Inspection Reports for
Avantara Elgin

The facility was found deficient in multiple areas including resident dignity, medication self-administration, application of compression stockings, pressure ulcer prevention, supervision and fall precautions, catheter care, medication administration, dietary compliance, and infection control practices.

The complaint investigation substantiated that the resident's thyroid medication was omitted upon readmission and missed during monthly medication regimen reviews, leading to adverse health effects.

The facility failed to ensure a licensed pharmacist identified the omission of a resident's thyroid medication during medication regimen reviews, resulting in the resident missing the medication for 79 days. The facility also failed to transcribe and administer the medication as ordered upon readmission, causing elevated thyroid-stimulating hormone levels and related symptoms.

The investigation was triggered by a complaint about unsafe shower chairs. The complaint was substantiated as the resident fell due to the chair abruptly stopping and tipping, causing fractures.

The facility failed to ensure safe transport of resident R24 to the shower room using a shower chair instead of a wheelchair, causing the chair to abruptly stop and tip, resulting in the resident falling and fracturing both legs. Staff and resident interviews confirmed the shower chairs were in poor repair and difficult to maneuver over floor transition strips.

The visit was complaint-related, investigating grievances about resident safety and care, weight monitoring, pressure ulcer treatment, accident prevention, catheter care, and food preparation. The report documents substantiated deficiencies in all these areas.

The facility failed to document and promptly resolve resident grievances, obtain resident weights as ordered, provide timely treatment orders for pressure ulcers, ensure safe transport of residents using shower chairs, maintain proper indwelling catheter care, and prepare pureed foods to a smooth consistency. These deficiencies affected multiple residents and posed risks of harm.

The complaint was substantiated as the facility failed to provide timely incontinence care to resident R10, leading to skin issues and discomfort.

The facility failed to ensure incontinence care was provided as requested for one resident (R10), resulting in prolonged exposure to wet briefs causing skin irritation and discomfort. Staff acknowledged that incontinence briefs should be changed as needed to prevent moisture-related skin issues.

The complaint investigation was substantiated. Resident R10 was physically abused by agency CNA V15, who roughly handled her, caused bruising, and exhibited a bad attitude. The facility delayed reporting and investigating the abuse, allowing V15 to continue working. The abuse was reported to the administrator on 11/7/2023, and immediate jeopardy was removed on 11/29/2023 after corrective actions.

The facility failed to protect resident R10 from physical, mental, and emotional abuse by agency staff V15, resulting in immediate jeopardy that was later removed. The facility also failed to timely report and investigate the abuse allegation, allowing V15 to continue working despite complaints. Multiple residents reported V15's bad attitude and neglectful care. The facility implemented corrective actions including removal of V15 and staff re-education.

The facility failed to provide the COVID-19 vaccine to one resident who requested it. The investigation revealed communication issues regarding vaccine availability and scheduling, with the pharmacy only offering a mass vaccination clinic after the resident's request.

The complaint investigation found substantiated issues including delayed grievance responses, inadequate ambulation assistance, improper wound care, medication administration errors, improper medication storage temperatures, and failure to follow infection control PPE protocols.

The facility failed to respond timely to resident grievances, assist a resident adequately with ambulation, apply wound dressings as ordered, identify and assess pressure wounds timely, administer medications as ordered, store medications at proper temperatures, and ensure housekeeping staff wore correct PPE in isolation rooms.

The investigation was complaint-driven based on multiple grievances from residents and family members regarding lack of medical record access, unaddressed grievances, inadequate ADL care, and insufficient staffing. The complaints were substantiated as the facility failed to meet regulatory requirements in these areas.

The facility failed to provide requested medical records to a resident's representative, did not properly investigate or respond to resident grievances, failed to provide adequate ADL care including toileting and repositioning for multiple residents, and was understaffed resulting in delayed or missed care.

The investigation was complaint-driven based on allegations of failure to involve residents and families in care planning, failure to address significant weight loss, and failure to provide assistance with showers for residents refusing care. The complaints were substantiated with findings of minimal to actual harm.

The facility failed to ensure care plan meetings were held with residents and their representatives after initial meetings, failed to initiate or update care plans to address significant weight loss and refusal of care such as showers, and failed to notify family or physicians of significant weight loss. Residents R1, R3, and R4 experienced ongoing weight loss and refusal of showers without appropriate interventions or notifications.

The complaint investigation was triggered by the elopement of two residents (R1 and R2) on 4/11/2023. The immediate jeopardy was substantiated and removed on 4/18/2023 after corrective actions including reassessment, 1:1 monitoring, and alarm system repairs.

The facility failed to provide adequate supervision and maintain functioning exit door alarm systems, resulting in two residents eloping and being unsupervised for approximately 90 minutes. The facility also failed to timely assess elopement risk and properly monitor alarm devices. Immediate jeopardy was identified but later removed after corrective actions.