Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Avondale Estates Of Elgin during CMS and state inspections, most recent first.
Surveyors found that several residents had medications, including controlled substances and over-the-counter drugs, stored at their bedsides in unlocked drawers or on tables without proper labeling, physician orders, or assessments. Staff confirmed that no orders or assessments were in place for bedside medication storage, and the facility's policy requiring secure storage was not followed.
Staff did not consistently follow Enhanced Barrier Precautions (EBP) when providing care to residents with wounds, urinary catheters, or IV lines. CNAs, RNs, and therapy staff were observed performing high-contact care activities without wearing required gowns, and in some cases, EBP signage was missing. Facility policy requires gowns and gloves for such care, but this was not adhered to for multiple residents.
The facility did not consistently use required tools to assess the appropriateness of antibiotic use for several residents, including those admitted from the hospital and those started on new antibiotics. In multiple cases, antibiotics were administered without completing the McGeers tool or other standardized assessments, or the tools were filled out incorrectly or after treatment had begun. Documentation such as Antibiotic Time Out forms was also missing for some residents.
A resident who required substantial assistance for toileting and was at risk for pressure ulcers developed MASD on both buttocks after experiencing a significant delay in incontinence care and inadequate drying by a CNA. The resident reported waiting 45 minutes for care, insufficient cleaning, and a soaked bed pad, with subsequent pain and redness confirmed by the wound care nurse. Facility staff failed to follow policy for proper incontinence care and did not communicate the skin issue to nursing staff.
A resident with severe pain related to B-cell lymphoma and left hip pain did not receive prescribed pain medications from facility staff from admission until the following morning, despite documented high pain scores and physician orders for Norco and Tylenol as needed. The resident reported being unable to sleep due to pain and self-administered his own Norco during the night, while staff acknowledged that pain management should have been provided.
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, including not conducting a voiding trial, not maintaining a proper care plan, and allowing the urinary drainage bag to lie on the floor.
The facility failed to change central venous catheter dressings within 48 hours for three residents, as required by policy. The responsible nurse was unaware of the policy, and the Infection Preventionist confirmed the requirement. Medical records showed the dressings were last changed on the same date, confirming non-compliance.
Failure to Secure and Properly Store Resident Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly secured and labeled in accordance with professional standards. Multiple residents were found to have medications, including controlled substances such as Norco, as well as over-the-counter drugs and topical creams, stored at their bedsides in unlocked drawers or on bedside tables. These medications were brought from home or kept by the residents without proper physician orders or assessments authorizing self-administration or bedside storage. In several cases, medications were unlabeled, and there was no documentation or order for the medications to remain at the bedside. Staff interviews confirmed that there were no physician orders or assessments for any of the residents to keep medications at their bedside, and the facility's own policy required all drugs and biologicals to be stored safely and securely. Despite this, staff allowed residents to retain medications in their rooms, and in one instance, a nurse only removed a controlled substance after a physician's round, but other medications remained unsecured. The lack of proper storage and documentation was observed in five out of five residents reviewed for medication storage.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to follow its own Enhanced Barrier Precautions (EBP) protocols for residents requiring these infection control measures. Certified Nursing Assistants (CNAs), Registered Nurses (RNs), and therapy staff were observed providing care to residents with active physician orders for EBP—due to conditions such as wounds, urinary catheters, and intravenous (IV) lines—without wearing the required gowns, and in some cases, without proper signage indicating EBP status. For example, a CNA assisted a resident with a wound after toileting without a gown, and another CNA provided a bed bath to a resident with a urinary catheter without donning a gown, despite EBP signage being present. Additionally, therapy staff provided care to a resident with a PICC line without gowns, and there was no EBP signage outside the room to alert staff to the required precautions. Further, a nurse administered IV medication to a resident with a PICC line while only wearing gloves and not a gown, contrary to facility policy. Interviews with the Assistant Director of Nursing (ADON) and other staff confirmed that the expectation was for all staff to wear gowns and gloves when providing care to residents on EBP, and that proper signage should be posted to inform staff of the required precautions. The facility's policy clearly states that gowns and gloves are required for high-contact care activities involving devices such as urinary catheters and central lines, but these protocols were not consistently followed for the residents reviewed.
Failure to Follow Antibiotic Stewardship Program and Documentation Protocols
Penalty
Summary
The facility failed to implement and follow its Antibiotic Stewardship Program for all residents reviewed who were receiving antibiotics. Specifically, the McGeers tool, which is intended to determine whether residents meet criteria for antibiotic use, was either not completed, completed after antibiotics were started, or filled out incorrectly for multiple residents. For example, one resident was admitted with sepsis and a urinary tract infection and received Macrobid, but the McGeers tool indicated criteria were not met, yet antibiotics were still administered. Another resident with a follicular disorder received Cephalexin for wounds, but the McGeers tool was completed incorrectly and after antibiotics had already been started. Additionally, several residents admitted from the hospital with ongoing antibiotic orders did not have the McGeers tool or any standardized assessment completed upon admission to determine the appropriateness of continuing antibiotics. In some cases, the facility relied solely on hospital orders without conducting its own assessment, and in others, documentation such as the Antibiotic Time Out form was missing. For one resident with multiple antibiotic orders for wounds and infections, the facility was unable to provide any completed McGeers tools or Antibiotic Time Out forms for the antibiotics administered.
