Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
AVENORA ELMHURST
ELMHURST, IL · 108 certified beds · Last Life Safety survey January 8, 2026
CMS Certification Number 145111 · first certified January 1967
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
32 citations — more than 85% of the 664 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 16 citations; the earlier surveys on file averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens December 2026 — about 1 month from now. This facility’s last Life Safety survey was January 2026. Facilities in IL are typically surveyed 11–14 months after the last one (median 13), measured over 739 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
8 of the 32 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 32 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 32 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 29, 2023 | 12 |
| October 10, 2024 | 4 |
| January 8, 2026 | 16 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 3 | 2026-01-08 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2026-01-08 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2026-01-08 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2026-01-08 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2026-01-08 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2026-01-08 |
| E-0025 | Create arrangements with other facilities to receive patients. | 1 | 2026-01-08 |
| E-0032 | Provide primary/alternate means for communication. | 1 | 2026-01-08 |
What the citations cover
- Smoke Deficiencies 13
- Emergency Preparedness Deficiencies 8
- Miscellaneous Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Emergency Preparedness Deficiencies | 8 |
| Miscellaneous Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 8, 2026 — 16 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (May 22, 2026) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (May 26, 2026) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (May 22, 2026) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (May 26, 2026) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (May 22, 2026) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (May 29, 2026) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has plan of correction |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 22, 2026) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 10, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (May 22, 2026) |
October 10, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 25, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 25, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (October 25, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 25, 2024) |
November 29, 2023 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (December 5, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0541 | Install properly constructed and protected linen or trash chutes. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 6, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 6, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.