Elgin, IL

Avantara Of Elgin

3-star overall rating with 3-star inspections with $162,560 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1950 Larkin Avenue, Elgin, IL

(847) 742-7070

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

112

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Healthcare

Operator or chain grouping

Approved since

1991-07-30

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

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

1.28

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.32

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

1.99

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

3.59

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.60

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

3.39

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

1.23

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

1.03

CMS adjusted RN staffing hours

Adjusted total hours

2.89

CMS adjusted total nurse staffing hours

Case-mix index

1.70

Higher values indicate more complex resident acuity

RN turnover

30%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,524

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

16.46

Composite VBP score used to determine payment impact.

Payment multiplier

0.9816

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.22

Baseline 19.67% · Performance 20.87% · Measure score 1.22 · Achievement 1.22 · Improvement 0

Healthcare-associated infections

1.52

Baseline 4.28% · Performance 7.38% · Measure score 1.52 · Achievement 1.52 · Improvement 0

Total nurse turnover

3.23

Baseline 63.16% · Performance 50.48% · Measure score 3.23 · Achievement 3.23 · Improvement 2.81

Adjusted total nurse staffing

0.61

Baseline 2.53 hours · Performance 2.89 hours · Measure score 0.61 · Achievement 0 · Improvement 0.61

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	8.21%	10.72% 2.5 pts better	No Different than the National Rate · Eligible stays 142 · Observed rate 4.23% · Lower 95% interval 5.7%
Discharge to community	60.26%	50.57% 9.7 pts better	Better than the National Rate · Eligible stays 134 · Observed rate 53.73% · Lower 95% interval 52.22%
Medicare spending per beneficiary	1	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 77 · Denominator 77
Falls with major injury	1.3%	0.77% 0.5 pts worse	Numerator 1 · Denominator 77
Discharge self-care score	34.48%	53.69% 19.2 pts worse	Numerator 20 · Denominator 58
Discharge mobility score	31.03%	50.94% 19.9 pts worse	Numerator 18 · Denominator 58
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 77 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.38%	7.12% 0.3 pts worse	No Different than the National Rate · Eligible stays 63 · Observed rate 9.52% · Lower 95% interval 4.33%
Staff COVID-19 vaccination coverage	5.26%	8.2% 2.9 pts worse	Numerator 5 · Denominator 95
Staff flu vaccination coverage	68.46%	42% 26.5 pts better	Numerator 89 · Denominator 130
Discharge function score	37.93%	56.45% 18.5 pts worse	Numerator 22 · Denominator 58
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 37 · Denominator 37
Resident COVID-19 vaccinations up to date	23.81%	25.2% 1.4 pts worse	Numerator 10 · Denominator 42

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	89.3%	89.6% 0.3 pts worse	93.4% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 86.6% · Q2 86.9% · Q3 90.6% · Q4 93.0% · 4Q avg 89.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	82.6%	91.6% 9 pts worse	95.5% 12.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 82.6%
Percentage of long-stay residents experiencing one or more falls with major injury	2.4%	3.3% 0.9 pts better	3.3% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.2% · Q3 3.5% · Q4 2.3% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	95.1%	50.3% 44.8 pts worse	11.4% 83.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 95.9% · Q3 93.8% · Q4 97.5% · 4Q avg 95.1%
Percentage of long-stay residents who lose too much weight	5.3%	6.5% 1.2 pts better	5.4% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.8% · Q3 1.5% · Q4 5.8% · 4Q avg 5.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.7%	18.5% 1.8 pts better	19.6% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 19.2% · Q3 14.5% · Q4 16.9% · 4Q avg 16.7%
Percentage of long-stay residents who received an antipsychotic medication	13.1%	22.8% 9.7 pts better	16.7% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 17.0% · Q3 13.2% · Q4 13.2% · 4Q avg 13.1% · 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	13.8%	17.2% 3.4 pts better	16.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 5.8% · Q3 18.9% · Q4 8.1% · 4Q avg 13.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.6%	15.0% 9.4 pts better	14.9% 9.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 4.2% · Q3 2.9% · Q4 4.2% · 4Q avg 5.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	1.1% 0.5 pts better	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.2%	1.7% 0.5 pts better	1.7% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.0%	21.3% 3.7 pts worse	19.8% 5.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 12.5% · Q3 22.7% · Q4 33.5% · 4Q avg 25.0%
Percentage of long-stay residents with pressure ulcers	1.9%	5.2% 3.3 pts better	5.1% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.1% · Q4 3.0% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	34.0%	68.8% 34.8 pts worse	81.7% 47.7 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 35.9% · Q3 46.2% · Q4 36.8% · 4Q avg 34.0%
Percentage of short-stay residents who had an outpatient emergency department visit	15.3%	14.0% 1.3 pts worse	12.0% 3.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 16.7% · Expected 12.2% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.1%	2.3% 1.2 pts better	1.6% 0.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.4% · Q3 1.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	18.5%	63.0% 44.5 pts worse	79.7% 61.2 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 18.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	32.1%	26.2% 5.9 pts worse	23.9% 8.2 pts worse	Short Stay · 20240701-20250630 · Adjusted 32.1% · Observed 34.5% · Expected 25.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-04 · Fire 2024-07-11

