C-
57/100AVENORA ELMHURST Inspection Report, Violations & Safety Grade (ELMHURST, Illinois)
200 EAST LAKE STREET, ELMHURST, Illinois 60126
Phone: 6305165000
CMS Overall:2/5
Overview & Bed Count
Certified Beds
108
Avg Residents/Day
40.5
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Du Page
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health2/5
Staffing3/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Illinois Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 1.07 | 0.71 | +0.35 |
| Total Nurse Hours per Resident per Day | 3.74 | 3.47 | +0.27 |
| CMS Staffing Rating | 3/5 | 2.2/5 | - |
| Nursing Staff Turnover | 43.8% | 43.7% | - |
Health Citation History
39 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-05-09 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2026-01-08 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2026-01-08 | Administration Deficiencies | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | F – Moderate Harm Potential |
| 2026-01-08 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2026-01-08 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2026-01-08 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2026-01-08 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2026-01-08 | Quality of Life and Care Deficiencies | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | D – Moderate Harm Potential |
| 2026-01-08 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2025-05-09 | Resident Rights Deficiencies | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | E – Moderate Harm Potential |
| 2025-02-26 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-10-10 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2024-10-10 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | G – Actual Harm |
| 2024-10-10 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-10-10 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2024-10-10 | Environmental Deficiencies | Keep all essential equipment working safely. | F – Moderate Harm Potential |
| 2024-10-10 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | E – Moderate Harm Potential |
| 2024-10-10 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2024-10-10 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D – Moderate Harm Potential |
| 2024-10-10 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2024-10-10 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-10-10 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D – Moderate Harm Potential |
| 2024-10-10 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2024-09-18 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2024-09-18 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-08-30 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2024-08-30 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-08-30 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2024-07-15 | Resident Rights Deficiencies | Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | D – Moderate Harm Potential |
| 2024-06-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J – Immediate Jeopardy |
| 2024-06-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | E – Moderate Harm Potential |
| 2023-11-29 | Nursing and Physician Services Deficiencies | Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | F – Moderate Harm Potential |
| 2023-11-29 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2023-11-29 | Infection Control Deficiencies | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | F – Moderate Harm Potential |
| 2023-11-29 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2023-11-29 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2023-11-29 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2023-11-29 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D – Moderate Harm Potential |
| 2023-11-29 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
Fire Safety Citation History
32 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-08 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2026-01-08 | Emergency Preparedness Deficiencies | Establish procedures for tracking staff and patients during an emergency. | F – Moderate Harm Potential |
| 2026-01-08 | Emergency Preparedness Deficiencies | Create arrangements with other facilities to receive patients. | F – Moderate Harm Potential |
| 2026-01-08 | Emergency Preparedness Deficiencies | Provide primary/alternate means for communication. | F – Moderate Harm Potential |
| 2026-01-08 | Emergency Preparedness Deficiencies | Provide family notifications of emergency plan. | F – Moderate Harm Potential |
| 2026-01-08 | Emergency Preparedness Deficiencies | Establish staff and initial training requirements. | F – Moderate Harm Potential |
| 2026-01-08 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2026-01-08 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-01-08 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2026-01-08 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2026-01-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2026-01-08 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | E – Moderate Harm Potential |
| 2026-01-08 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2026-01-08 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2026-01-08 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2026-01-08 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | E – Moderate Harm Potential |
| 2024-10-10 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2024-10-10 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2024-10-10 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2024-10-10 | Smoke Deficiencies | Install an approved automatic sprinkler system. | E – Moderate Harm Potential |
| 2023-11-29 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | F – Moderate Harm Potential |
| 2023-11-29 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | F – Moderate Harm Potential |
| 2023-11-29 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2023-11-29 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2023-11-29 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2023-11-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2023-11-29 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | E – Moderate Harm Potential |
| 2023-11-29 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2023-11-29 | Smoke Deficiencies | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | E – Moderate Harm Potential |
| 2023-11-29 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E – Moderate Harm Potential |
| 2023-11-29 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2023-11-29 | Services Deficiencies | Install properly constructed and protected linen or trash chutes. | E – Moderate Harm Potential |
Total Penalties & Fines
$195,380
Total Fine Amount (CMS)
4
Number of Fines
7
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-05-09 | Fine | $23,870 | - |
| 2026-01-08 | Fine | $38,376 | - |
| 2026-01-08 | Payment Denial | - | 7 days starting 2026-01-30 |
| 2024-07-15 | Fine | $68,842 | - |
| 2024-07-15 | Payment Denial | - | 98 days starting 2024-09-20 |
| 2024-06-05 | Fine | $64,292 | - |
| 2023-11-29 | Payment Denial | - | 76 days starting 2024-01-24 |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the ELMHURST area at no cost.
Find Safe, Vetted Facilities Near ELMHURST
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.