Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Avenue At Aurora during CMS and state inspections, most recent first.
Medication administration was not accurately documented for a resident with COPD, GERD, pain management needs, and multiple other diagnoses. During an observed med pass, an LPN gave 13 medication cups including PRN Tylenol, but the MAR later showed pantoprazole and two COPD inhalers as administered even though they were not observed being given. The MAR also lacked documentation for the PRN Tylenol dose and the reason for it, while the LPN confirmed the Tylenol was given but not charted and stated the inhalers were not administered because the resident typically refused them after a breathing treatment.
Two residents at risk for falls did not receive individualized and effective fall prevention interventions. One resident, with cognitive impairment and a history of falls, suffered multiple unwitnessed falls—including one resulting in fatal injuries—while care plans and documentation failed to address or update supervisory and safety needs. Another resident was found in a standard wheelchair instead of the prescribed tilt-in-space wheelchair, contrary to orders and care plan. Staff relied on generic interventions, and documentation of incidents and interventions was incomplete.
Two residents at risk for falls did not have required fall prevention interventions in place, including a perimeter mattress, reacher, and reminder signage. Staff were unaware of some interventions, and observations confirmed their absence, despite care plans and facility policy requiring these measures.
A CNA failed to follow infection control protocols during incontinence care for a resident with a history of UTIs and chronic conditions. The CNA did not perform hand hygiene between glove changes or before exiting the room, and placed washcloths in the bathroom sink instead of using a clean basin, contrary to facility policy. Staff interviews confirmed these actions did not meet infection prevention standards.
The facility failed to provide sufficient staff to meet residents' needs, leading to delayed call light responses and inadequate care. A resident with multiple medical conditions was found in a wet gown and incontinence brief after her call light was activated for over two hours. The call light system at the nurses' station was not functioning properly, and the facility was short-staffed, exacerbating the issue.
A resident with multiple medical conditions was left in a wet gown and incontinence brief for an extended period due to staff being too busy and a malfunctioning call light monitor. The facility failed to follow its policies on timely response to call lights and incontinence care.
A facility failed to ensure proper care and monitoring of a resident's surgical vac following surgery. The resident returned without documented discharge instructions or physician orders, and the surgical vac became disconnected without physician notification. The issue was discovered days later, and the wound vac was eventually discontinued.
The facility failed to ensure a comprehensive pain assessment for a resident upon admission and after discontinuation of a narcotic medication. The resident experienced significant pain and difficulty receiving pain medication, which was not consistently documented or provided. Interviews with staff confirmed the lack of proper pain assessments and documentation, leading to inadequate pain control and limited participation in therapy.
A resident with schizoaffective disorder and bipolar disorder did not receive a scheduled risperidone injection on time, resulting in a 12-day delay. Additionally, post-surgical Gabapentin was not administered until four days after it was ordered. The facility failed to document and communicate these medication errors appropriately.
Medication Administration Not Accurately Documented
Penalty
Summary
The facility failed to ensure medications were accurately documented as administered for one resident with diagnoses including sepsis, UTI, COPD, metabolic encephalopathy, GERD, atrial fibrillation, heart failure, and anxiety. The resident’s record showed orders for pantoprazole 40 mg via PEG tube each morning, scheduled inhalers for COPD, and acetaminophen 325 mg tablets as needed for pain. The resident’s care plan also addressed COPD, pain management, and GERD, with interventions requiring medications to be given as ordered and documented. During observation of the morning medication pass, an LPN prepared and administered 13 medicine cups containing multiple medications, including two acetaminophen tablets, but the observed medications did not include the ordered pantoprazole or the two inhalers. The MAR later showed checkmarks and initials indicating that pantoprazole, umeclidinium bromide, and fluticasone-salmeterol had been administered, even though they were not observed being given. The MAR also did not document the acetaminophen administration or the reason for giving it, and there was no documentation that the resident had expressed or exhibited pain. The resident stated she had received Tylenol with her morning medications and did not want the two inhalers because she had already received a breathing treatment earlier that morning. The LPN confirmed that the acetaminophen had been administered but not documented, stated the inhalers were not given because the resident typically refused them after a breathing treatment, and could not recall whether pantoprazole had actually been administered. The facility policy required medications to be documented directly after administration, PRN medications to include the date, time, and reason, and refusals to be documented as not given with an explanatory note.
