped and attributed the fall to the frayed condition of the sling. The facility's accident investigation and fall incident reports also indicated that the sling should have been inspected prior to use and that the failure to do so led to the incident. The manufacturer's instructions for the lift required that all sling attachments be checked for wear before each use, but the facility's policy did not include instructions for equipment checks before use. As a result of the fall, the resident sustained multiple fractures, including to the right hip, left pelvis, pubic bone, and lumbar vertebra, and required transfer to the hospital for evaluation and treatment. The incident was witnessed and documented in the resident's progress notes and hospital records, which detailed the injuries and the circumstances of the fall.
Failure to Maintain and Replace Mechanical Lift Sling Leads to Resident Fall
Penalty
Summary
The facility failed to follow the manufacturer's maintenance recommendations for a mechanical lift-sling transferring device, resulting in the use of worn and unsafe equipment. A resident with multiple diagnoses, including impaired mobility and generalized weakness, was dependent on staff and a mechanical lift for transfers. On the day of the incident, two CNAs attempted to transfer the resident using a mechanical lift when the sling's lower left strap ripped, causing the resident to fall to the floor. Both CNAs reported that the sling was old, worn out from overuse, and had not been replaced since the resident's admission. The Director of Nursing confirmed that the sling's straps were completely ripped and that the sling appeared worn out from overuse. The facility did not have a policy for maintaining lift sling equipment, and the DON was unaware of the manufacturer's service life recommendations. The resident's care plan indicated a risk for falls and required the use of a mechanical lift with staff assistance. Documentation from the accident investigation and fall incident reports confirmed that the fall occurred because the sling broke, and that the sling should have been inspected prior to use. The manufacturer's guidelines specified that slings should be inspected after each laundering and discarded if found to be bleached, torn, cut, frayed, or broken, with an expected service life of thirteen months. The facility's policy required providing an environment free from hazards and ensuring the use of safe assistive devices, but this was not followed in the case of the mechanical lift sling.
Failure to Schedule Follow-Up Appointment for Resident with Fracture
Penalty
Summary
The facility failed to schedule a follow-up doctor appointment for a resident diagnosed with a stress fracture of the left radius. The resident's mother reported that the facility did not arrange the necessary follow-up appointment. The transportation scheduler, responsible for scheduling such appointments, confirmed that the resident's last orthopedic visit was conducted by the facility's ADAPT staff, and no subsequent appointment was scheduled. The Program Director for ADAPT stated that the after-visit summary from the orthopedic appointment indicated a follow-up was needed the week of March 17th, and this information was given to a registered nurse. However, the registered nurse was unsure if the appointment was scheduled and had passed the after-visit summary to the transportation scheduler, who only became aware of the need for a follow-up appointment after receiving the paperwork belatedly. The orthopedic after-visit summary explicitly instructed scheduling a follow-up in three weeks, which was not done, as confirmed by the progress note entered by the registered nurse.
Incomplete Medical Records Post-Discharge Due to EHR Transition
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident (R2) after discharge. R2 was admitted with diagnoses of depression and cellulitis and was discharged in December. She requested her complete medical records, including doctor's notes and a list of medications, to review her treatment, particularly the antibiotics prescribed for cellulitis. However, the facility was unable to provide a complete set of records due to a change in the electronic health record (EHR) system from PCC to Sigma Care, which resulted in a lack of access to the previous records. The medical record staff (V12) and the Director of Nursing (V2) confirmed the inability to access the old EHR system, which contained essential documents such as physician order sheets, progress notes, medication administration records (MAR), minimum data set (MDS), and care plans of discharged residents. The facility's administrator (V1) acknowledged the requirement to keep records for years after discharge and mentioned that the new owner was coordinating with the previous owners to regain access to the PCC system. Despite these efforts, the resident was left without a complete set of her medical records, highlighting a deficiency in maintaining accurate and complete medical records post-discharge.
