Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anna Maria Of Aurora during CMS and state inspections, most recent first.
Kitchen sanitation and food storage deficiencies were identified when surveyors found expired and unlabeled food items in the walk-in and unit refrigerators, a missing freezer thermometer, scoops stored in flour and sugar bins, and heavily soiled kitchen equipment including the stove, oven, and utensil drawers. The sanitizer log and dish machine temp log were incomplete, and the DM confirmed staff were not keeping leftovers or leaving scoops in bins, but there was no posted cleaning task schedule or sign-off sheet for daily cleaning tasks.
Improper Dumpster and Refuse Area Maintenance: During a kitchen tour, the dumpster lid was observed open, the dumpster was overflowing, and four bags of garbage were on the ground around it. The DM confirmed the dumpster was supposed to be emptied daily, was not covered, and garbage bags should not have been left on the ground. The facility policy stated trash must be removed frequently but did not specify a set frequency.
Unidentified pills and pill residue were found in the North and South med carts during observation. An LPN verified 18 loose pills and powdered residue in the North cart drawers, and another LPN verified two loose pills in the South cart drawer. The facility policy stated med storage areas are to be kept clean, well lit, and free of clutter.
Failure to place hearing aids as ordered: A resident with HOH, a BIMS score of 12, and bilateral hearing aids had an order and care plan directing staff to place the aids in her ears daily, but staff kept them in the med cart and did not assist her as requested. During observation, the resident was yelling, unable to hear others, and later was seen trying to insert a hearing aid herself while stating no one helps her put them in; an LPN acknowledged the aids had not been placed and that she had not asked the resident if she wanted them in.
Inaccurate oxygen administration and tubing documentation were found for two residents. One resident with COPD, CHF, SOB, and anemia had orders for oxygen every shift and weekly tubing changes, but staff documented oxygen as given even though observations and nursing notes showed the oxygen was off, the concentrator was not in use, and the resident was not wearing the nasal cannula. Another resident with Alzheimer’s disease and dysphagia had an order for oxygen PRN for comfort and weekly tubing changes, but the oxygen was not in use and the tubing in the room did not match the charted change dates; the DON verified the documentation was not accurate.
Inaccurate Documentation of Wound Treatments and Oxygen Tubing Changes: The facility had inaccurate medical record documentation for three residents. One resident with wounds had multiple blank TAR entries for ordered wound treatments, and two staff later stated they performed treatments but did not chart them. Two other residents had oxygen tubing change orders, but the TAR was signed off as completed even though observation found tubing dated earlier than the documented changes, and the DON verified the records were not accurate.
A resident with COVID-19 was on droplet precautions, but an x-ray technician entered the room and provided services while wearing only a surgical mask instead of the N95 required by the DON for anyone entering the room. The technician said she did not know the mask requirements, and the room signage listed droplet/contact precautions with an N95 only for aerosolizing procedures. The facility’s x-ray service agreement did not include infection control practices, and the infection control designee confirmed the signage should have required an N95 for all services in the room.
A resident at high risk for falls experienced multiple falls resulting in injuries due to inadequate supervision and ineffective fall prevention measures. Despite having a care plan with interventions like personal alarms and medication, the resident was left unattended, leading to falls in the rehab gym and dining area. The facility's failure to implement a comprehensive fall prevention program and timely assess the resident post-fall contributed to the harm.
