Avantara Libertyville

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based 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 (Resident R1) reviewed for dependent care in the sample of 7. Findings include:Resident R1's Final Incident report of 08/12/2025 at 11:00AM, shows, Resident R1 needs the assistance of staff for bed mobility . Resident R1 requested assistance from staff to start her day. As V4 CNA assisted Resident R1 to roll to her side Resident R1's leg fell off the bed. V4 CNA attempted to lift Resident R1's legs back on to the bed, due to Resident R1's large size and V4's small size, Resident R1 and V4 CNA fell approximately 4 feet from the bed to the floor. Resident R1's legs crossed during

the fall. Due to Resident R1's morbid obesity, osteoarthritis, and the impact pressure of the fall, Resident R1 sustained a left and a right femur fracture.Resident R1's Vital Sign record dated 08/12/2025 at 5:00PM, shows, Pain at 12:35PM, 2/10, Pain at 5:00PM, 8/10.Resident R1's Progress Note dated 8/12/2025 at 5:46PM, shows, patient resting in bed

during X-ray wait time. Continues to report left leg pain rated 8/10 on pain scale.Resident R1's Progress Note dated 8/12/2025 at 10:21PM, shows, X-ray results received at 10:05PM, indicating left femur fracture. Medical Doctor.Nurse Practitioner.resident informed of results; continues to report left leg pain rated 8/10. Order received from Medical Doctor to transfer patient to hospital for further evaluation and management.On 08/20/2025 at 12:15PM, V3 LPN-Licensed Practical Nurse said, when I initially assessed Resident R1 after the fall, Resident R1 denied pain. I went back and re-assessed Resident R1 and she complained of a low-level pain to the thigh. I provided acetaminophen and updated V5 Nurse Practitioner of the left thigh pain; an X-ray for the hip was ordered. X-ray did not arrive during my shift. I gave report to the evening shift.On 08/25/25 at 1:30PM, V5 Nurse Practitioner said, she was not notified of Resident R1's increase in pain. The staff should have notified (V5) of Resident R1's 8/10 pain.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Avantara Libertyville

1500 South Milwaukee Avenue Libertyville, IL 60048

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to provide bed mobility in a safe manner for 1of 7 residents (Resident R1) reviewed for safety/falls in the sample of 7. This failure resulted in Resident R1 falling from Resident R1's bed and sustaining left and right femur fractures requiring hospitalization.Findings include:Resident R1's Care Plan initiated 04/10/2024 shows, Resident R1 is diagnosed with morbid obesity and generalized osteoarthritis. Resident R1 has an activity of daily living self-care performance deficit related to general weakness, immobility, and decreased activity endurance.Resident R1 Minimum Data Set, dated [DATE REDACTED] shows, Resident R1 is dependent on staff to roll left and right. Resident R1's Progress Notes dated 8/12/2025 at 10:36PM, shows, Radiology Note, Results: FRACTURE OF

THE PROXIMAL LEFT FEMUR.Resident R1's Progress Notes dated 8/12/2025 at 11:50PM, resident transported to emergency room per non-emergency ambulance via stretcher.Resident R1's Final Incident report of 08/12/2025 at 11:00AM, shows, Resident R1 needs the assistance of staff for bed mobility . Resident R1 requested assistance from staff to start her day. As V4 CNA assisted Resident R1 to roll to her side Resident R1's leg fell off the bed. V4 CNA attempted to lift Resident R1's legs back on to the bed, due to Resident R1's large size and V4's small size, Resident R1 and V4 CNA fell approximately 4 feet from the bed to the floor. Resident R1's legs crossed during the fall. Due to Resident R1's morbid obesity, osteoarthritis, and the impact pressure of the fall, Resident R1 sustained a left and a right femur fracture.Resident R1's Progress Notes dated 8/13/2025 at 6:30AM, shows, called emergency room for an update on resident status . Resident is admitted with a diagnosis of Closed fracture of proximal end of left femur; closed fracture of distal end of right femur; left urethral stone.On 08/20/2025 at 10:27AM, Resident R7 said, my roommate (Resident R1) is in the hospital. Resident R1 fell when the CNA-Certified Nursing Assist was providing incontinent care. It was a hard fall. Resident R1 weighs over 300 pounds and the CNA is small. The CNA was not able to catch her. On 08/20/2025 at 12:15PM, V3 LPN-Licensed Practical Nurse said, Resident R1's X-ray showed she broke her left and right femur bones. The CNA that was taking care of Resident R1 rolled her leg too close to the side of the bed. The CNA tried to lift Resident R1's leg back into the bed, but Resident R1 had to be lowered to the ground. V3 stated when V3 went in the room Resident R1 was sitting by

the bed on the floor. Resident R1 said, there was a POP to the right knee and later complained of left thigh pain.On 08/20/25 at 12:30PM, V4 CNA said, I was preparing Resident R1 to get out of bed into the wheelchair. I rolled Resident R1 from one side to the other during morning care. Resident 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. Resident R1's legs crossed as

we went to the floor. Resident R1 ended up sitting on the floor with her legs crossed in a sitting position. I uncrossed them and called the nurse. We placed a sling under her and used a mechanical lift to put her back into the bed. On 08/20/2025 at 1:43PM, V2 DON-Director of Nursing said, Resident R1's legs swung over the side of the bed.

The CNA is very small. With Resident R1's weight, combined with Resident R1's legs being crossed as Resident R1 went to the ground,

the left and right hip fractures happened.On 08/21/2025 at 2:05PM, V5 NP-Nurse Practitioner said, Resident R1 started slipping off the bed. Resident R1 is morbidly obese; the CNA is small. I was notified of an audible POP to the right knee during the fall. Later Resident R1 started complaining of left hip pain. I ordered X-rays.

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