Failure to Protect Residents from Peer Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by their peers, resulting in psychological harm. One resident, R2, reported that a female peer, R1, entered his room uninvited and inappropriately touched him. Despite R2's attempts to ask R1 to leave, she continued to follow him around the facility, causing him to feel scared and uncomfortable. R2 reported the incident to the Activity Director and requested police involvement when he saw R1 again, fearing further inappropriate behavior. Another resident, R5, reported being slapped in the face by a male peer, R3, while resting in the day room. This incident left R5 feeling scared and wanting to leave the facility. The Director of Nursing documented the incident, noting a red mark on R5's cheek, but there was no further assessment of R5's injury or her request for discharge. The facility's policy on abuse prevention was not effectively implemented, as it failed to protect these residents from abuse by other residents.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of resident-to-resident physical abuse to local law enforcement as required by their policy. The incident involved two residents, both of whom were cognitively intact, engaging in a physical altercation in the TV lounge. The altercation began when one resident was struck in the face by the other without any prior provocation. The resident who was hit then followed the aggressor, leading to a mutual exchange of blows. Despite the facility's policy mandating the reporting of such incidents to law enforcement, the administrator did not report the incident or provide an investigation report when requested. The medical records of both residents involved in the altercation did not contain any documentation of assessments of their physical or mental conditions following the incident. The facility's policy, titled Illinois Abuse Prevention Policy, specifies that local law enforcement should be contacted in cases of physical abuse involving injury inflicted by one resident on another. However, the facility did not adhere to this policy, as the incident was neither reported to law enforcement nor documented appropriately in the residents' medical records.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report two incidents of resident-to-resident physical abuse to the State Agency as required by their policy. The first incident involved a resident with multiple diagnoses, including schizoaffective disorder and diabetes, who was cognitively intact. This resident was involved in an altercation with another resident, resulting in a reddened cheek for the latter. The Director of Nursing confirmed there was no incident report or assessment following this event, and the Administrator admitted the incident was not reported to the State Agency. The second incident involved another resident with schizoaffective disorder and other medical conditions, who was also cognitively intact. This resident was involved in a physical altercation with the same resident from the first incident. The altercation was witnessed by a Restorative Aide, who intervened, and the resident was subsequently transferred to the hospital. However, there was no documentation of the residents' physical condition or mood following the incident, and the Administrator acknowledged that the incident was not reported to the State Agency or local police, despite recognizing it as abuse.
Failure to Investigate Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to investigate two incidents of resident-to-resident physical abuse in accordance with its policy. The first incident involved a physical altercation between two residents, R3 and R5, on December 17, 2024. R5 reported being slapped in the face by R3 while resting in the lounge. The Director of Nursing, V2, acknowledged the incident but stated there was no incident report. R3's progress notes confirmed the altercation, noting R3 had a raised hand over R5 and R5 had a reddened cheek. The second incident occurred on December 24, 2024, involving R3 and R4. R4 reported being hit in the face by R3 while in the TV lounge, which led to a physical altercation between the two. A Restorative Aide, V7, witnessed the altercation and intervened by verbally redirecting the residents. Despite these incidents, the facility did not have investigation reports for either event, as required by their Illinois Abuse Prevention Policy. This policy mandates a complete written report of the investigation within five working days of the occurrence, which was not fulfilled in these cases.