A resident's debit card was misappropriated in a facility, leading to unauthorized transactions. The resident's wallet was found in a staff restroom, and camera footage showed an STNA entering the resident's room around the time of the transactions. Despite the evidence, the STNA denied involvement, and the police were involved in the ongoing investigation.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner and failed to maintain the unit refrigerators as required. During an initial kitchen tour with the Dietary Manager, surveyors found multiple expired or outdated food items in the walk-in refrigerator, including leftover egg salad, cranberry sauce, pumpkin puree, and sliced turkey lunchmeat with use-by dates ranging from 11/10/25 to 12/12/25. A thermometer was not present in the walk-in freezer, and scoops were stored inside both the flour and sugar bins, submerged in the products. Surveyors also observed extensive cleanliness issues in the kitchen. The six-burner gas stove was heavily soiled around the burner grates, griddle, front, side, and surrounding perimeter, and the convection oven was heavily soiled on the bottom inside area. The utensil drawers contained crumbs and a dried white spill of unknown origin. The three-compartment sink sanitizer log and the dish machine temperature log were incomplete for multiple dates in November and December, and the Dietary Manager confirmed the logs were not completed as required. The Dietary Manager also confirmed staff were not supposed to keep leftovers or leave scoops in the bins, and stated there was no posted cleaning task schedule or sign-off sheet for daily cleaning tasks. On a separate observation of the unit refrigerators, surveyors found sticky shelves and multiple unlabeled or undated food items, including French onion dip, chive and onion dip, partially eaten turtle cheesecake, beef pot roast, and leftover soup. The Administrator in Training confirmed these findings and also confirmed the refrigerator sign stated the units would be cleaned weekly on Fridays, which did not match the facility policy stating the refrigerators were to be cleaned every three days. Review of facility policies and cleaning checklists showed expectations for cleaning, sanitizing, and labeling food, but the observed conditions and incomplete logs showed these requirements were not being followed.
Improper Dumpster and Refuse Area Maintenance
Penalty
Summary
The facility failed to ensure the dumpster and refuse area were maintained in a clean and sanitary condition. During an initial kitchen tour with the Dietary Manager, the dumpster lid was observed open, the dumpster was overflowing, and four bags of garbage were lying on the ground around the dumpster. The Dietary Manager confirmed that the dumpster was supposed to be emptied daily, that it was not covered, and that garbage bags should not have been left on the ground. Review of the facility’s undated Sanitation Policy under waste disposal and pest control stated that trash must be removed frequently, but it did not specify how often trash was to be taken out or how often the dumpster would be emptied.
Unidentified Pills and Residue Found in Medication Carts
Penalty
Summary
The facility failed to maintain clean medication storage in the North and South medication carts. During observation of the North medication cart with LPN #720, surveyors found 18 unidentified pills on the bottom of the first and second drawers, along with powdered pill residue along the bottom and corners of those drawers. LPN #720 verified the loose medications and residue during interview. During observation of the South medication cart with LPN #501, surveyors found two unidentified pills on the bottom of the second drawer, and LPN #501 verified the loose pills during interview. Review of the facility’s medication storage policy stated that medication storage areas are to be kept clean, well lit, and free of clutter.
Failure to Place Hearing Aids as Ordered
Penalty
Summary
The facility failed to ensure assistive hearing devices were in place to maintain hearing abilities for Resident #20, who had diagnoses including paroxysmal atrial fibrillation, gastro-esophageal reflux disease without esophagitis, and chronic kidney disease. The medical record showed an order to place the resident’s bilateral hearing aids in her ears and lock them in the medication cart as needed per request, and the care plan identified potential impaired communication related to hard of hearing with interventions to assist with hearing aids and place them in every morning and remove them every night. The MDS showed a BIMS score of 12 and that the resident required assistance with ADLs. A progress note documented that new hearing aids with new ear molds arrived to the facility. During observation and interview, the resident was seated in her wheelchair with family visiting and was yelling when asked questions, had trouble understanding others, and stated she could not hear what was being said. Family stated the resident had trouble hearing, had new hearing aids that were to be placed in her ears daily, and that staff were aware of the request but did not put them in as requested. An LPN stated the resident was hard of hearing, that the hearing aids were kept in the medication cart, and that the resident’s new hearing aids had arrived about three weeks earlier; the LPN also stated the hearing aids had been removed because the resident brushed her hair behind her ears and caused them to fall out, and acknowledged she did not ask the resident if she wanted them placed in her ears. Later, the resident was observed trying to place a hearing aid into her left ear and stated no one helps me put them in and that she could not hear anyone talk. The LPN then stated she was unaware the resident was upset and attempting to put her hearing aids in, and confirmed the findings.