9 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-07-11 · Fire 2023-08-16

8 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-08-16 · Fire 2022-08-05

21 health deficiencies

Top issue: Quality of Life and Care (8 deficiencies)

10 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-07-11

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-08-08

E · Potential for more than minimal harm 2024-07-11

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-22

E · Potential for more than minimal harm 2024-07-11

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-07-22

E · Potential for more than minimal harm 2023-08-16

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-08-29

E · Potential for more than minimal harm 2023-08-16

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-10-16

F · Potential for more than minimal harm 2022-08-05

E15 · Emergency Preparedness Deficiencies

Fire Safety

Address subsistence needs for staff and patients.

Corrected 2022-09-02

F · Potential for more than minimal harm 2022-08-05

E22 · Emergency Preparedness Deficiencies

Fire Safety

Establish policies and procedures for sheltering.

Corrected 2022-09-02

F · Potential for more than minimal harm 2022-08-05

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2022-09-02

F · Potential for more than minimal harm 2022-08-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-10

F · Potential for more than minimal harm 2022-08-05

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2022-09-02

E · Potential for more than minimal harm 2022-08-05

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2022-09-02

E · Potential for more than minimal harm 2022-08-05

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2022-09-02

E · Potential for more than minimal harm 2022-08-05

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-09-02

E · Potential for more than minimal harm 2022-08-05

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2022-09-02

C · Minimal harm 2022-08-05

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2022-09-02

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-09-04

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-09-05

E · Potential for more than minimal harm 2025-09-04

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 2025-09-05

E · Potential for more than minimal harm 2025-09-04

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 2025-09-05

E · Potential for more than minimal harm 2025-09-04

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2025-09-05

D · Potential for more than minimal harm 2025-09-04

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 2025-09-05

D · Potential for more than minimal harm 2025-09-04

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-09-05

D · Potential for more than minimal harm 2025-09-04

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-09-05

D · Potential for more than minimal harm 2025-09-04

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 2025-09-05

D · Potential for more than minimal harm 2025-09-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-09-05

D · Potential for more than minimal harm 2024-11-21

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-11-27

D · Potential for more than minimal harm 2024-11-21

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-11-27

G · Actual harm 2024-07-11

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 2024-07-19

E · Potential for more than minimal harm 2024-07-11

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-07-19

E · Potential for more than minimal harm 2024-07-11

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-07-19

E · Potential for more than minimal harm 2024-07-11

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-07-19

D · Potential for more than minimal harm 2024-07-11

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-07-19

D · Potential for more than minimal harm 2024-07-11

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 2024-07-19

D · Potential for more than minimal harm 2023-12-16

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-12-18

J · Immediate jeopardy 2023-11-30

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 2023-12-01

G · Actual harm 2023-11-30

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-12-01

D · Potential for more than minimal harm 2023-11-30

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-12-01

D · Potential for more than minimal harm 2023-11-22

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2023-11-23

E · Potential for more than minimal harm 2023-08-16

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 2023-08-17