Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Avantara Lake Zurich during CMS and state inspections, most recent first.
A resident with a pelvic fracture, who was alert and oriented, was unable to locate her call light when she needed to use the bedpan. After waiting for assistance and not being checked on by staff, she urinated in her brief and remained soiled, leading her to call 911 for help. Staff later found her wet and upset, with the call light tied to the bed rail and not visible to her.
A resident with severe cognitive impairment and multiple medical conditions exited the facility through an unsecured front entrance during the night, undetected by staff due to a non-functioning door alarm. The resident was found across a major highway, confused, hypothermic, and injured, and was subsequently hospitalized with an acute subdural hematoma, hypothermia, and injuries from an unwitnessed fall.
A cook at the facility was observed handling food with contaminated gloves, failing to follow proper handwashing and glove application procedures. Despite having a designated handwashing station, the cook washed hands in a food prep sink and applied gloves with wet hands, leading to potential cross-contamination. The Food Service Director acknowledged these improper practices, which violate the facility's hygiene standards.
The facility failed to maintain proper infection control measures, including inadequate isolation precautions for residents with influenza and improper use of PPE by staff. Residents with feeding tubes and catheters were not managed with enhanced barrier precautions, and staff did not consistently follow hand hygiene protocols, leading to potential cross-contamination.
A facility failed to provide least restrictive interventions before using a physical restraint on a resident with a history of falls and cognitive deficits. The resident was observed with a lap belt restraint during supervised activities, which was not released as required. Staff interviews revealed the restraint was used due to the resident's fall risk and agitation, but the facility did not consistently follow its policy to release the restraint during supervised activities.
A resident with congestive heart failure was not weighed daily as ordered, with only two weights documented in January. The facility's policy requires daily weight monitoring for such residents, but staff interviews confirmed this was not done, despite the resident's condition necessitating close monitoring.
A resident with a suprapubic catheter experienced issues with catheter drainage and pain due to the absence of a required dressing, leading to skin redness and discomfort. The facility failed to follow physician orders for catheter site care, and the facility's policy lacked specific instructions for suprapubic catheter care.
Two residents with indwelling catheters in a facility experienced inadequate catheter care, leading to hospitalizations for urinary tract infections. The facility failed to document catheter care, monitor urine output, and prevent cross-contamination. Catheter bags were mixed up between residents, and catheter tubing was found kinked, preventing proper drainage. The facility's policy on catheter care was not followed, resulting in significant health risks for the residents.
A resident with multiple health conditions was left unsupervised while taking medications, resulting in pills being scattered on the floor. The resident, who was shaky and unable to take medications independently, did not have water available initially and accidentally knocked over the medication cup. RNs and the DON confirmed the need for supervision during medication administration, which was not provided, violating the facility's medication pass policy.
A long-term care facility failed to accurately assess and supervise residents at risk of elopement, leading to incidents where one resident left the facility unsupervised and another wandered to a different floor. The facility did not maintain accurate elopement risk records, and there were delays in updating care plans and notifying family members. Staff interviews revealed issues with securing exit doors and using alarm systems.
A resident with a history of aggressive behavior hit another resident in the face, highlighting a failure in the facility's abuse prevention measures. Despite known behavioral issues, the resident's care plan lacked updated interventions, and non-pharmacological strategies showed no change in outcomes. The facility's policy on abuse was not effectively implemented, as evidenced by the incident and the lack of contact information for the nurse on duty.
Resident Left Unattended and Unable to Access Call Light
Penalty
Summary
A resident with a recent pelvic fracture, who was alert and oriented, reported that on her first night in the facility she was unable to locate her call light when she needed to use the bedpan. The resident stated that no staff came to check on her, resulting in her urinating in her brief and remaining in a soiled state. She described feeling frustrated, humiliated, and eventually scared due to the lack of assistance, which led her to call 911 for help. When staff responded after being notified by the police, the resident was found wet and upset, and the call light was discovered tied to the bed rail, though the resident had not seen it. Staff interviews confirmed that the resident was alert, oriented, and able to communicate her needs, but had not received timely assistance. The LPN and CNA involved acknowledged the resident's distress and the delay in care. The facility's policy requires staff to respect residents' privacy and dignity at all times, but this was not upheld in this instance, as the resident was left unattended and in a state of discomfort for an extended period.