Failure to Provide Timely and Adequate Incontinence Care Resulting in MASD
Penalty
Summary
A resident who was occasionally incontinent of bladder and always incontinent of bowel did not receive timely and appropriate incontinence care, resulting in the development of Moisture Associated Skin Damage (MASD) on both buttocks. The resident reported waiting 45 minutes for his call light to be answered during the midnight shift, observing a CNA walking in the hallway and ignoring his request. When care was finally provided, the CNA did not adequately wipe or dry the resident, and the resident had to request a change of a soaked bed pad. During assessment, the resident verbalized pain when the reddened area was touched, and the wound care nurse confirmed the presence of MASD due to moist skin. Further review revealed that the CNA who provided care at 9:10 AM had not previously attended to the resident since starting her shift at 6:00 AM. The LPN on duty was unaware of the skin issue, and there was no communication from the previous shift regarding the resident's condition. The resident's care plan indicated a need for substantial assistance with toileting hygiene, and the Braden Scale identified the resident as at risk for pressure ulcers. Facility policy required staff to thoroughly rinse and pat dry the area after incontinence care, but this procedure was not followed, contributing to the skin breakdown.
Failure to Provide Timely Pain Management
Penalty
Summary
A resident with a history of B-cell lymphoma and left hip pain was admitted to the facility and reported severe pain, rating it as 8-9 out of 10 upon admission. Despite having physician orders for Norco and Tylenol to be administered as needed for pain, the resident did not receive any pain medication from the facility from the time of admission in the evening until the following morning. The resident stated that he was unable to sleep due to pain and resorted to taking his own supply of Norco during the night to manage his discomfort. Documentation in the medical record, including the Medication Administration Record and progress notes, confirmed that no pain medication was administered by facility staff during this period, despite high pain scores being recorded. Facility staff, including the Assistant Director of Nursing, acknowledged that the resident's pain should have been managed better and that medications were available for emergency use. The facility's pain management policy required pain assessments at least every shift and appropriate interventions to be implemented. However, the resident's pain was not addressed in a timely manner, resulting in unmanaged pain overnight and the resident self-administering medication brought from home.
Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter. The resident, who was admitted with multiple diagnoses including chronic diastolic congestive heart failure, type 2 diabetes mellitus, and chronic obstructive pulmonary disease, did not have a voiding trial attempted to remove the catheter. The facility's Infection Prevention Nurse confirmed that a voiding trial should have been conducted but was not. Additionally, the resident's baseline care plan did not include any goals or interventions for catheter care and maintenance, which was only initiated after the surveyor's observation. The resident's urinary drainage bag was also observed lying on the floor, contrary to the facility's policy that requires the bag to be kept off the floor and covered for privacy. The facility's policy on catheter care was not followed, as evidenced by the lack of a baseline care plan for the indwelling urinary catheter and the improper handling of the urinary drainage bag. The resident's electronic medical record showed no assessment or trial of a toileting program, and the care plan nurse confirmed that the care plan lacked necessary details for catheter care. The facility's failure to adhere to its own policies and procedures for catheter care and maintenance led to the identified deficiencies.
Failure to Change Central Venous Catheter Dressings as per Policy
Penalty
Summary
The facility failed to ensure that three residents' central venous catheter dressings were changed within 48 hours as per the facility policy. Resident 44, a male with diagnoses including aftercare following joint replacement surgery and infection due to an internal joint prosthesis, had a central venous catheter dressing dated May 19, 2024, which was not changed by May 22, 2024. Similarly, Resident 23, a female with diagnoses including bacteremia and effusion of the left knee, and Resident 357, a male with diagnoses including osteomyelitis and cutaneous abscess of the face, both had central venous catheter dressings dated May 19, 2024, which were also not changed by May 22, 2024. The facility's policy requires that dressings with gauze be changed every 48 hours to prevent infection and monitor the insertion site, but this was not adhered to for these residents. During the investigation, it was found that the responsible nurse, V7, was unaware of the policy regarding the frequency of dressing changes for central venous catheters. The Infection Preventionist, V2, confirmed that the dressings should be changed every 48 hours if gauze is used. The Treatment Administration Records for all three residents indicated that their dressings were last changed on May 19, 2024, confirming the failure to comply with the facility's policy. This deficiency was observed through direct inspection, interviews with staff, and review of medical records.
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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.
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Nursing homes near Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearl Of Elgin, The | 1.9 mi | ★★★★★ | 1 | 0 |
| Highland Oaks | 2 mi | ★★★★★ | 0 | 0 |
| Aperion Care Elgin | 3.1 mi | ★★★★★ | 2 | 0 |
| River View Rehab Center | 3.2 mi | ★★★★★ | 28 | 0 |
| The Pearl Of Fox River Valley | 3.3 mi | ★★★★★ | 13 | 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.