Improper Medication and Blood Glucose Monitoring Procedures
Penalty
Summary
The facility failed to adhere to proper administration guidelines for eye drops and blood glucose monitoring, affecting two residents. A resident was observed receiving eye drops incorrectly, as the LPN administered the drops directly onto the eyeball instead of into the lower eyelid pouch as per the facility's procedure. This resulted in the drops falling onto the resident's cheek, indicating a deviation from the established protocol for eye drop administration. Another resident, diagnosed with type 2 diabetes, had their blood glucose level checked improperly. The LPN used an alcohol wipe to discard the first drop of blood and did not allow the alcohol to dry before collecting the blood sample. This practice can alter the blood glucose reading, as confirmed by the LPN and the DON. The facility's failure to follow proper procedures for both eye drop administration and blood glucose monitoring led to these deficiencies.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to securely store medications and properly label and date insulin vials after initial use. A Licensed Practical Nurse (LPN) was unable to locate an insulin vial for a resident with type 2 diabetes and opened a new vial without labeling it with an open date, contrary to the facility's policy. Additionally, expired medications were found in the medication cart, including eye drops that were past their 28-day usage period. The Director of Nursing acknowledged that the insulin vial should have been labeled with an open date and that expired medications should have been discarded. Furthermore, a medication was found at the bedside of a resident's room without proper authorization or documentation. A yellow pill was observed on a bookshelf in a resident's room over several days, and the resident's records did not show any assessment or order allowing medications to be stored at the bedside. Staff members confirmed that residents were not allowed to keep medications at the bedside unless there was a specific order, and medications should not be left unattended in residents' rooms. The Director of Nursing reiterated that medications should be stored securely and only accessible to authorized personnel.
Failure to Administer Vaccines to Residents
Penalty
Summary
The facility failed to provide influenza and pneumonia vaccines to three residents, as identified during a survey. The Director of Nursing (DON), who also serves as the Infection Preventionist, was unable to explain why the vaccines were not administered to all residents. The DON mentioned that a vaccine day had occurred before her tenure, but she was uncertain if the residents had requested the vaccines or if the facility had offered them. This lack of clarity and follow-through resulted in the residents not receiving their vaccinations until the survey was conducted. The residents involved had significant medical histories that made them vulnerable to complications from influenza and pneumonia. One resident had chronic obstructive pulmonary disease, pneumonia, and other respiratory issues. Another resident had conditions such as hydrocephalus and diabetes, while the third resident had bipolar disorder and hypertension. Despite these conditions, the facility's policy to offer vaccinations to all residents was not effectively implemented, as evidenced by the consent forms being signed only during the survey.
Failure to Initiate CPR Due to Code Status Confusion
Penalty
Summary
The facility failed to initiate CPR for a resident with full code status, resulting in the resident's death. The resident, who had a history of bipolar disorder, dementia, and schizoaffective disorder, was found not breathing, and no CPR was initiated despite having a POLST form indicating full code status. The nurse on duty, V5, was under the impression that the resident was on hospice with a DNR order, which was incorrect. This misunderstanding led to a delay in emergency response, as V5 spent time trying to verify the resident's code status instead of initiating CPR. The facility also lacked a system to ensure that advance directives were completed timely and available to direct care staff. The resident's POLST form was not easily accessible, and there was confusion among staff regarding the resident's code status. The nurse, V5, did not perform CPR and assumed the resident was a DNR based on incorrect information. This assumption was compounded by the fact that the facility's process for verifying advanced directives was not clear to the agency nurse, V5, who was unfamiliar with the facility's procedures. Additionally, the facility's failure to maintain accurate and accessible records of residents' code statuses was evident in the review of other residents' charts, which also lacked completed POLST forms. This systemic issue contributed to the immediate jeopardy situation, as it had the potential to affect all residents in the facility. The lack of a clear and efficient process for handling advance directives and code status verification was a significant factor in the deficiency.
Deficiencies in Advance Directives and Investigation Procedures
Penalty
Summary
The administrator of the facility failed to ensure that Advance Directives were completed in a timely manner and made available to direct care staff. This deficiency was observed through the absence of completed POLST forms in the paper charts of several residents, including R5, R9, R10, R11, R16, and R17. The facility's process for obtaining POLST forms involved coordination between nursing and social services, but inconsistencies were noted, particularly with the transition to the PCC electronic medical records system. Social services staff reported ongoing issues with access to the system, which hindered their ability to correct discrepancies and ensure accurate documentation of residents' code statuses. Additionally, the facility failed to coordinate advanced directives with hospice and the guardian for a resident, R1, who had expressed a desire not to live anymore. Despite being cognitively intact and having communicated her wishes to the Medical Director, there was no documentation of discussions with R1's state guardian regarding changes to her POLST form or advanced directives. R1 was admitted to hospice care without a change in her full code status, and the hospice nurse initiated conversations about her advanced directives only after her condition declined significantly. The lack of timely communication and coordination between the facility, hospice, and the guardian resulted in R1 remaining a full code at the time of her death. Furthermore, the facility did not adhere to its Abuse Prevention Program policy by failing to remove an employee, V5, who was under investigation for neglect during an active investigation. V5, a nurse, did not implement CPR when discovering R1 deceased and spent time attempting to locate DNR paperwork instead. Despite the ongoing investigation, V5 was observed working as a floor nurse, which contradicted the facility's policy of removing employees accused of neglect from resident contact until the investigation's conclusion. The facility's final investigative report on R1's death lacked a summary and outcome, indicating incomplete documentation of the investigation process.