Failure to Secure Front Entrance Results in Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the front entrance was safely supervised and/or secured, resulting in a resident with severe cognitive impairment and multiple medical conditions exiting the building without staff knowledge. The resident, who was at high risk for falls and had a care plan indicating the need for a safe environment and supervision, was last seen in bed by a CNA during the night shift. Staff discovered the resident missing approximately 45 minutes later and began searching the facility, initially believing that door alarms would have sounded if the resident had exited. Upon checking, staff found that the front door alarm was not activated or not functioning, and the alarm did not sound when tested. The resident was eventually found by police across a four-lane highway, wearing only a hospital gown, a brief, and shoes, in cold weather conditions. The resident was confused, had sustained injuries including a missing tooth and abrasions, and was hypothermic with a body temperature of 93.2°F. Emergency department records confirmed an acute subdural hematoma, hypothermia due to cold environment, and an unwitnessed fall. The resident was admitted to the hospital for further care. Interviews with staff and review of video footage confirmed that the resident exited through the front door during the early morning hours, and that the door alarm system was not functioning as required. The facility's elopement policy required adequate supervision and a safe environment for all residents, but these measures were not effectively implemented, allowing the resident to leave the facility undetected.
Removal Plan
- Conducted a full house audit of all residents to identify those who are an elopement risk.
- Conducted in-services with all staff on the elopement policy.
- Evaluated and inspected the front door alarm system and found it to be in good working condition.
- Installed a lock box over the kill switch located in the ceiling, with access limited to supervisory/authorized staff.
- Installed a new code panel on the internal set of glass doors requiring a code to exit the facility.
- Checked all other exit doors and found them to be fully engaged and functioning.
- Checked all bed/chair/personal alarms and found them to be in good working condition.
- Checked doors equipped with the Wander Guard system and found them to be properly functioning.
- Initiated a QA audit tool for maintenance to check the alarmed doors and wander guard equipped doors for proper functioning.
- In-serviced all staff on the importance of immediately responding to exit door alarms.
- In-serviced all staff on ensuring that the front exit door alarm is consistently activated.
- Initiated a QA audit tool to ensure that the front alarm door is properly functioning.
- Held an emergency QAPI meeting attended by the Medical Director to develop and approve the plan of correction.
- Agreed to discuss all trends identified in the monthly QAPI meeting until resolution.
Improper Food Handling and Hygiene Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling and hygiene practices, leading to potential cross-contamination. During an observation, a cook, identified as V6, was seen washing his hands and then applying gloves with wet hands, which is against hygiene standards. V6 proceeded to handle food items, including frozen vegetables and carrots, with the same contaminated gloves. He also touched various surfaces, such as the trash can lid and freezer handle, without changing gloves, further increasing the risk of cross-contamination. The Food Service Director, V5, acknowledged the improper practices and stated that there is a designated handwashing station that should be used instead of the food prep sink. Despite this, V6 continued to wash his hands in the food prep sink and apply gloves with wet hands. V5 confirmed that hands should be dry before applying gloves to prevent bacteria from remaining on the hands and emphasized that touching food with contaminated gloves is unacceptable. The facility's hygiene standards and procedures, as well as the cook's job description, clearly outline the proper handwashing and glove usage protocols. These include washing hands with soap and warm water, drying them thoroughly before applying gloves, and changing gloves after handling garbage or dirty equipment. The failure to adhere to these standards poses a risk of foodborne illness due to cross-contamination, as highlighted by the Centers for Disease Control and Prevention (CDC).
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by multiple instances of non-compliance with contact and droplet isolation precautions. One resident, diagnosed with influenza, was observed outside of her isolation room in the group dining area without a mask, despite orders for strict droplet isolation. The infection control preventionist confirmed that the resident should have remained in her room and meals should have been delivered there. Additionally, staff were observed not wearing the required personal protective equipment (PPE) when entering the resident's room, which could lead to cross-contamination. Another resident with a gastrostomy tube did not have enhanced barrier precautions (EBP) signage or PPE available outside their room, which is necessary for residents with feeding tubes to prevent infection. The infection control preventionist acknowledged the oversight and noted that staff should ensure EBP signs and PPE are in place. Furthermore, a resident with influenza was not properly isolated, as staff entered the room without the required PPE and failed to perform hand hygiene, increasing the risk of spreading the infection. Additional deficiencies were noted in the handling of residents with catheters and during incontinence care. Staff did not adhere to proper PPE protocols, such as wearing gowns and changing gloves between tasks, which are critical to preventing cross-contamination. The facility's policies on hand hygiene and infection control were not consistently followed, as evidenced by staff not performing hand hygiene after glove removal and not wearing appropriate PPE during high-contact care activities.