Inaccurate oxygen administration and tubing documentation
Penalty
Summary
The facility failed to ensure proper delivery of oxygen and accurate documentation of oxygen administration for two residents. Resident #01 had diagnoses including chronic diastolic congestive heart failure, COPD, shortness of breath, and anemia. His care plan included oxygen at 2 liters per nasal cannula for shortness of breath and comfort, and later noted an oxygen weaning program. Physician orders included oxygen every shift and weekly oxygen tubing changes. However, the MAR showed oxygen signed off as administered each shift even though nursing notes and observations documented that he was not wearing oxygen, the concentrator was not in use, and the oxygen tank was shut off. The DON verified the documentation was not accurate and confirmed the resident was not wearing his oxygen as ordered. Resident #01’s record also showed inconsistent documentation related to oxygen weaning and respiratory status. A telephone order was entered for oxygen at 2 liters per nasal cannula for comfort and shortness of breath, followed by orders to check pulse oximetry and wean oxygen as tolerated. Nursing notes documented that he remained off oxygen with pulse oximetry readings of 97 percent on room air, and the NP noted his oxygen saturation had been stable on room air. Despite this, the quarterly MDS did not document oxygen therapy delivered, while the MAR continued to show oxygen administration as completed. The DON confirmed the oxygen order was not changed to as-needed even though the resident was not wearing oxygen and the charting did not match the observed condition. Resident #17 had diagnoses including Alzheimer’s disease, anemia, and dysphagia, and no respiratory diagnosis was listed. Her care plan addressed altered respiratory status related to shortness of breath with exertion and included oxygen at 2 liters as needed for comfort and changing oxygen tubing as ordered. The physician order required weekly tubing changes, and the TAR was initialed as completed by an LPN on two dates. However, observation showed the oxygen concentrator sitting next to the bed and not in use, and the tubing in the room was dated to an earlier date than the documented changes. The DON verified the tubing documentation was not accurate in the medical record.
Inaccurate Documentation of Wound Treatments and Oxygen Tubing Changes
Penalty
Summary
The facility failed to ensure medical records contained accurate documentation for three residents. For one resident with paranoid schizophrenia, anxiety disorder, and left ankle and heel wounds, the record showed wound treatment orders for the left medial ankle and left heel, but the Treatment Administration Record (TAR) had multiple blank entries on several dates for both treatments. The resident stated he believed his treatments were completed as ordered, while an MDS/LPN verified the blank TAR entries indicated the treatments were not documented as completed. Two staff members later provided witness statements stating they performed the treatments on separate dates but did not chart them. For another resident with chronic diastolic CHF, COPD, shortness of breath, and anemia, the physician ordered oxygen at 2 liters via nasal cannula and weekly oxygen tubing changes. The December 2025 TAR showed the tubing change was initialed as completed by an LPN on two dates. However, during observation the oxygen concentrator tubing in the resident’s room was dated 11/26/25, and the DON verified the tubing date did not match the TAR documentation. The DON stated the documentation was not accurate in the resident’s medical record. For a third resident with Alzheimer’s disease, anemia, and dysphagia, the record showed an order for oxygen at 2 liters as needed for comfort and a weekly tubing change order. The December 2025 TAR again showed tubing changes initialed as completed by the same LPN on two dates, but observation found the tubing in the room dated 11/26/25. The DON verified the tubing date and the TAR entries did not match and stated the documentation was not accurate. Facility policy reviewed by surveyors addressed oxygen administration, clean dressing changes, and charting, but did not include documentation requirements for oxygen tubing changes or ensuring treatments were documented as completed in the TAR.
