Health inspection·August 25, 2025

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 (R1) reviewed for dependent care in the sample of 7. Findings include:R1's Final Incident report of 08/12/2025 at 11:00AM, shows, R1 needs the assistance of staff for bed mobility . R1 requested assistance from staff to start her day. As V4 CNA assisted R1 to roll to her side R1's leg fell off the bed. V4 CNA attempted to lift R1's legs back on to the bed, due to R1's large size and V4's small size, R1 and V4 CNA fell approximately 4 feet from the bed to the floor. R1's legs crossed during the fall. Due to R1's morbid obesity, osteoarthritis, and the impact pressure of the fall, R1 sustained a left and a right femur fracture.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.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.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 R1 after the fall, R1 denied pain. I went back and re-assessed 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 R1's increase in pain. The staff should have notified (V5) of R1's 8/10 pain. Page 1 of 2 145593 145593 08/25/2025 Avantara Libertyville 1500 South Milwaukee Avenue Libertyville, IL 60048

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 **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 (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.Findings include:R1's Care Plan initiated 04/10/2024 shows, R1 is diagnosed with morbid obesity and generalized osteoarthritis. R1 has an activity of daily living self-care performance deficit related to general weakness, immobility, and decreased activity endurance.R1 Minimum Data Set, dated [DATE] shows, R1 is dependent on staff to roll left and right. R1's Progress Notes dated 8/12/2025 at 10:36PM, shows, Radiology Note, Results: FRACTURE OF THE PROXIMAL LEFT FEMUR.R1's Progress Notes dated 8/12/2025 at 11:50PM, resident transported to emergency room per non-emergency ambulance via stretcher.R1's Final Incident report of 08/12/2025 at 11:00AM, shows, R1 needs the assistance of staff for bed mobility . R1 requested assistance from staff to start her day. As V4 CNA assisted R1 to roll to her side R1's leg fell off the bed. V4 CNA attempted to lift R1's legs back on to the bed, due to R1's large size and V4's small size, R1 and V4 CNA fell approximately 4 feet from the bed to the floor. R1's legs crossed during the fall. Due to R1's morbid obesity, osteoarthritis, and the impact pressure of the fall, R1 sustained a left and a right femur fracture.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, R7 said, my roommate (R1) is in the hospital. R1 fell when the CNA-Certified Nursing Assist was providing incontinent care. It was a hard fall. 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, R1's X-ray showed she broke her left and right femur bones. The CNA that was taking care of R1 rolled her leg too close to the side of the bed. The CNA tried to lift R1's leg back into the bed, but R1 had to be lowered to the ground. V3 stated when V3 went in the room R1 was sitting by the bed on the floor. 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 R1 to get out of bed into the wheelchair. I rolled R1 from one side to the other during morning care. 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. 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. 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, 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.On 08/21/2025 at 2:05PM, V5 NP-Nurse Practitioner said, R1 started slipping off the bed. R1 is morbidly obese; the CNA is small. I was notified of an audible POP to the right knee during the fall. Later R1 started complaining of left hip pain. I ordered X-rays. 145593 Page 2 of 2