Failure to Implement Least Restrictive Interventions Before Restraint Use
Penalty
Summary
The facility failed to ensure that least restrictive interventions were provided before implementing a physical restraint for a resident, identified as R90, who was observed with a lap belt restraint in place during supervised activities. On multiple occasions, R90 was seen with the restraint secured while sitting in his wheelchair, including during meal times and activities, without the restraint being released. Interviews with staff revealed that the restraint was used due to R90's history of falls and agitation, but it was noted that the resident could not consistently remove the restraint on command due to cognitive deficits. The facility's policy requires non-restraining interventions to be utilized first, and physical restraints should only be used as a last resort. However, the restraint was applied after R90's fall shortly after admission, and the staff did not consistently release the restraint during supervised activities as required. R90's care plan indicated a high risk for falls and included the use of a self-release belt, but the resident was unable to remove it consistently. The facility's failure to adhere to its restraint policy and ensure the restraint was released during supervised activities led to the deficiency.
Failure to Conduct Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure daily weights were conducted for a resident with congestive heart failure, as ordered by the physician. The resident, admitted with diagnoses including Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes, and hypertension, had a physician's order to monitor weight daily before breakfast and notify the physician of any significant weight gain. However, the electronic Medication Administration Record (eMAR) for January 2025 showed that only two weights were documented, with 14 out of 16 weights not completed. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the resident was not being weighed daily as required. The facility's policy for residents with congestive heart failure mandates daily weight monitoring to manage fluid balance, yet this protocol was not followed. The Director of Nursing acknowledged the oversight, noting that the Certified Nursing Assistants were responsible for taking daily weights and reporting them to the nurses for documentation and physician notification, which was not occurring as ordered.
Failure to Provide Proper Suprapubic Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to a deficiency. The resident, identified as R32, reported issues with his catheter not draining properly and experiencing pain. Upon inspection by a registered nurse (RN), it was observed that the resident did not have a dressing over the suprapubic catheter, and urine was leaking around the catheter tubing, causing skin redness. The catheter drainage bag showed no drainage, and sediment was present in the tubing. The nurse manager confirmed that the resident was supposed to have a dressing in place, as per the physician's orders, but it had not been applied. Further examination by a licensed practical nurse (LPN) revealed drainage around the catheter tubing and reddened skin at the urostomy site. The LPN cleaned the area with saline and applied a new dressing, although the resident experienced discomfort during the process. The physician's orders required wound care to the catheter site, including cleaning with normal saline, applying skin prep, and covering with a dry dressing twice daily and as needed. The facility's indwelling catheter policy did not include specific care instructions for a suprapubic catheter, contributing to the oversight in care.
Inadequate Catheter Care and Cross-Contamination Risks
Penalty
Summary
The facility failed to provide appropriate catheter care and prevent cross-contamination for two residents with indwelling catheters. Resident 1, who was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, had a suprapubic catheter in place. The facility's records showed no documentation of catheter care, urine output, or dressing changes around the catheter stoma site. During an observation, it was noted that Resident 1's catheter tubing was kinked, preventing urine from draining properly, and the catheter bag was placed above the bladder level, causing urine to back up into the tubing. Resident 1 was hospitalized with a urinary tract infection and acute kidney injury. Resident 2, who shared a room with Resident 1, also had an indwelling catheter and was admitted with diagnoses including obstructive reflux uropathy. The facility's records showed no evidence of catheter care or scheduled catheter changes as ordered. Resident 2 expressed concerns about the handling of catheters, noting that catheter bags were often mixed up between her and her roommate. She reported that catheter care was only performed during showers or when incontinent of stool. Resident 2 was hospitalized with a urinary tract infection and electrolyte imbalance, and her catheter was changed at the hospital. The facility's policy on urinary catheter care emphasized the importance of preventing catheter-associated urinary tract infections by ensuring proper catheter maintenance, including keeping the drainage bag below the bladder level and monitoring for kinks in the tubing. However, the facility failed to adhere to these guidelines, resulting in inadequate catheter care and cross-contamination risks for the residents involved.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure proper supervision of a resident during medication administration, leading to a deficiency in pharmaceutical services. The incident involved a resident who was admitted with multiple diagnoses, including Type 2 Diabetes, hypertension, and chronic congestive heart failure, among others. The resident, who had no cognitive impairment, was found with several pills scattered on the floor in her room. She reported that she did not have water to take her medications when they were initially brought to her, and due to shakiness, she accidentally knocked the cup of medications over. The Registered Nurse (RN) acknowledged that the resident was shaky and should have been supervised while taking her medications. Another RN confirmed that it is not acceptable to leave medications at a resident's bedside for safety reasons and that supervision is necessary to ensure medications are taken. The Director of Nursing (DON) stated that the resident is not capable of taking medications independently and should be supervised during administration. The facility's policy requires adherence to medication pass procedures, which were not followed in this instance.