Failure to Implement Individualized Fall Prevention and Supervision
Penalty
Summary
The facility failed to develop and implement a comprehensive, individualized, and effective fall prevention program for two residents identified as being at risk for falls. One resident, who was a new admission with a history of falls, cognitive impairment, and multiple comorbidities, experienced multiple unwitnessed falls, including one that resulted in a cervical fracture and intracranial hemorrhage, ultimately leading to death. Despite being assessed as high risk for falls, the resident's care plan and bedside Kardex lacked specific, individualized interventions to address his supervisory needs and did not reflect changes after each fall. The interventions in place, such as gripper socks and a low bed, were generic and not tailored to the resident's evolving condition or behaviors, such as confusion and restlessness. Documentation was inconsistent, and there was no evidence of interdisciplinary coordination or timely updates to the care plan following each incident. The facility's investigation and documentation of falls were incomplete. For several falls, there were missing or inadequate staff witness statements, lack of detailed incident reports, and insufficient information regarding the circumstances and interventions in place at the time of each fall. Staff interviews revealed a lack of clarity regarding individualized fall interventions, with some staff relying on standard protocols rather than resident-specific needs. Supervisory needs, particularly when the resident was in common areas, were not addressed in the care plan or consistently implemented, resulting in periods where the resident was left unsupervised despite being identified as needing increased supervision. A second resident, also at risk for falls and with cognitive impairment, was observed in a standard wheelchair rather than the prescribed tilt-in-space wheelchair, contrary to physician orders and the care plan. This deviation from the care plan was confirmed by staff and indicated a failure to ensure that planned fall safety interventions were in place. The facility's fall management policy required individualized assessment and intervention, but in practice, interventions were not consistently individualized or implemented as planned for residents at risk for falls.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions for two residents identified as being at risk for falls. For one resident with severe cognitive impairment, muscle weakness, and a history of falls, the care plan included a perimeter mattress and a reacher, but upon observation, neither was present in the resident's room after a room change. The CNA was unaware of the reacher, and the DON confirmed the absence of both the perimeter mattress and reacher. This resident had previously experienced an unwitnessed fall, and the fall investigation noted improper footwear at the time of the incident. For another resident with moderate cognitive impairment, limited mobility, and a history of falls, the care plan required a 'call before you fall' sign and ensuring the call light was within reach. After a fall during a self-transfer, the investigation recommended adding the sign to the resident's room. However, observation revealed that the sign was not present, and the CNA was unaware of any fall prevention interventions for this resident. The DON confirmed the absence of the required reminder sign. The facility's policy required identification of residents at risk for falls and the implementation of care plan interventions, which were not consistently in place for these residents.
Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
During an observation of incontinence care for Resident #32, a CNA failed to maintain proper infection control practices. The CNA did not perform hand hygiene before entering the resident's room, after changing gloves, or before exiting the room. Instead, the CNA repeatedly donned new gloves without washing or sanitizing hands between glove changes. Additionally, the CNA placed washcloths directly in the resident's bathroom sink, rather than using a clean basin as required by facility policy. These actions were witnessed during the care of a resident who was always incontinent of bladder and bowel and had a history of urinary tract infections, chronic kidney disease, and impaired mobility. Interviews with the CNA, another CNA, an RN, and the Director of Nursing confirmed that the correct procedure was not followed. All staff interviewed acknowledged that hand hygiene should be performed before and after glove use and before entering and after exiting the resident's room. Facility policy also requires the use of a clean basin for incontinence care and prohibits placing washcloths in the sink due to infection control concerns. The failure to adhere to these protocols was confirmed by both staff interviews and review of facility policies.
Insufficient Staffing and Call Light System Issues
Penalty
Summary
The facility failed to provide sufficient staff to meet the needs of all residents, affecting all 91 residents. Resident Council Minutes indicated that residents experienced long call light response times, although they could not specify exact times. Resident #57, who had multiple medical conditions including sepsis and acute respiratory failure, was observed with a call light activated for over two hours without response. The resident was found in a wet gown and incontinence brief, indicating a lack of timely incontinence care and assistance with activities of daily living (ADLs). The call light system at the nurses' station was not functioning properly, as it did not emit a sound to alert staff of activated call lights, further contributing to delayed responses. Staff interviews revealed that the volume on the call light monitor was not adjusted, and there was confusion about how to operate the system. Additionally, the facility was short-staffed, with only three STNAs assigned to the South nursing unit instead of the usual four. This staffing shortage made it difficult for staff to respond promptly to call lights and meet residents' needs. Multiple residents and staff confirmed that call light response times were often delayed, especially during busy periods or when the facility was short-handed.
Failure to Provide Timely Assistance with Dressing and Incontinence Care
Penalty
Summary
The facility failed to ensure timely assistance with dressing and incontinence care for a resident. Resident #57, who was admitted with diagnoses including sepsis, type two diabetes mellitus with ketoacidosis, cellulitis of the lower limb, and acute respiratory failure with hypoxia, was observed to have her call light on for an extended period without response. The resident's care plan required staff to check her every two hours for incontinence and assist with dressing, but these interventions were not followed. The resident was found in a wet hospital gown and incontinence brief, indicating a lack of timely care and assistance. On the day of the incident, the resident's call light was activated around 12:00 P.M. and remained on for at least two hours without being answered. The resident's family member confirmed the call light was on during her entire visit. When a State tested Nursing Assistant (STNA) finally responded, it was revealed that the call light monitor at the nurses' station was not making any sound to alert staff. The resident expressed that she had been waiting for assistance for at least 45 minutes and had been left in a wet gown and incontinence brief since the morning. Interviews with staff confirmed that the facility was short-handed and busy, which contributed to the delay in care. The STNA assigned to the resident admitted to being too busy to provide the necessary assistance and did not return to help the resident until much later in the day. The Licensed Practical Nurse (LPN) also confirmed that the call light monitor was not functioning properly, and she did not know how to adjust the volume. The facility's policies on responding to call lights and providing incontinence care were not followed, leading to the resident's prolonged discomfort and unmet needs.
