Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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
observations, interviews and records reviewed the facility failed to follow fall prevention interventions to
include supervision/monitoring and use of assistive/safety devices to prevent the risk of falling. This affected
three of three residents (R1-R3) reviewed for falls and fall prevention interventions. This failure resulted in
R1 being involved in a fall incident sustaining a fracture of the L4 and L5, Lumbar Spine, and R3 being
involved in a fall incident resulting in an Oblique Fracture of the Left Fifth Metatarsal and of the Neck of the
Right Radius.
Findings include:
A.R3's diagnosis include but are not limited to Spinal Stenosis, Anemia, Dementia, Osteoarthritis, Difficulty
in Walking, Age Relate Physical Debility, Altered Mental Status, Lumbago with Sciatica, Right Side, and
Radiculopathy - Lumbar Region. R3's Cognitive assessment dated [DATE] indicates mildly impaired.
On 10/29/23 at 2:49PM The surveyor observed a star on the door, near R3's name, door closed. V3,
Restorative Aid, in the room with the roommate. V3 sitting a chair near roommate. R3 opened the door and
greeted the surveyor. R3 walking in the room then to sink to finish washing. R3 hanging washcloth on towel
rack and then stumbled while turning, but regained balance, loud squeaking sound from shoe, before sitting
on his bed. R3 said yes, I fell I was up alone in my room. R3 said I did not call for help. R3 said I was
ashamed and did not call for help. R3 said I don't call for help when I need to use the bathroom or get
something. No alarms sounding with the resident in the room.
On 10/29/23 at 3:15PM V3, Restorative Aid, said I was in R3's room working with R3's roommate. V3 said I
work with R3 for range of motion. V3 said R3 can walk with a standby. V3 said R3 was using the washroom
I was in the room. V3 said I did not see him stumble. V3 said I would not have gotten to R3 from where I
was if he was falling. V3 said R3 does not have alarms on and he should. V3 said I did not [NAME] R3's
alarms off when I went in the room.
On 10/30/23 at 9:52AM V9, Fall Nurse, said R3 is a fall risk. R3's diagnosis include Spinal Stenosis,
Arthritis, Debility, Lack of Coordination, and Altered Mental Status. V9 said R3 had one fall on 10/17/23. V9
said R3 should be supervision for ambulation. V9 said this means R3 should have a person in the room
while ambulating. V9 said R3 is not stand by assist for ambulation. V9 said Staff should be standing when
supervising residents. V9 said staff don't need to sit so they can move faster for staff. V9 said R3
complained about the alarms being too loud so I stopped them. V9 said R3 is alert and can call for assist
with the call light. V9 said she was unsuccessful in reaching the night shift agency staff to interview about
R3's fall. V9 said it is unknown if the alarm was answered or
(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 4
Event ID:
145667
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
145667
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara Park Ridge
1601 North Western Avenue
Park Ridge, IL 60068
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
if the alarm was in place and on at the time of R3's fall. V9 said R3 sustained a fracture on right foot.
Level of Harm - Actual harm
On 10/30/23 at 11:30AM V11, Therapy Director, said R3 is currently supposed to be walking with a walker
and supervision, including yesterday. V11 said prior to R3's fall on 10/17/23 R3 required supervision for
ambulation. V11 said supervision means staff should be in eyesight during ambulation.
Residents Affected - Few
R3's Fall Risk Evaluation dated 10/17/23 score is 13, high risk.
R3's care plan dated 9/15/23 identifies R3 at risk for falls related to Spinal Stenosis with Radiculopathy,
Right Hip, Osteoarthritis, Altered Mental Status, Dementia, Depression, and Debility. Interventions dated
9/15/23 include bed alarm and chair alarm.
R3's care plan for Activity of Daily Living and Fall Risk do not address R3's ambulation ability/status.
R3's Functional Status dated 9/21/23 indicates he needs staff assistance during transfers and was not
ambulating at the time.
Incident Report dated 10/17/23 documents R3 notified staff he fell during the night and did not report or call
for help. Resident statement, in part, reads I was trying to use the rest room and fell.
