Avantara Joliet

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received required staff assistance for toileting, incontinence care, nail care, hair care, and oral hygiene. This applies to 8 of 10 residents (R6, R12, R40, R47, R67, R99, R105, and R126) in a sample of 27. The Findings Include: 1. The face sheet for R126 shows multiple diagnoses, including displaced intertrochanteric fracture of the left femur (subsequent encounter for closed fracture with routine healing), unspecified fracture of the lower end of the left femur, diaphragmatic hernia without obstruction or gangrene, and cervical spondylosis without myelopathy or radiculopathy. R126 is a [AGE] year-old female who was newly admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS) dated [DATE], shows R126 is dependent on staff for toileting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide G Tube (gastrostomy tube) site care to residents on enteral tube feeding. This applies to 4 of 4 residents (R12, R28, R50, R101) reviewed for G Tube care in a sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy regarding the management and care of peripherally inserted central catheter (PICC) intravenous lines, including ensuring that PICC insertion sites were assessed and monitored every shift for signs and symptoms of infection. This applies to 4 of 4 residents (R31, R67, R102, and R125) reviewed with PICC lines in a sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medications from the cart and date ophthalmic medications upon opening to determine its expiration date. This applies to 7 of 7 residents (R6, R26, R31, R77, R101, R108, R109) reviewed for medication storage and labeling in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a treatment order, assess, and treat a resident with skin alteration. The facility also failed to follow the physician's treatment order for a resident with moisture-associated skin dermatitis. This applies to 2 of 2 residents (R48, 123) reviewed skin alteration in a sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to assess and auscultate the AV (arteriovenous) fistula for a resident receiving hemodialysis according to the physician's order. This applies to 1 of 1 resident (R6) reviewed for dialysis in the sample of 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow pharmacy recommendations for infusing Intravenous Vancomycin to a resident. This applies to 1 of 1 resident (R31) reviewed for significant medication error in the sample 27The

Inspectors wroteBased on observation, interview and record review, the facility failed to provide recommended dietary portions to meet resident nutrition needs and preference. This applies to 2 of 2 residents (R17 and R63) reviewed for dining in the sample of 27.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was transferred safely. This failure resulted in R1 sustaining a 10-12-centimeter laceration to left lower leg which required 18 sutures. This applies to one resident (R1) reviewed for injuries in a sample of four.

Inspectors wroteBased on interview and record review, the facility failed to recognize a resident's significant weight loss of 17.8% in one month and implement timely interventions. This failure resulted in R1's continual weight loss of 24% in three months and eventual hospitalization. This applies to one resident (R1) reviewed for decreased oral intake.

Inspectors wroteBased on interview and record review the facility failed to adequately assess, administer medications, and notify the physician for a resident who had not had a bowel movement in over 3 days on several occasions. This failure contributed to (R1) developing a fecal impaction, pain and inflammation in her colon. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 7.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and develop a discharge plan for resident (R1) with a discharge goal to return to the community. This applies to 1 out of 3 residents (R1) reviewed for discharge services. R1's Medical Record showed R1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, generalized muscle weakness, and syncope. On 2/07/2025 at 11:40 AM, R1 was sitting in her wheelchair receiving 2 L (liters) of continuous oxygen via a nasal cannula. R1 stated she was frustrated because there had been delays with her discharge the prior week and now her discharge date was changed to 2/11/2025. On 2/07/2025 at 3:30 PM, V10 (R1's daughter) was interviewed via telephone. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain an oxygen therapy order for a resident (R1) who required the use of continuous oxygen. This applies to 1 out of 3 residents (R1) reviewed for oxygen therapy. R1's Medical Record showed R1 was admitted to the facility on [DATE] with multiple diagnoses including chronic obstructive pulmonary disease, asthma, congestive heart failure, and syncope. R1's MDS (Minimum Data Set) dated 1/13/2025 showed R1 was admitted with continuous oxygen therapy. On 2/07/2025 at 9:25 AM, R1 was sitting in her wheelchair receiving 2 L (liters) of continuous oxygen via a nasal cannula. R1 stated she had recently been admitted to the facility with oxygen. R1 continued to say her oxygen therapy was new and was explained by the facility's staff that she now required the use of continuous oxygen. [...]

