Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Memorial Community Care during CMS and state inspections, most recent first.
QAPI committee meetings did not include the required Medical Director member. The facility’s QAPI policy listed the Medical Director as a committee member, but meeting minutes showed the Medical Director was absent from quarterly meetings, and the ADM confirmed the MD only reviewed the QAPI minutes instead of attending. The issue had the potential to affect all 33 residents in the facility.
The facility's dishwasher failed to reach the required wash cycle temperature of 160°F, compromising dish sanitization for all residents. Despite the rinse cycle meeting the necessary 180°F, the wash cycle consistently fell short, with temperatures ranging from 142°F to 159°F. Staff interviews confirmed awareness of the issue, and maintenance efforts were ongoing to address the deficiency.
A facility failed to inform a resident about changes to their Metformin medication, leading to the resident refusing the medication due to lack of notification. The resident, who was cognitively intact, had a care plan goal to direct their care but lacked interventions for this goal. Additionally, another resident with dementia had not been re-evaluated for eye care needs since admission, despite declining an eye exam initially. The facility did not document any follow-up on the resident's vision care needs.
The facility inaccurately coded the MDS for three residents, leading to discrepancies in their assessments. A resident with serious mental illness was not properly coded, and two residents receiving antipsychotic medications had incorrect GDR documentation on their MDS, despite provider documentation indicating contraindications.
The facility failed to ensure timely physician visits for two residents, resulting in gaps of 126 and 147 days between visits. The DON and FA confirmed the lack of a process to meet the 60-day visit requirement, contributing to the oversight.
QAPI Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that the required members of the Quality Assurance and Performance Improvement (QAPI) Committee attended the quarterly meetings. The facility’s undated QAPI policy identified the Medical Director as a committee member, but the QAPI meeting minutes dated 10.14.2025, 11.11.2026, 12.9.2025, and 1.13.2026 showed that the Medical Director was not present at those meetings. During an interview on 2.2.2026 at 9:00 AM, the Administrator confirmed that the Medical Director does not attend the facility’s quarterly QAPI committee meetings and only reviews the nursing facility’s QAPI minutes. The deficiency had the potential to affect the 33 residents in the facility at the time of the survey.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the water temperatures of their high-temperature dishwasher met the required levels for effective sanitization. The dishwasher, which is used to clean dishes and utensils for all residents, required a minimum water temperature of 160 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the rinse cycle. However, observations and record reviews revealed that the wash cycle temperatures consistently fell below the required 160 degrees Fahrenheit, with recorded temperatures ranging from 142 to 159 degrees Fahrenheit over the months of August and September 2024. Although the rinse cycle temperatures often met or exceeded the required 180 degrees Fahrenheit, the failure to achieve the necessary wash cycle temperature compromised the sanitization process. Interviews with facility staff, including a dietary aide, the facility administrator, the infection control nurse, and maintenance personnel, confirmed awareness of the issue. The dietary aide acknowledged the difficulty in reaching the required wash cycle temperature and indicated reliance on the dishwasher instead of the three-sink sanitization method. The facility administrator confirmed the deficiency and emphasized the need to use the three-sink method until the dishwasher was repaired. The infection control nurse mistakenly believed that the rinse cycle temperature sufficed for sanitization, while maintenance personnel confirmed ongoing efforts to repair the dishwasher, hindered by delays in receiving necessary supplies and technician support.
Failure to Inform Residents of Medication Changes and Re-evaluate Eye Care Needs
Penalty
Summary
The facility failed to inform a resident about changes in their medication regimen, specifically regarding the medication Metformin, which is used to regulate blood sugar levels. Resident 14, who was admitted with a diagnosis of diabetes, expressed concern about not being informed of the medication change and refused to take the medication until notified. The resident was cognitively intact, as indicated by a BIMS score of 15, and had a care plan goal to direct their care and remain independent. However, there were no interventions listed for this goal, and the Medication Administration Record showed that the resident declined the medication on several occasions without any documented reason. The Director of Nursing confirmed that there was no documentation of the resident being notified about the medication change, which is a requirement when resident orders are altered. Additionally, the facility did not re-evaluate or update the eye care needs of another resident, Resident 17, who had been admitted with dementia and depressive disorder. Despite having adequate vision with corrective lenses, the resident had not seen an eye doctor since admission in 2018. The resident's care plan noted that they declined a vision exam upon admission, but there was no documentation of any follow-up or re-evaluation of this decision. The Facility Administrator confirmed that the resident or their responsible party had not been asked about scheduling an eye exam since the initial admission, highlighting a lapse in ensuring ongoing assessment of the resident's vision care needs.
Inaccurate MDS Coding for Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to discrepancies in their assessments. Resident 4 was admitted with diagnoses including anxiety, major depression, and psychosis. Despite a Preadmission Screening and Resident Review (PASRR) indicating a serious mental illness, the MDS did not reflect this condition. Interviews with the Social Service Director and MDS Coordinator confirmed the oversight in coding the resident's serious mental illness on the MDS. Resident 14 was admitted with anxiety and major depressive disorder. The quarterly MDS inaccurately indicated that a Gradual Dose Reduction (GDR) for antipsychotic medications was not clinically contraindicated, despite documentation from the resident's primary provider stating otherwise. Similarly, Resident 17, diagnosed with dementia and depressive disorder, had an MDS that failed to reflect the contraindication for a GDR, as documented by the psychiatric provider. Interviews with the MDS Coordinator confirmed these coding errors for both residents.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were completed within the required time intervals for two residents, resulting in significant gaps between visits. Resident 7 did not have an in-person physician or advanced practice professional visit for a period of 126 days, from early December 2023 to early April 2024. Similarly, Resident 23 went without a required visit for 147 days, from late October 2023 to late March 2024. These lapses were identified through record reviews and confirmed by interviews with the Director of Nursing (DON) and the Facility Administrator (FA). The DON acknowledged that residents were not seen by a physician as mandated every 60 days, revealing a lack of awareness of this regulatory requirement. The FA confirmed the absence of a process to ensure compliance with the 60-day visit mandate, which contributed to the oversight. Both the DON and FA recognized the deficiency, with the FA indicating that a process would be implemented to address the issue, although no specific corrective actions were detailed in the report.
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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) |
|---|---|---|---|---|
| Westfield Quality Care Of Aurora | 0.4 mi | ★★★★★ | 1 | 0 |
| Legacy Square | 12.2 mi | ★★★★★ | 10 | 1 |
| Adept Nursing & Rehab Of Central City | 16.1 mi | ★★★★★ | 1 | 0 |
| Litzenberg Memorial County Hospital | 16.2 mi | ★★★★★ | 5 | 0 |
| Harvard Rest Haven | 17.7 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 July 2026) and official state health department websites.