Avantara Libertyville: Fall Breaks Both Legs - IL
The incident occurred on August 12 at Avantara Libertyville when the resident requested assistance to begin her morning routine. As the nursing assistant helped roll the resident to her side, the resident's leg fell off the bed.
The nursing assistant attempted to lift the resident's legs back onto the bed. Due to the resident's large size and the assistant's small stature, both fell approximately four feet from the bed to the floor. The resident's legs crossed during the fall.
The impact, combined with the resident's morbid obesity and osteoarthritis, caused fractures to both her left and right femurs.
At 12:35 that afternoon, the resident reported her pain level as 2 out of 10. By 5:00 PM, her pain had jumped to 8 out of 10.
A licensed practical nurse who initially assessed the resident after the fall said the resident denied pain at first. "I went back and re-assessed R1 and she complained of a low-level pain to the thigh," the nurse said during an interview on August 20. "I provided acetaminophen and updated V5 Nurse Practitioner of the left thigh pain; an X-ray for the hip was ordered."
The X-ray didn't arrive during the nurse's shift, and she gave report to the evening shift.
Progress notes show the resident was resting in bed at 5:46 PM while waiting for X-ray results, continuing to report left leg pain rated 8 out of 10. The X-ray results came back at 10:05 PM, confirming a left femur fracture.
Medical staff were informed of the results, and the resident continued reporting 8 out of 10 pain. A doctor ordered her transfer to the hospital for further evaluation and management.
But the nurse practitioner responsible for the resident's care was never told about the dramatic increase in pain levels.
"She was not notified of R1's increase in pain," the nurse practitioner said during an August 25 interview. "The staff should have notified (V5) of R1's 8/10 pain."
Federal regulations require nursing homes to immediately notify the resident's doctor and family members of situations that affect the resident, including injuries and changes in condition. The facility's failure to communicate the resident's worsening pain meant the doctor couldn't adjust treatment or pain management protocols during the critical hours after the fractures occurred.
The resident required assistance with bed mobility before the fall due to her physical limitations. The incident report noted that her morbid obesity and osteoarthritis contributed to the severity of her injuries when combined with the impact pressure from the four-foot fall.
Federal inspectors found the facility failed to follow proper notification procedures for one of seven residents reviewed during their complaint investigation. The violation was classified as causing minimal harm or potential for actual harm, affecting few residents.
The inspection occurred on August 25, nearly two weeks after the fall that left the resident with bilateral femur fractures and a night of unmanaged severe pain while staff failed to alert her doctor to her deteriorating condition.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avantara Libertyville from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
AVANTARA LIBERTYVILLE in LIBERTYVILLE, IL was cited for violations during a health inspection on August 25, 2025.
The incident occurred on August 12 at Avantara Libertyville when the resident requested assistance to begin her morning routine.
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.