Cycle 1
Health 2025-06-27 · Fire 2025-06-27
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Elgin, IL
Avondale Estates Of Elgin
5-star overall rating with 5-star inspections with $15,958 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1754-1760 Capital Street, Elgin, IL
(847) 531-6004
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
62
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-01-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.67
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.06
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
5.74
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
2.68
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
5.40
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.42
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.35
CMS adjusted RN staffing hours
Adjusted total hours
4.64
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,410
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.00% · Performance 22.64% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.25
Baseline 5.63% · Performance 7.16% · Measure score 2.25 · Achievement 2.25 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.47
Baseline 3.33 hours · Performance 3.50 hours · Measure score 1.47 · Achievement 1.47 · Improvement 0.19
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 738 · Observed rate 10.03% · Lower 95% interval 8.62% |
| Discharge to community | 68.1% |
50.57%
17.5 pts better
|
Better than the National Rate · Eligible stays 722 · Observed rate 64.13% · Lower 95% interval 64.95% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.55% |
95.27%
4.3 pts better
|
Numerator 442 · Denominator 444 |
| Falls with major injury | 0.45% |
0.77%
0.3 pts better
|
Numerator 2 · Denominator 444 |
| Discharge self-care score | 28% |
53.69%
25.7 pts worse
|
Numerator 91 · Denominator 325 |
| Discharge mobility score | 26.15% |
50.94%
24.8 pts worse
|
Numerator 85 · Denominator 325 |
| Pressure ulcers or injuries, new or worsened | 1.8% |
2.29%
0.5 pts better
|
Numerator 8 · Denominator 444 · Adjusted rate 1.9% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 418 · Observed rate 6.46% · Lower 95% interval 5.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 162 |
| Staff flu vaccination coverage | 73.62% |
42%
31.6 pts better
|
Numerator 120 · Denominator 163 |
| Discharge function score | 24% |
56.45%
32.5 pts worse
|
Numerator 78 · Denominator 325 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 158 · Denominator 158 |
| Transfer of health information to patient | 99.63% |
96.28%
3.3 pts better
|
Numerator 266 · Denominator 267 |
| Resident COVID-19 vaccinations up to date | 15.73% |
25.2%
9.5 pts worse
|
Numerator 39 · Denominator 248 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
89.6%
8.2 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 97.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 69.8% |
50.3%
19.5 pts worse
|
11.4%
58.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 69.8% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.5%
1.4 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
18.5%
1.5 pts worse
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.7% |
22.8%
19.1 pts better
|
16.7%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.0%
2.2 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.3% |
1.7%
0.6 pts worse
|
1.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.0% |
21.3%
10.7 pts worse
|
19.8%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.0% |
| Percentage of long-stay residents with pressure ulcers | 10.4% |
5.2%
5.2 pts worse
|
5.1%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
68.8%
29.5 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 98.3% · Q3 98.5% · Q4 98.4% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.9% |
14.0%
2.1 pts better
|
12.0%
0.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 11.4% · Expected 10.7% · 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 2.0% · Q2 0.9% · Q3 0.3% · Q4 1.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.7% |
63.0%
27.7 pts better
|
79.7%
11 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
26.2%
1.4 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 27.1% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-07-03 · Fire 2023-07-03
4 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-27
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 2025-07-14
E · Potential for more than minimal harm
2025-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-14
E · Potential for more than minimal harm
2025-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-14
E · Potential for more than minimal harm
2024-05-23
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-05-28
E · Potential for more than minimal harm
2024-05-23
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 2024-05-28
E · Potential for more than minimal harm
2024-05-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-28
E · Potential for more than minimal harm
2024-05-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-28
E · Potential for more than minimal harm
2024-05-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-28
E · Potential for more than minimal harm
2023-07-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-07-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-07-03
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-07-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-27
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 2025-07-07
E · Potential for more than minimal harm
2025-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-07
E · Potential for more than minimal harm
2025-06-27
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-07
D · Potential for more than minimal harm
2025-06-27
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 2025-07-07
D · Potential for more than minimal harm
2025-06-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-07
D · Potential for more than minimal harm
2024-05-23
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 2024-05-24
D · Potential for more than minimal harm
2024-05-23
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-05-24
K · Immediate jeopardy
2023-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-17
F · Potential for more than minimal harm
2023-07-03
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 2023-07-17
E · Potential for more than minimal harm
2023-07-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-07-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-17
Penalties and ownership
What sits behind the stars
$15,958
2023-07-03
Fine
Fine · fine $15,958
Fine
Ownership
Beem March Trust U/A/D 4/09/19
5% Or Greater Direct Ownership Interest · Organization
Skz Holdings Inc
5% Or Greater Direct Ownership Interest · Organization
Baver, Barak
Corporate Officer · Individual
Bertachhi, Allison
W-2 Managing Employee · Individual
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#3
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