Failure to Initiate CPR for Resident with Full Code Status
Penalty
Summary
The facility failed to protect a resident from neglect by not initiating cardiopulmonary resuscitation (CPR) despite the resident's Practitioner Order for Life-Sustaining Treatment (POLST) indicating a full code status. The resident, an elderly individual with diagnoses including Bipolar Disorder, Dementia, and Schizoaffective Disorder, was found unresponsive by a nursing assistant. The nurse on duty, V5, did not start CPR because she was unsure of the resident's advanced directives, despite the POLST form indicating the need for resuscitation. Instead, V5 spent time searching for a Do Not Resuscitate (DNR) order, contacting hospice, and handling another resident's issue, leading to a significant delay in emergency response. The Director of Nursing, V2, confirmed that the resident was a full code in the facility's records and that CPR should have been initiated. The Deputy Coroner also expressed concern that CPR was not started, emphasizing that without a valid DNR, the resident should have received emergency interventions. The facility's policy on abuse prevention defines neglect as the failure to provide necessary services to avoid harm, which was evident in this case as the staff did not perform CPR, resulting in the resident's death without the appropriate emergency response.
Failure to Implement Abuse Policy During Investigation
Penalty
Summary
The facility failed to implement its abuse policy during an active neglect investigation involving a resident who was found deceased. The policy mandates that any employee accused of abuse or neglect be immediately removed from resident contact until the investigation is concluded. However, the nurse involved in the incident continued to work as a floor nurse, administering medications and caring for residents, despite the ongoing investigation. This failure to remove the staff member from resident contact during the investigation is a direct violation of the facility's abuse prevention policy. Additionally, the facility did not submit a timely final investigative report to the state agency, as required by their policy. The report was undated and provided late, lacking a final investigative summary. The administrator was still investigating the circumstances surrounding the incident when the report was requested, and the report had not been submitted to the state agency by the time of the survey. This delay in reporting and lack of a conclusive investigation further highlights the facility's failure to adhere to its own policies and procedures regarding abuse prevention and investigation.
Failure to Coordinate Advanced Directives with Hospice and Guardian
Penalty
Summary
The facility failed to coordinate advanced directives with hospice and a guardian in a timely manner for a resident who was reviewed for hospice care. The resident, who had diagnoses including Bipolar Disorder, Dementia, and Schizoaffective Disorder, was documented as cognitively intact and had expressed a desire not to live anymore to the Medical Director. Despite this, the resident's POLST form indicated a full code status, and there was no documentation of discussions with the state guardian regarding changes to the advanced directives. The Medical Director had ordered a hospice evaluation due to the resident's refusal to eat and failure to thrive, and the state guardian was informed of the clinical situation and consented to hospice services. However, there was a lack of communication and documentation regarding the resident's expressed wishes and the need to update the POLST form. The resident was admitted to hospice, but the hospice nurse noted that the resident's full code status was not addressed until the resident began declining, and the state guardian confirmed that no prior conversations about advanced directives had occurred. The facility's Director of Nursing assumed that the resident was a DNR upon hospice admission, but there was no confirmation from hospice that discussions with the guardian had taken place. The Social Service Director also did not pursue discussions about advanced directives. The hospice nurse initiated a conversation with the state guardian about the resident's code status only after the resident's condition worsened, highlighting the facility's failure to ensure timely coordination of advanced directives with hospice and the guardian.
