Cycle 1
Health 2025-01-16 · Fire 2025-01-16
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lake Zurich, IL
Avantara Lake Zurich
5-star overall rating with 4-star inspections with $22,925 in total fines with 7 recent health deficiencies
900 South Rand Road, Lake Zurich, IL
(847) 726-1200
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
203
Certified beds
Average residents
144
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1994-09-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.06
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.46
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.01
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
2.65
CMS adjusted total nurse staffing hours
Case-mix index
1.81
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,446
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.18% · Performance 22.08% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.93
Baseline 5.91% · Performance 6.06% · Measure score 5.93 · Achievement 5.93 · Improvement 0
Total nurse turnover
5.96
Baseline 60.00% · Performance 39.32% · Measure score 5.96 · Achievement 5.96 · Improvement 5.38
Adjusted total nurse staffing
0
Baseline 2.60 hours · Performance 2.47 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.62% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 419 · Observed rate 10.02% · Lower 95% interval 7.79% |
| Discharge to community | 59.26% |
50.57%
8.7 pts better
|
Better than the National Rate · Eligible stays 372 · Observed rate 55.11% · Lower 95% interval 54.95% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 242 · Denominator 242 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 242 |
| Discharge self-care score | 60.1% |
53.69%
6.4 pts better
|
Numerator 119 · Denominator 198 |
| Discharge mobility score | 74.75% |
50.94%
23.8 pts better
|
Numerator 148 · Denominator 198 |
| Pressure ulcers or injuries, new or worsened | 1.24% |
2.29%
1.1 pts better
|
Numerator 3 · Denominator 242 · Adjusted rate 0.76% |
| Healthcare-associated infections requiring hospitalization | 6.06% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 212 · Observed rate 5.19% · Lower 95% interval 3.49% |
| Staff COVID-19 vaccination coverage | 3.88% |
8.2%
4.3 pts worse
|
Numerator 5 · Denominator 129 |
| Staff flu vaccination coverage | 64.06% |
42%
22.1 pts better
|
Numerator 82 · Denominator 128 |
| Discharge function score | 72.73% |
56.45%
16.3 pts better
|
Numerator 144 · Denominator 198 |
| Transfer of health information to provider | 93.18% |
95.95%
2.8 pts worse
|
Numerator 41 · Denominator 44 |
| Transfer of health information to patient | 97.28% |
96.28%
1 pts better
|
Numerator 143 · Denominator 147 |
| Resident COVID-19 vaccinations up to date | 46.92% |
25.2%
21.7 pts better
|
Numerator 61 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
2.0
0.9 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
2.3
1.8 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
89.6%
9.8 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 100.0% · Q3 99.1% · Q4 99.1% · 4Q avg 99.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.4% |
91.6%
1.2 pts worse
|
95.5%
5.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.3%
1.4 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.4% · Q3 7.3% · Q4 6.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 98.6% |
50.3%
48.3 pts worse
|
11.4%
87.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 98.2% · Q3 99.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.5%
3.2 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 2.1% · Q3 1.2% · Q4 4.2% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
18.5%
10.5 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 9.3% · Q3 6.9% · Q4 7.3% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.7% |
22.8%
2.1 pts better
|
16.7%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 22.7% · Q3 19.4% · Q4 22.5% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.8% |
17.2%
6.4 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 13.5% · Q3 10.1% · Q4 8.3% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.9% |
15.0%
6.1 pts better
|
14.9%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 13.2% · Q3 7.3% · Q4 6.7% · 4Q avg 8.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
1.1%
0.1 pts better
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 3.3% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
21.3%
9.6 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 34.7% · Q3 38.4% · Q4 24.3% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.2%
3.2 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.2% · Q3 1.3% · Q4 2.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
68.8%
27.4 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 95.8% · Q3 95.9% · Q4 98.0% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
14.0%
7 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 6.5% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
2.3%
1.5 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.5% · Q4 0.5% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
63.0%
27.9 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
26.2%
4.9 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 19.0% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-07 · Fire 2024-02-07
14 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-15 · Fire 2023-03-15
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-08-28
J · Immediate jeopardy
2025-05-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-01-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-22
E · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-16
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-16
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-22
D · Potential for more than minimal harm
2024-10-18
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-10-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-10-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-06-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-19
G · Actual harm
2024-03-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-06
E · Potential for more than minimal harm
2024-02-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-26
D · Potential for more than minimal harm
2024-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-10
D · Potential for more than minimal harm
2024-02-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-10
D · Potential for more than minimal harm
2024-02-07
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-02-10
D · Potential for more than minimal harm
2024-02-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-10
D · Potential for more than minimal harm
2024-02-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-10
D · Potential for more than minimal harm
2024-02-07
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-15
E · Potential for more than minimal harm
2023-03-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-15
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-03-22
D · Potential for more than minimal harm
2023-03-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-03-22
Penalties and ownership
What sits behind the stars
$22,925
2025-05-12
Fine
Fine · fine $22,925
Fine
Ownership
Ninio, Mordechay
5% Or Greater Direct Ownership Interest · Individual
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Garden, Daniel
5% Or Greater Direct Ownership Interest · Individual
Dulaca, Susan
W-2 Managing Employee · Individual
Tbdmd Il, LLC
Operational/Managerial Control · Organization
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