Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Avantara Joliet

JOLIET, IL · 154 certified beds · Last Life Safety survey August 29, 2024

CMS Certification Number 145029 · first certified January 1967

Ownership

Operated by PRIME HEALTHCARE · For profit - Limited Liability company

  • New ownershipOwnership changed March 1, 2025 (change of ownership)to VILLA FRANCISCAN from PRESENCE LIFE CONNECTIONS
13
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
5
Inspection & testing records
Of the citations on file

Position within IL

13 citations — more than 44% of the 666 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

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 3 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (July 2025 to October 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was August 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 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 three years in Maryland. How the window is measured

Get an email about Avantara Joliet

One email when it happens. No account; stop it any time with one click.

Which alerts

2 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 ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 13 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)

6 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 13 Life Safety citations above. The Physical Environment Index

  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.

This facility13IL median15National median11
Citations on file over three years, compared
MeasureCitations
This facility13
Median facility in IL15
Median facility nationally11

Survey history

Citations at each Life Safety survey
42022-1262023-1032024-08
Citations at each Life Safety survey
Survey dateCitations
December 15, 20224
October 6, 20236
August 29, 20243

Most-cited tags

Most-cited tags at this facility
K-03722K-03632K-02112K-09231E-00261K-03211K-09111K-03441
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22024-08-29
K-0363Install corridor and hallway doors that block smoke.22023-10-06
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.22023-10-06
K-0923Have proper medical gas storage and administration areas.12023-10-06
E-0026Establish roles under a Waiver declared by secretary.12023-10-06
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.12024-08-29
K-0911Meet requirements for the installation and maintenance of electrical systems.12023-10-06
K-0344Have an alternate power supply for its alarm system.12023-10-06

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 6
  • Egress Deficiencies 3
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Emergency Preparedness Deficiencies 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies6
Egress Deficiencies3
Gas, Vacuum, and Electrical Systems Deficiencies2
Emergency Preparedness Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 29, 2024 — 3 citations

Citations issued on August 29, 2024
TagWhat the surveyor checksStatus
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (September 20, 2024)
K-0321Ensure 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 (October 24, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (September 20, 2024)

October 6, 2023 — 6 citations

Citations issued on October 6, 2023
TagWhat the surveyor checksStatus
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (October 18, 2023)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (December 30, 2023)
K-0344Have an alternate power supply for its alarm system.Deficient, Provider has date of correction (October 31, 2023)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (October 31, 2023)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (October 24, 2023)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (October 24, 2023)

December 15, 2022 — 4 citations

Citations issued on December 15, 2022
TagWhat the surveyor checksStatus
E-0015Address subsistence needs for staff and patients.Deficient, Provider has date of correction (January 16, 2023)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (December 31, 2022)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 31, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (January 16, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.