Inspection·January 15, 2025

F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Actual harm Residents Affected - Few Based on interview and record review, the facility failed to ensure a resident's Physician/Nurse Practitioner was immediately notified of a fall where the resident had hit his head. This failure resulted in an over six-hour delay in hospitalization and treatment. This applies to 1 of 3 residents (R3) reviewed for notification of changes. Findings include: The facility's 1/6/25 reportable Serious Injury Incident form for R3 showed Resident noted on his right side next to his bed. Resident was transferred to hospital. admitted with 4 [millimeter] hyper density left frontoparietal lobe suspicious for a small focus of intraparenchymal hemorrhage . R3's 1/4/25 progress note showed 9:30 PM, resident observed, laying on the floor on his right side, next to his bed, bruise noted, on right side of face with swelling .call out to [Nurse Practitioner (V16)] .neuro-check in progress . This progress note was timed at 11:48 PM, two hours after R3's fall. R3's 1/5/25 progress note showed [Nurse on Duty] called Dr. on call, NP [V16], to get orders. Waiting on call back. Resident will continue to be monitored for safety . This progress note was timed at 4:10 AM, over six hours after R3's fall. R3's 1/5/25 progress note from 4:22 AM showed Received a call back from [V16] at 4:13 AM, orders to send resident to ER (Emergency Room) for further assessment. R3's nursing progress note does not show the time R3 went to the hospital or how he was transported. On 1/9/25 at 2:00 PM, V1 (Administrator) stated when the night nurse had come on duty, she called the Nurse Practitioner on call to get orders. V1 stated R3's fall was unwitnessed. On 1/10/25 at 3:10 PM, V16 (Nurse Practitioner) stated he does not recall every detail and he was not alarmed by the initial call he received- there was no obvious injury. V16 stated when they called him again though he thought there was something wrong. V16 stated he has to make decisions based on the information that is given to him. V16 stated if the resident hits their head and the resident is on Coumadin (anti-coagulant medication), you send them to the hospital. R3's Face Sheet showed diagnoses that include long term use of anticoagulant and personal history of venous thrombosis and embolism. R3's January 2025 Physician Order Sheet showed a 1/2/25 order for 3mg of Coumadin daily, and a standing order for Resident on Anticoagulant monitor for signs of (continued on next page) 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 Facility ID: If continuation sheet Page 1 of 2 Event ID: 145029 Printed: 05/15/2026 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 145029 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avantara Joliet 210 North Springfield Avenue Joliet, IL 60435 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)