Inspectors wroteBased on interview and record review the facility failed to send an escort with a resident for an outside imaging appointment. This applies to 1 of 3 residents (R1) reviewed for transportation and escort to medical appointments, in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Physician/Nurse Practitioner was immediately notified of a fall where the resident had hit his head. This failure resulted in an over six-hour delay in hospitalization and treatment. This applies to 1 of 3 residents (R3) reviewed for notification of changes.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents identified as needing assistance with personal hygiene and grooming. This applies to 6 of 6 residents (R13, R44, R49, R91, R106 and R125) reviewed for ADLs (activities of daily living) in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care in a manner that would prevent urinary tract infection (UTI). This applies to 4 of 5 residents (R26, R117, R126, and R9) reviewed for bowel and bladder care in the sample of 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve ground chicken for residents on mechanical soft diets. This applies to 4 of 4 residents (R67, R105, R109, R296) reviewed for dining in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control process related to hand hygiene and gloving during provisions of incontinence care. This applies to 5 of 21 residents (R9, R26, R116, R117, R126) reviewed for infection prevention in the sample of 21.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident's signed POLST (Practitioner Order for Life-Sustaining Treatment) form and physician's order are consistent to reflect the resident's treatment wishes in an event of a medical emergency. This applies to 1 of 1 resident (R47) reviewed for advance directives in the sample of 21.

Inspectors wroteBased on interview and record review the facility failed to have two staff assist during a full body mechanical lift transfer. This applies to 1 of 3 residents (R49) reviewed for accidents and supervision in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and provide gastrostomy tube (g-tube) care as ordered by the physician. This applies to 1 of 3 residents (R15) reviewed for Tube Feeding in the sample of 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications according to physician's order. There were 26 medication opportunities with 2 medication errors resulting to 7.69 % error rate. This applies to 1 of 6 residents (R12) reviewed for medication administration in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to transmit discharge Minimum Data Sheet (MDS) records within 14 days as required by state and federal regulations. This applies to 5 of 5 residents (R76, R129, R66, R40, and R127) reviewed for Minimum Data Set (MDS) transmission in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe transfer with a mechanical lift for 1 resident (R1). This failure resulted in R1 falling off the side of her bed and obtaining an 8cm (centimeter) laceration to her head requiring 15 staples. This past noncompliance occurred from June 23, 2024, to July 13, 2024. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to perform wound treatments, and failed to perform weekly skin assessments as ordered by a physician for a resident (R2) with an arterial heel ulcer. This applies to 1 of 3 residents reviewed for wounds in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to assess and obtain physician's orders upon identification of an unstageable pressure ulcer for a resident (R4). This applies to 1 of 3 residents reviewed for wounds in the sample of 13.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was retaining urine had his bladder scanned and was catheterized. These failures resulted in the resident being hospitalized with urosepsis for eight days. This applies to 1 of 3 residents (R1) reviewed for urinary catheters.

Inspectors wroteBased on observation, interview, and record review the facility failed to update the POA (Power of Attorney) on status changes of a resident. This applies to 1 of 3 residents (R1) reviewed for notification of changes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were assessed and treated for nail care by the podiatrist. This applies to 6 of 6 residents (R1, R2, R3, R4, R5 and R6) reviewed for podiatry care appointments in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label, date, seal food items in the kitchen, and practice proper hand hygiene and food sanitation procedures during meal service. This applies to all residents that receive oral nutrition and foods prepares in the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit MDS (Minimum Data Set) assessments within the required 92-day timeframe. This applies to 4 residents (R4, R59, R87 and R92) reviewed for MDS in a sample of 30 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who are dependent on staff for personal hygiene and grooming. This applies to 4 of 4 residents (R42, R71, R78, R383) reviewed for ADLs in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure hazardous chemicals on a memory care unit. This applies to five residents (R4, R59, R124, R336 and R337) reviewed for safety in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to replace respiratory equipment and store it in a sanitary manner. This applies to 4 of 4 residents (R33, R85, R89, and R112) reviewed for respiratory care in a sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to securely store and dispose of medications. This failure applies to 4 residents (R33, R45, R92 and R334) in a sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to carry out wound/skin care per physician orders. This applies to 1 resident (R488) reviewed for wound/skin care in a sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide IV (intravenous) site care for insertion site dressings. This applies to 2 of 3 residents (R63 and R90) reviewed for IV treatment and care in a sample of 30.

Inspectors wroteBased on interview and record review, the facility failed to facilitate transportation services for dialysis as ordered by physician. This applies to 1 resident (R14) reviewed for dialysis in a sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement physician orders to monitor right T-Tube (drainage tube) site every shift and have a treatment plan for dressing changes to a surgical wound that was draining. This applies to 1 of 1 resident (R1) in the sample of 3 reviewed for physician orders.