Failure to Follow Droplet Precautions for Resident with COVID-19
Penalty
Summary
The facility failed to ensure droplet infection control precautions were followed for a resident with COVID-19. The resident was admitted with diagnoses including chronic respiratory failure and hypoxia, COVID-19, chronic congestive heart failure, and obstructive sleep apnea. The medical record showed a nursing note documenting a positive COVID-19 test and droplet precautions, along with a physician order for droplet precaution isolation due to COVID-19 and a care plan identifying the resident as at risk for complications related to COVID-19 and on droplet precautions. During observation, an x-ray technician entered the resident’s room and provided x-ray services while wearing a gown, gloves, face shield, and surgical mask. The technician stated she did not know the rules regarding what type of mask to use and did not ask staff before entering the room, and she confirmed she had worn only a surgical mask while within six feet of the resident. The room door had signage for special droplet/contact precautions that listed a face mask, eye protection, gown, and gloves, with an N95 required only for aerosolizing procedures. The DON and the infection control designee confirmed that staff and vendors entering the room should have worn an N95 mask, and the facility’s x-ray service agreement did not include infection control practices or following facility infection control policies.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to provide adequate supervision and implement an effective fall prevention program for a resident identified as high risk for falls. The resident, who had a history of multiple falls and cognitive impairments, experienced several falls during their stay, resulting in injuries. On one occasion, the resident fell in the rehab gym when a Physical Therapy Assistant left them unattended to retrieve equipment. Despite having a personal alarm, the resident stood up and fell, leading to rib fractures that were not immediately identified. The resident's care plan included various interventions to mitigate fall risks, such as administering pain medication, keeping the call light within reach, and using personal alarms. However, these measures were insufficient as the resident continued to fall. The resident's wife discovered bruising days after one fall, prompting an x-ray that revealed multiple rib fractures. The facility's response to the falls was inadequate, as evidenced by the lack of timely assessment and intervention following the incidents. Interviews with staff and the resident's wife highlighted the resident's non-compliance and cognitive challenges, which contributed to the falls. Staff acknowledged the need for constant supervision, yet the resident was left unattended on multiple occasions. The facility's policy on fall prevention was not effectively implemented, as the interdisciplinary team failed to identify and apply appropriate interventions to prevent further falls and injuries.
Misappropriation of Resident's Debit Card
Penalty
Summary
The facility failed to protect a resident from the wrongful use of her belongings, specifically her debit card, which was misappropriated. The incident involved a resident with intact cognition who required assistance for transfers and used a walker for ambulation. Her wallet was found by a housekeeper in a staff restroom, and upon its return, the resident discovered her debit card was missing. The resident, with the help of the Director of Nursing (DON), identified unauthorized transactions made with her card, leading to the closure of her bank account. The facility's investigation included reviewing camera footage, which showed a State tested Nurse Aide (STNA) entering and leaving the resident's room and the facility around the time of the unauthorized transactions. Despite the circumstantial evidence, the STNA denied any knowledge of the resident's wallet or its disappearance. The facility involved the police, and an investigation was ongoing at the time of the report. The facility's policy on abuse, neglect, and misappropriation was reviewed, which stated that the facility would not tolerate such actions and would investigate all allegations. The resident expressed distress over the incident, noting that she had to cancel her card immediately and that the situation was unsettling for her and her family. Despite the investigation, the facility could not conclusively determine the perpetrator of the theft.
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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) |
|---|---|---|---|---|
| Kensington At Anna Maria | 0.1 mi | ★★★★★ | 9 | 0 |
| Aurora Manor Special Care Cent | 2.2 mi | ★★★★★ | 14 | 1 |
| Avenue At Aurora | 2.8 mi | ★★★★★ | 7 | 0 |
| Canterbury Of Twinsburg | 3.5 mi | ★★★★★ | 0 | 0 |
| Twinsburg Post Acute | 4.7 mi | ★★★★★ | 19 | 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.