Avantara Libertyville

Inspectors wroteBased on interview and record review the facility failed to provide a resident with the Physician prescribed diet, failed to have a policy in place regarding changes in dietary orders, and failed to implement a physician diet order change. This failure resulted in R1 choking on her food and expiring at the hospital. This applied to one of three residents (R1) reviewed for diets in the sample of three. The Immediate Jeopardy began on 5/17/26 when R1 received physician orders for a downgrade in diet to pureed and the next morning was served a mechanical soft diet rather than the Physician prescribed puree diet. R1 choked and expired at the hospital. V1 (Administrator) was notified of the Immediate Jeopardy on 5/22/26 at 9:58 AM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide bed mobility in a safe manner for 1of 7 residents (R1) reviewed for safety/falls in the sample of 7. This failure resulted in R1 falling from R1's bed and sustaining left and right femur fractures requiring hospitalization.

Inspectors wroteBased on interview, and record review, the facility failed to notify the physician on a resident experiencing a change in condition for 1 of 7 residents (R1) reviewed for dependent care in the sample of 7.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nursing assistants were certified after completing the training program. This applies to all 114 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in a sanitary manner. This has the potential to affect all 122 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain weights as ordered for residents with congestive heart failure (CHF) for 4 of 24 residents (R38, R66, R244, and R11) reviewed for quality of care in the sample of 24.

Inspectors wrote3. R113's careplan, dated 6/1/24, shows, (R113) is on EBP due to presence of indwelling catheter with interventions that include: ensure that gown and gloves are used during high-contact resident care activities like .changing briefs, or assisting in toileting, .device care-urinary catheter. R113's door had a sign posted that show, STOP, Enhance Barrier Precaution (EBP) . Everyone must: .Wear gloves and gown for the following High Contact Resident Care Activities: Changing brief, device care use .urinary catheter. On 9/23/24 at 10:05 AM, V14 (CNA) entered R113's room with just gloves on, and emptied R113's catheter bag. Then V14 proceeded to provide incontinence care and catheter care to R113, again just wearing gloves. When it was time to transfer R113 to his wheelchair, V15 (CNA Supervisor), wearing gloves and gown, handed a gown to V14. [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure pressure relieving interventions were in place for 2 of 5 residents (R106 and R30) reviewed for pressure injury in the sample 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care to prevent urinary tract infection to 1 of 6 residents (R113) reviewed for catheter care in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized activities for a resident with dementia for 1 of 3 residents (R76) reviewed for dementia care in the sample of 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatments were completed as ordered for a resident with pressure injuries for 1 of 3 residents (R2) reviewed for pressure in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food safety. This has the potential to affect all 100 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms and environment were clean and home like for 6 of 23 residents (R69, R54, R84, R16, R59 and R17) reviewed for homelike environment in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide R79 with a PASRR (Preadmission Screening and Resident Review) thirty days after admission for one of seven residents (R79) reviewed for Preadmission Screening for individuals with a mental disorder in the sample of twenty.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure reducing interventions were in place for a resident which applies to 1 of 8 residents (R78) reviewed for pressure wounds in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to standards of practice for 1 of 23 residents (R84) reviewed for pharmacy services in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle dishes in sanitary manner and failed to ensure dry goods were stored 6 inches off the floor. This applies to all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was treated in a dignified manner for 1 of 18 residents (R235) reviewed for dignity in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with privacy during incontinence care for one of 18 residents (R68) reviewed for privacy in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with leg edema had compression wraps on for 1 of 18 residents (R64) reviewed for edema in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment during incontinence care/bed mobility to prevent a fall, and failed to ensure a resident with dysphasia (difficult with swallowing) was supervised while drinking, for 2 of 18 residents (R17 and R187) reviewed for safety and supervision in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician ordered medications were administered by a nurse. The facility failed to ensure physician ordered medications were administered to a resident. The failures apply to 3 of 18 residents (R84, R236, R186) reviewed for pharmacy services in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure visitors wore PPE (personal protective equipment) in the room of a COVID-19 positive resident. The facility failed to ensure staff changed gloves and performed hand hygiene to prevent cross contamination. These failures apply to 3 of 18 residents (R237, R68, R32) reviewed for infection control in the sample of 18.