Health inspection·January 9, 2026

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately initiate chest compressions and call 911 for one full code resident (R1) who was found unresponsive without a pulse. This affected one of three residents (R1) reviewed for CPR. Findings include:Based on interview and record review, the facility failed to immediately initiate chest compressions and call 911 for one full code resident (R1) who was found unresponsive without a pulse. This affected one of three residents (R1) reviewed for CPR. Findings include:R1 was admitted to the facility on [DATE] with a diagnosis of type II diabetes, bradycardia, cerebral infarction, pulmonary hypertension, anemia, chronic respiratory failure, congestive heart failure, obstructive pulmonary disease and sleep apnea.R1's physician orders dated [DATE] document full code.On [DATE] at 7:13AM, V27 (Certified nursing aide, CNA) was assigned to R1 on overnight shift on [DATE]. V27 said around 4:30 she attempted to provide care to R1. V27 said she tried to wake R1 up and was not responding. V27 said she called for the nurse who came and check for pulse but could not find one. V27 said V7 (Nurse) was not sure if R1 was a full code so she went to check and came right back to confirm R1 was a full code. V27 said V7 said she did not know how to call overhead page ‘code blue' so V27 went to get the other nurse on the unit. V27 said V26 (Nurse) called the code and went to room to start compressions.On [DATE] at 7:27AM, V25 (Certified nursing aide, CNA) was assigned to R1's unit on 12/30 overnight shift. V25 said she was providing care to a patient when she heard the page for a code blue. V25 said she saw V26 (Nurse) at nursing station. Other nurses came up to the unit from the elevator, V20 (Nurse) and V28 (Nurse) came up to unit asking if anyone called 911. V25 said she saw V7 (Agency nurse) on the phone and V26 went back to the R1's room. V28 told V7 that she needed to call 911 not trace ambulance. V28 called 911.On [DATE] 12:42pm, V26 was assigned to R1's unit on 12/30 overnight shift. V26 said she was in a patient's room on other side of unit when an aide came to tell her there was a code blue. V26 said she overhead paged that there was a code and went to the R1's room. V26 said no one was in the room when she arrived. V26 said she checked R1's pulses with no pulse felt and started compressions. On [DATE] at 9:31AM, V28 who was assigned to first floor on overnight shift 12/30. V28 said she heard the page for code blue. V28 said when she got to R1's unit she called 911 from the facility phone because she wasn't sure if anyone had called. V28 said she doesn't recall if V7 called other ambulance company or 911.On [DATE] at 3:36PM, V31 (MD) said she would expect staff to immediately begin chest compressions upon finding a full code resident without a pulse and unresponsive. V31 said it's important due to time and the sooner you are able to start chest compressions that helps to get the blood pumping back to the patient.On [DATE] at 1:51PM, V2 (Director of nursing) said staff should immediately start chest compressions upon finding a resident a full code resident without a pulse and unresponsive.According to the American heart association, in adult cardiac arrest, resuscitation should generally be conducted where the patient is found, as long as Page 1 of 2 145607 145607 01/09/2026 Avantara Palos Heights 7850 West College Drive Palos Heights, IL 60463

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few high-quality cardiopulmonary resuscitation (CPR) can be administered safely and effectively. After identifying an adult in cardiac arrest, a lone responder should activate the emergency response system first, then immediately begin CPR. Early, high-quality CPR and prompt defibrillation are the most important interventions associated with improved outcomes in adult cardiac arrest. The fundamental basic life support tasks of recognition of cardiac arrest, activation of emergency response, performance of chest compressions and ventilations, and use of an AED for defibrillation are critical components representing the first links of the Chain of Survival that must be optimized so persons with cardiac arrest can fully benefit from advanced cardiovascular care therapies. Immediate initiation of chest compressions is one of the most impactful interventions for survival from cardiac arrest.Facility code blue policy reviewed [DATE] documents: to maintain a well-coordinated and organized emergency care to a resident at any given time while medical interventions are managed according to the established standard of care. The assigned nurse will initiate the medical emergency interventions for full code status per facility protocol after evaluating the signs and symptoms of cardiac arrest. One staff will lead the team by assigning staff while CPR is in progress. Call 911, notify primary doctor, call family, prepares the transfer forms.Interview attempts with V7 (Agency nurse) were unsuccessful. V7 basic life support card dated [DATE] documents V7 completed American heart association basic life support (CPR and AED) program. 145607 Page 2 of 2