Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
AVANTARA PALOS HEIGHTS
PALOS HEIGHTS, IL · 184 certified beds · Last Life Safety survey November 1, 2024
CMS Certification Number 145607 · first certified March 1989
Ownership
Operated by LEGACY HEALTHCARE · For profit - Limited Liability company
- Ownership changed February 1, 2023 (change of ownership)from MANOR CARE OF PALOS HEIGHTS IL LLC
Position within IL
16 citations — more than 54% 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
The latest survey found 5 citations; the earlier surveys in the window averaged 5.5. 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 (September 2025 to December 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was November 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
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3 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
1 of the 16 citations on file is 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)
9 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 16 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 | 16 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 2, 2023 | 8 |
| December 29, 2023 | 3 |
| November 1, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-11-01 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-12-29 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 2 | 2024-11-01 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2023-12-29 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2024-11-01 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-03-02 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-03-02 |
| E-0022 | Establish policies and procedures for sheltering. | 1 | 2024-11-01 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Construction Deficiencies 1
- Emergency Preparedness Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Construction Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 1, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 18, 2024) |
December 29, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 16, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 19, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (January 16, 2024) |
March 2, 2023 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (March 17, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 17, 2023) |
| K-0930 | Ensure proper storage of liquid oxygen. | Deficient, Provider has date of correction (March 17, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.