The facility Incident Report dated 10/18/23 documents after hospital evaluation R3 findings include Oblique
Fracture of the Fifth Metatarsal and of the Neck of the Right Radius - initial encounter.
R3's hospital record dated 10/17/23 states oblique fracture through the fifth metatarsal shaft. Closed
non-displaced fracture of fifth metatarsal bone of left foot and closed non-displaced fracture of neck of right
radius.
B. R1's diagnosis include but are not limited to Fracture of Left Femur, Anemia, and Hypertension.
On 10/29/23 at 1:27PM V2, Licensed Practical Nurse, said R1 fell because he had a Urinary Tract Infection
and may have had a behavior change. V2 said R1 could not walk. V2 said I was called to the room and saw
R1 on the floor. V2 said I don't know what CNA was assigned to him. V2 said I was not assigned to R1.
On 10/29/23 at 2:08PM V12, Nurse Supervisor said on 9/11/23 when I went to R1's room I saw him on the
floor. V12 said R1 either pulled the light or the alarm sounding. V12 said R1 did not know he was on the
floor. V12 said when I asked R12 about the fall, he said oh, I'm on the floor. V12 said I am not sure of R1's
his mental status at the time. V12 said R1 was on isolation at the time and his room door was closed. V12
said R1 was on his back. He was right next to the bed. V12 said R1 was not a fall risk. V12 said I did not
see him fall and I do not know what he was trying to do.
On 10/30/23 at 9:52AM V9, Fall Nurse, said V5,Nurse, and V13, CNA, were interviewed and said R1 tried
to transfer without assistance. V13 said she did not see the fall, V13 said to V9 I was providing care to
another resident. V9 said V5, Nurse, said V12, Nurse Supervisor, called me and said R1 was on the floor.
V9 said she was told V12 was rounding and saw the call light on and when he entered the room R1 was on
the floor. V9 said R1 is always in bed, he had not tried to get up. V9 said R1 was on antibiotic and could
have been confused causing him to fall. V9 said R1's baseline was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145667
If continuation sheet
Page 2 of 4
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
145667
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara Park Ridge
1601 North Western Avenue
Park Ridge, IL 60068
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
Level of Harm - Actual harm
Residents Affected - Few
incontinent of urine. V9 said I don't know what R1 was trying to do when he fell. V9 said R1 required a
mechanical lift for transfer, and he was not strong enough to stand. V9 said R1's door was closed for
isolation. V9 said there was no other cnas involved in R1's care, V13 was the assigned CNA. V9 had no
additional interviews for R1's fall. While reviewing R1's incident report/investigation with V9, she was unable
to say when R1 was last turned, repositioned, or received incontinent care. V9 was unable to say who
assisted in repositioning R1 during the shift.
On 10/29/23 at 11:32AM V8, R1's wife, said R1 had fractures of the L4 and L5 in his back he did not have
those before the fall.
R1's care plan dated 2/18/2023 states R1 is at risk for falls related to left femur fracture status post surgery,
anemia, abnormal gait and mobility. Interventions for R1 include bed alarm in place chair alarm in place,
requires two staff participation to reposition and turn in bed.
Incident report for R1 dated 9/11/2023 reads R1 verbalized pain to the right leg and facial grimacing was
noted level of pain is 6 out of 10.
Review of R1's medication administration record and physician orders for September 2023 do not include
treatment of urinary tract infection.
Physical therapy Discharge summary dated [DATE] documents R1 to require partial/moderate assistance
with sitting to standing. Transfers from chair to bed require partial/moderate assistance. Substantial/Maximal
assistance for toilet use and patient was unable to ambulate.
The facility's incident report to IDPH on 9/11/23 reveals R1 was transferred to the hospital on 9/11/23. R1
was admitted to the hospital with lower back trauma. A CT of the spine revealed L4 and L5 compression
deformities that are new compared to 9/25/2022 and represent acute fractures.
C.R2's diagnosis include but are not limited to Fall, Compression Fracture of Vertebra, Anemia, Difficulty in
Walking, Weakness, and Osteoporosis.