Failure to Use Wheelchair Footrests Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the use of wheelchair footrests during transportation, resulting in a resident, identified as R4, falling from the wheelchair and sustaining a forehead laceration. R4, who was cognitively severely impaired and dependent on substantial assistance for activities of daily living, was being wheeled by a Certified Nursing Assistant (CNA) identified as V11. During the transport from the dining hall to his room, R4 placed his feet on the floor, causing the wheelchair to brake and leading to his fall. R4's care plan, revised prior to the incident, indicated the need for monitoring and intervention to reduce self-injury risks, including the use of footrests. However, V11 admitted to not attaching the footrests during the transport, acknowledging the oversight as a significant lesson. The Director of Nursing confirmed that staff should ensure residents' feet are on footrests during wheelchair transport. The incident resulted in R4 being sent to the hospital with a forehead laceration and returning with stitches and bruising.
Failure to Provide Nutritionally Equivalent Substitute Menu Items
Penalty
Summary
The facility failed to serve substitute menu items with similar nutritional content as the main entree. This deficiency was observed in five residents who received meals that did not meet the nutritional standards of the main menu items. For instance, one resident reported receiving a sandwich with minimal protein content instead of the main entree, which provided significantly more protein. Another resident, who is allergic to many foods, often received a grilled cheese sandwich or a peanut butter and jelly sandwich, both of which did not match the nutritional value of the main entree. The facility's food service supervisor provided a list of substitute items, but these items were not nutritionally equivalent to the main menu items served on the same days. The registered dietitian confirmed that substitute items should be equivalent to the main menu entree served. The facility's menu spreadsheets for specific dates showed that the main entrees provided significantly more protein compared to the substitute items. For example, the main entree on one day included a braised pork bun providing 14 grams of protein, while the substitute deli sandwich provided only 3 grams of protein from bologna and 5 grams from cheese. Similarly, the main entree on another day included Salisbury steak providing 18 grams of protein, while the substitute grilled cheese sandwich provided only 14 grams of protein. These discrepancies indicate that the facility did not ensure that substitute menu items met the nutritional content of the main entrees, leading to a deficiency in the quality of care provided to the residents.
Failure to Notify Residents of Room Transfers
Penalty
Summary
The facility failed to notify residents in advance and provide reasons for room changes or transfers. This deficiency was observed in two residents. The first resident, who has multiple medical diagnoses including Bipolar Disorder, Rheumatoid Arthritis, and Sjogren syndrome, was transferred to another bedroom without prior notice. The resident's family member and the resident herself expressed that they were not informed about the reason for the transfer. The Director of Nursing (DON) mentioned that the transfer was for deep cleaning but did not provide a truthful explanation due to confidentiality reasons. The resident's progress notes did not document any prior notification for the room transfer or the reason for the change. The resident's former roommate remained in the original room and now has a new roommate, indicating inconsistency in the reason provided for the transfer. The second resident, who has multiple medical diagnoses including Major Disorder and Panic Disorder, was also transferred to a new room without prior notification. The resident expressed that the sudden transfer was upsetting. The progress notes indicated an attempt to notify the resident's brother, but there was no documentation of prior notification to the resident herself. A Social Service progress note later documented the reason for the transfer. The Social Services Staff confirmed that residents and their families should be notified in advance of room changes, but this procedure was not followed in these cases. The facility's policy states that residents should be given notice before room or roommate changes, but this policy was not adhered to in these instances.
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What surveyors actually found near you
We read the 601 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Asbury Gardens Nsg & Rehab | 1.3 mi | ★★★★★ | 5 | 0 |
| Avantara Aurora | 1.9 mi | ★★★★★ | 11 | 0 |
| Grove Of Fox Valley,the | 2.4 mi | ★★★★★ | 12 | 0 |
| Michaelsen Health Center | 3.2 mi | ★★★★★ | 3 | 0 |
| Batavia Rehabilitation And Health Care Center | 3.4 mi | ★★★★★ | 1 | 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.