Elopement Risk Management Failures in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments and adequate supervision for residents at risk of elopement, leading to two separate incidents involving residents R1 and R2. R1, who had severe cognitive impairment and was independently ambulatory, was initially assessed as not at risk for elopement. However, a subsequent assessment identified him as high risk. Despite this, R1 managed to elope from the facility by cutting off his wanderguard and exiting through an unlocked door without triggering the alarm. The incident report noted that R1 was found at a nearby gas station after being reported missing by another resident. The facility's policy required immediate notification of the resident's family and physician, but this was delayed by 24 hours. R2, another resident with a history of Alzheimer's disease and cognitive disorders, was found wandering on a different floor within the facility. Although R2 did not leave the building, the incident was not documented in her medical record, and there was a delay in updating her care plan to reflect her elopement risk. The facility's policy required regular elopement risk assessments, but R2's assessments were not conducted quarterly as required, with a significant gap between assessments. Staff interviews revealed that exit doors were not consistently secured, and there was confusion about the use of wander devices and alarm systems. Additionally, the facility failed to maintain accurate and up-to-date elopement risk signs and records. Discrepancies were found between the elopement risk signs posted at the nurse's station and those in the elopement binder, with some residents not listed or incorrectly listed. The facility's policy required these records to be updated regularly, but staff were unable to confirm when the last updates were made. This lack of accurate documentation and communication contributed to the facility's inability to adequately supervise and protect residents at risk of elopement.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident physical abuse, involving two residents. Resident R3, who has a history of Alzheimer's disease, dementia with moderate agitation, and other mental health conditions, was involved in an incident where they physically hit another resident, R6, on the face. This incident was witnessed by a Certified Nursing Assistant (CNA), who reported that R3 has a history of verbally aggressive behaviors and had previously exhibited physical aggression towards others. R3's care plan, which was initiated to address behavior problems related to dementia and adjustment issues, did not have any new or additional interventions added since its initiation. Despite R3's known history of aggressive behaviors, including verbal and physical aggression, the care plan remained unchanged. The facility's records show multiple instances of R3's aggressive behavior, including yelling, swatting at residents and staff, and threatening to hit them with a shoe, yet no pharmacological interventions were implemented, and non-pharmacological interventions showed no change in outcomes. The facility's policy on abuse and neglect emphasizes providing care in an environment free from abuse, yet the incident on 4/28/24 indicates a failure to adhere to this policy. The Director of Nursing acknowledged R3's known behaviors and stated that staff were to increase monitoring and keep R3 engaged in activities following the incident. However, the lack of updated interventions in R3's care plan and the absence of contact information for the nurse on duty during the incident suggest deficiencies in the facility's response to managing R3's behaviors and preventing further incidents of abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 992 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Zurich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Long Grove Rehab &hc Ctr | 2.9 mi | ★★★★★ | 10 | 2 |
| Thrive Of Lake County | 3.7 mi | ★★★★★ | 3 | 0 |
| Avantara Long Grove | 4.3 mi | ★★★★★ | 0 | 0 |
| Prairieview At The Garlands | 4.9 mi | ★★★★★ | 3 | 0 |
| Little Sisters Of The Poor Of Palatine | 5.7 mi | ★★★★★ | 0 | 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.