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
(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:
145607
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
145607
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/09/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara Palos Heights
7850 West College Drive
Palos Heights, IL 60463
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 0678
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Event ID:
Facility ID:
145607
If continuation sheet
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