Avantara Joliet: G-Tube Care Failures Found in Inspection - IL
The resident, identified in inspection records as R101, had a gastrostomy tube, a surgically placed feeding tube that passes through the abdominal wall directly into the stomach. The insertion point where that tube meets the skin had no dressing on it at all. The encrusted material had spread far enough to stain through R101's facility gown.
A nurse identified in the report as V3 told inspectors that R101 was supposed to have a dressing applied to the site and that the site should be kept clean, per physician order.
The facility's own written procedure, revised as recently as June 30, 2025, spelled out exactly what that care was supposed to look like. Staff were required to cleanse the stoma site and cover it with dry gauze every day. The gauze was to be placed on top of the tube's bumper, the small disc that holds the tube in position against the skin, or a thin layer of breathable gauze could be tucked underneath the disc. The procedure was not a suggestion. It carried a physician order behind it.
None of it had been done.
Gastrostomy tube sites that go without regular cleaning and dressing can develop infections. The skin around the insertion point is already compromised by the tube's presence, and dried secretions that collect and crust at the site create conditions where bacteria can take hold. The fact that material had already seeped through R101's gown indicated the neglect had not been brief.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, and noted that the lapse affected some residents, not just R101.
The complaint inspection, conducted on December 24, 2025, captured a single documented finding, but the finding was specific and unambiguous. A resident with a surgical opening in their abdomen requiring daily wound care had not received it. The site was visibly dirty. The nurse who saw it confirmed it should have been dressed.
Avantara Joliet is a skilled nursing facility in Will County. The Christmas Eve visit was a complaint inspection, meaning someone, whether a resident, a family member, or a staff member, had contacted regulators with a concern serious enough to trigger an unannounced visit on a holiday.
What inspectors found when they arrived was consistent with what complaint inspections so often reveal: not a dramatic failure requiring emergency response, but the quieter kind, a resident in a soiled gown, a wound site crusted over, a daily care task that had simply not been done. These are the violations that rarely make news. They accumulate in inspection records while residents absorb the consequences.
R101 could not dress their own wound. They were dependent on staff to follow the physician's order, to follow the facility's own written procedure, to notice the encrusted material and address it. On Christmas Eve, when inspectors walked in, that had not happened.
The nurse confirmed it should have.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Joliet from 2025-12-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
Avantara Joliet in JOLIET, IL was cited for violations during a health inspection on December 24, 2025.
The insertion point where that tube meets the skin had no dressing on it at all.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.