Avantara Lake Zurich

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dishes were air-dried prior to stacking. This has the potential to effect all residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated in a dignified manner for 4 of 30 residents (R152, R12, R14, and R113) reviewed for dignity in the sample of 30.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure pressure relieving interventions were in place and failed to ensure ordered treatments were in place for five of eight residents (R113, R75, R9, F26, and R31) reviewed for pressure injuries in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident and their personal property were respected. This applies to 1 of 30 residents (R76) reviewed for resident rights in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care to residents that require staff assistance with toileting. This applies to 2 of 30 residents (R17 and R14) reviewed for activities of daily living in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's skin was cleansed after an incontinent episode for one of four residents (R74) reviewed for incontinence in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement person-centered dietary interventions to support independent eating, maintain dignity, and promote adequate nutritional intake for one resident (R112) with a diagnosis of dementia and a preference to eat meals using their hands in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents consumed their medications when medications were administered for 2 of 6 residents (R164 and R33) reviewed for pharmacy services in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered (at ordered times and ordered routes). There were 30 opportunities with 6 errors resulting in a 20 % error rate. This applies to 3 of 4 residents (R102, R107, R162) observed in the medication pass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff changed gloves and performed hand hygiene to prevent cross contamination, and failed to ensure staff wore the required personal protective equipment for enhanced barrier precautions for three of 30 residents (R74, R17, and R64) reviewed for infection control in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was treated in a dignified manner for 1 of 5 residents (R1) reviewed for dignity in the sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the front entrance to the facility was safely supervised and/or secured to prevent 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6 from exiting the facility unbeknown to the staff. This failure resulted in R1 leaving the facility in the early morning hours and crossing four lanes of a major east-west arterial road where the speed limit is 50 miles per hour (MPH) wearing only a hospital gown, a brief, and shoes. R1 became hypothermic and was admitted to the hospital with an acute subdural hematoma, hypothermia due to cold environment, and unwitnessed fall. The Immediate Jeopardy began on 4/13/25 when staff could not find a resident in the facility. V1, Administrator, was notified of the Immediate Jeopardy on 5/12/25 at 4:20 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was handled in a manner to prevent cross-contamination and failed to ensure a cook performed hand hygiene in a manner to prevent cross contamination. This affects all the residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure contact/droplet isolation precautions were maintained (R99, R131), failed to ensure enhanced barrier precautions were posted (R113), and failed to ensure personal protective equipment (PPE) was worn in a manner to prevent cross contamination (R131, R52, R32) for 5 of 5 residents reviewed for infection control in the sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure least restrictive interventions were provided prior to the implementation of a physical restraint and failed to release the restraint during supervised activities for 1 of 2 residents reviewed for restraints in the sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure daily weights were done for a resident with congestive heart failure for 1 of 1 residents (R80) reviewed for weights in the sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a dressing in place for the suprapubic catheter and failed to ensure the dressing change to the suprapubic catheter was done as ordered for 1 of 3 residents (R32) reviewed for catheters in the sample of 27.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an indwelling catheter and provide catheter care for residents in a manner to prevent cross contamination for 2 of 3 residents (R1, R2) reviewed for catheters in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure supervision of a resident while taking medications for 1 of 1 resident (R1) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accurate assessments were completed for a resident at risk for elopement, failed to ensure quarterly elopement risk assessments were completed, failed to ensure a resident at risk for elopement did not leave the facility unsupervised, failed to ensure exit doors were completely shut with alarm activated, and failed to maintain elopement risk signs and book to ensure they were complete and accurate for 2 of 3 residents (R1 and R2) reviewed for elopement in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from resident to resident physical abuse. This applies to 2 of 6 residents (R3, R6) reviewed for abuse in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident with a history of falls and right sided weakness was safely transferred. This failure resulted in R1 sustaining a fall, hitting her head on the bedside table, and falling on her left side during a transfer. R1 was sent out to the local hospital and CT showed acute displaced fracture of the right ilium and right acetabulum. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure opened, multi-dose vials of medication were labeled with expiration dates for 4 of 7 residents (R2, R5, R10, R6) reviewed for medication storage in the sample of 11.

Inspectors wroteBased on observation, interview and record review the failed to ensure resident medications were administered according to professional standards and to meet the needs of the residents for 2 of 4 residents (R1, R4) reviewed for medication administration in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to ensure a significant medication error did not occur for a newly admitted resident. This failure applies to 1 of 4 residents (R1) reviewed for medication administration in the sample of 11.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's prescribed treatment order was changed daily for a resident who has stage 4 left ischial pressure ulcer. This applies to 1 of 3 residents (R5) reviewed for pressure ulcers in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were in place for 1 of 28 residents (R19) reviewed for safety in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor the behavior of wandering into other residents' rooms for dementia residents for 2 of 8 residents (R19 and R84) reviewed for dementia care in the sample of 28.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were not left unattended at resident's bedside. This applies to 1 of 28 residents (R2) reviewed for pharmacy services in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to ensure an anti-viral medication was discontinued. This applies to 1 of 5 residents (R25) reviewed for unnecessary medications in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to ensure PRN (when needed) anti-anxiety medications had a stop date. This applies to 2 of 5 residents (R25 & R26) reviewed for unnecessary medications in the sample 28.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications at ordered times. There were 28 opportunities with 12 errors resulting in a 42.86% error rate. This applies to 3 of 3 residents (R28, R33, R54) observed in the medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from significant medication error. This applies to 2 of 3 residents (R28, R33) reviewed for medication administration in the sample of 28.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were offered and/or received the recommended pneumococcal immunizations for 1 of 5 residents (R40) reviewed for immunizations in the sample of 28.