Failure to Ensure Proper Care and Monitoring of Surgical Vac
Penalty
Summary
The facility failed to ensure a resident had physician orders and instructions for the care and monitoring of her wound incision management system. Resident #92, who had a left trimalleolar ankle fracture and underwent surgery, returned to the facility without documented discharge instructions or physician orders for her surgical vac. The medical record did not contain evidence of an assessment of the surgical site, cast, or surgical vac upon her return, nor were there instructions for the care and monitoring of the surgical vac from 03/12/24 through her discharge on 04/12/24. The progress notes revealed that the surgical vac became disconnected on 03/15/24, and the nurses were unable to achieve suction. There was no documentation that the physician was notified of this issue. Further progress notes from 03/15/24 through 03/23/24 did not indicate whether the surgical vac was functioning properly or draining appropriately. On 03/23/24, a family member discovered discharge instructions in a bag that came back with the resident, which had been misplaced. The surgeon was contacted, and the wound vac was eventually discontinued on 03/25/24. Interviews with the DON and RN #164 revealed that the resident returned from surgery without discharge instructions, and the chaotic shift change contributed to the lack of documentation. The DON confirmed that there were no physician orders or instructions for the surgical vac in the medical record and that daily assessments were not documented. The RN admitted to not remembering specifics about the resident's return and the wound vac's location or condition.
Failure to Ensure Comprehensive Pain Management
Penalty
Summary
The facility failed to ensure a comprehensive pain assessment for a resident upon admission and after the discontinuation of a narcotic medication. Resident #95, who was admitted with severe burns on the right lower leg and a history of malignant neoplasm, did not have a completed pain assessment upon admission. Additionally, after the discontinuation of oxycodone, there was no comprehensive pain reevaluation documented. The resident's medical record indicated that pain assessments were required every shift, but these were not consistently documented, and non-pharmacological interventions were not attempted or recorded as required by the physician's orders. The resident reported significant pain and difficulty in receiving pain medication, particularly oxycodone, which was not available for several days. The resident expressed that the transition from the hospital to the facility was challenging, and he had to repeatedly ask for pain medication, which was not automatically provided. The resident experienced severe pain that interfered with his ability to participate in physical therapy, and he reported that his pain was not adequately managed, leading to increased discomfort and inability to perform functional activities. Interviews with facility staff, including LPNs and the Director of Nursing, confirmed that the pain assessments were not completed as required and that there was a lack of documentation regarding the resident's pain levels and the administration of pain medication. The facility's policy on pain management was not followed, resulting in inadequate pain control for the resident. The Director of Rehab also noted that the resident's participation in therapy was limited due to unmanaged pain, further highlighting the deficiency in pain management practices at the facility.
Failure to Administer Prescribed Medications Timely
Penalty
Summary
The facility failed to ensure that Resident #92 was free from significant medication errors. Resident #92, who had a history of schizoaffective disorder and bipolar disorder, was admitted to the facility with a planned risperidone injection scheduled for 03/15/24. Despite this, the risperidone injection was not ordered until 03/14/24, and there was no documentation explaining the delay. Furthermore, the injection was not administered on 03/15/24 as ordered, and there was no evidence that the physician was notified of this failure. The resident did not receive the risperidone injection until 03/27/24, 12 days after it was due, and only after the family member intervened by obtaining the medication from the pharmacy and bringing it to the facility. Additionally, Resident #92 underwent surgery on 03/12/24 and was prescribed Gabapentin to manage post-surgical pain. However, the facility did not administer the Gabapentin until 03/16/24, four days after it was ordered. The delay was attributed to the discharge instructions being misplaced and not immediately brought to the attention of the facility staff. The family member discovered the discharge instructions in a bag that came back with the resident and informed the facility, leading to the eventual administration of the medication. Interviews with facility staff, including the DON and UM, revealed that the risperidone injection was not obtained initially due to its high cost, and there was a lack of follow-up to ensure the resident received the necessary medication. The facility's failure to administer the prescribed medications in a timely manner and to document and communicate these issues appropriately resulted in significant medication errors for Resident #92.
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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) |
|---|---|---|---|---|
| Aurora Manor Special Care Cent | 0.9 mi | ★★★★★ | 14 | 1 |
| Kensington At Anna Maria | 2.7 mi | ★★★★★ | 9 | 0 |
| Anna Maria Of Aurora | 2.8 mi | ★★★★★ | 12 | 0 |
| Twinsburg Post Acute | 4.9 mi | ★★★★★ | 19 | 0 |
| Arbors At Streetsboro | 5 mi | ★★★★★ | 17 | 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.