Avantara Libertyville: Resident Breaks Both Femurs - IL
The August 12 incident at Avantara Libertyville left the resident hospitalized with a broken left proximal femur and broken right distal femur. Federal inspectors found the facility failed to provide safe bed mobility assistance.
The resident, identified in inspection records as R1, weighs over 300 pounds and requires staff assistance to roll left and right in bed due to morbid obesity, osteoarthritis, and mobility deficits. Her care plan shows she has "general weakness, immobility, and decreased activity endurance."
That morning, R1 requested help from staff to start her day. As certified nursing assistant V4 helped roll R1 to her side, the resident's leg fell off the bed.
"Due to R1's large size and V4's small size," the incident report states, the nursing assistant attempted to lift R1's legs back onto the bed alone.
She couldn't.
"R1 and V4 CNA fell approximately 4 feet from the bed to the floor," according to the facility's incident report. "R1's legs crossed during the fall."
The impact was devastating. "Due to R1's morbid obesity, osteoarthritis, and the impact pressure of the fall, R1 sustained a left and a right femur fracture," inspectors documented.
R1's roommate witnessed the aftermath. "It was a hard fall," the roommate told inspectors on August 20. "R1 weighs over 300 pounds and the CNA is small. The CNA was not able to catch her."
The nursing assistant, V4, described the terrifying moments to investigators: "R1's leg fell off the side of the bed, I was not able to do anything, I tried to put her back into bed. I grabbed her waist and lowered her to floor."
But the damage was done. "R1's legs crossed as we went to the floor. R1 ended up sitting on the floor with her legs crossed in a sitting position."
V4 uncrossed the resident's legs and called for help. Staff used a mechanical lift to get R1 back into bed.
The licensed practical nurse who responded found R1 sitting on the floor beside her bed. "R1 said, there was a POP to the right knee and later complained of left thigh pain," the nurse told inspectors.
X-rays revealed the extent of the injuries. Emergency room staff confirmed fractures to both femurs when the facility called for an update the next morning.
The Director of Nursing explained the physics of the fall to investigators: "R1's legs swung over the side of the bed. The CNA is very small. With R1's weight, combined with R1's legs being crossed as R1 went to the ground, the left and right hip fractures happened."
The facility's nurse practitioner, who ordered the X-rays, described receiving the initial injury report: "I was notified of an audible POP to the right knee during the fall. Later R1 started complaining of left hip pain."
Federal inspectors determined this represented an "actual harm" violation affecting the resident's safety. The inspection found Avantara Libertyville failed to ensure its nursing home area was "free from accident hazards" and failed to provide "adequate supervision to prevent accidents."
The incident report reveals a dangerous mismatch between resident needs and staff capabilities. R1 required assistance for basic bed mobility due to her size and medical conditions, yet received help from a single small nursing assistant who couldn't safely manage the transfer alone.
R1 remains hospitalized. The emergency room admission note shows she was diagnosed not only with the bilateral femur fractures but also with a left urethral stone, suggesting additional complications from the fall and subsequent medical treatment.
The facility transported R1 by stretcher via non-emergency ambulance the evening of August 12, nearly 12 hours after the morning fall that broke both her legs.
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 August 12 incident at Avantara Libertyville left the resident hospitalized with a broken left proximal femur and broken right distal femur.
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.