On 10/29/23 at 10:33 AM R2 called for the nurse in the dining room and asked V2, LPN, to check his blood
sugar. V2 said in 2 minutes I will be there. The surveyor remained monitoring R2 until 10:45AM and V2 did
not return him.
On 10/29/23 at 1:27PM V2, LPN, said R2 is very alert but we must help him. V2 said R2 requires 2 person
assistance to get from wheelchair to the bed we use the mechanical lift.
On 10/29/23 at 3:32PM V4, Registered Nurse, said R2 used the call light around 6:45AM. V4 said R2 said
he wanted to get up and sit in the wheelchair. I asked him to wait for the CNA. V4 said R2 called again, he
said I want to get up, I just need some help, he did not want to wait. V4 said on the third time R2 called I
helped him to get up. V4 said I helped him lower his feet from the bed, I held his arms, he was helping, but
then his feet were shaking, he got weak. V4 said I was about to fall. V4 said the safest thing to do was to put
him on the floor. V4 said this was my first time working with the resident. The surveyor asked V4 how she
knows the transfer status of the residents she is assigned to. V4 was unable to answer. V4 said R2 is 1
assist. V4 said R2 said he is going to help me, and he said he can help.
On 10/30/23 at 9:52AM V9, Fall Nurse, said R2 is high risk for falls because he has fractures in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145667
If continuation sheet
Page 3 of 4
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
145667
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Avantara Park Ridge
1601 North Western Avenue
Park Ridge, IL 60068
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
Level of Harm - Actual harm
Residents Affected - Few
the spine, lack of coordination weakness, and history of falls. V9 said R2 is a 2 person assist with a
mechanical lift for transfers. V9 said to use the commode R2 is a 2 person assist. V9 said R2 has required 2
person since his admission. V9 said the cause of the fall on 10/12/23 was related to R2 asking to transfer
out of bed. V9 said the Staff Care Binder is used to notify staff of resident transfer status. V9 said the V4
can look at the binder to know what care to provide. V9 said R2 is cooperative with the mechanical lift.
Incident report dated 10/12/23 reads R2 requested to get out of bed and into his wheelchair. This writer, V4,
told him to wait for his CNA. Report reads I still want to sit in my wheelchair. At 7:00AM writer attempted to
transfer R2 from bed to wheelchair. R2's legs began to shake and R2 became unsteady. R2 assisted to the
floor.
Review of R2's Incident Reports identify falls on 9/16/23; 9/29/23; and 10/12/23.
R2's care plan dated 9/18/23 states R2 require 2 staff participation with mechanical lift transfers to prevent
fall.
On 10/30/23 at 9:52 AM V9, Fall Nurse, said a resident's diagnosis can increase the risk for falls such as
Hypertension, Diabetes, Parkinson's, Impaired Memory, Dementia, Alzheimer's, Weakness, Debility,
Seizure, and Syncope. V9 said the Root Cause Analysis is what led to the fall. V9 said the plan is
developed from the cause.
On 10/30/23 at 2:32PM V15, MDS Coordinator, said the purpose of the care plan is so the nurses can find
the intervention for the plan of care of the resident. V15 said I expect the nurses to follow the careplan. V15
said when an intervention is no longer needed we do review and update the care plan. V15 said we can
add and remove interventions or resolve them.
The facility fall prevention program guidelines dated December 5th 2022 states fall prevention program
guidelines shall be implemented to promote safety of all residents in the facility. safety interventions shall be
initiated and implemented for each resident identified at risk for fall. All assigned nursing personnel and
facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently
maintained. All file incidents shall be monitored, analyzed, root causes identified.
The facility Fall Occurrence policy dated 7/17/23 reads it is the policy of the facility to ensure that residents
are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and
revised as necessary. If a resident has fallen, the resident is automatically considered as high risk for falls.
The falls coordinator will add the intervention in the residence care plan. The interventions will be
reevaluated and revised as necessary.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145667
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ · About this visit
Common questions about this visit
What happened during the November 2, 2023 survey of AVANTARA PARK RIDGE?
This was a inspection survey of AVANTARA PARK RIDGE on November 2, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AVANTARA PARK RIDGE on November 2, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.