Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 22, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to identify and properly document a fall for a resident (R1) with a history of falling and to implement the facility's fall policy.
Complaint Details
The complaint investigation revealed that the facility did not report or document a fall of resident R1 on 1/16/25, did not complete an incident report or post-fall assessments, and failed to update the care plan. Staff considered the event a behavior rather than a fall. The Restorative Director was not informed and did not follow fall policy procedures.
Findings
The facility failed to identify a fall for resident R1 on 1/16/25, did not complete required incident reports or assessments, and did not update the care plan after the fall. Staff considered R1 sliding from his wheelchair while reaching for toys as a behavior rather than a fall, contrary to facility policy. The Restorative Director was unaware of the fall and the fall policy was not followed.
Deficiencies (1)
Failed to identify a fall for a resident with a history of falling and failed to implement fall policy for 1 of 3 residents reviewed for safety/supervision.
Report Facts
Residents affected: 3
Residents affected: 1
Percentage of work performed by staff for transfers: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse (RN) | Named in findings related to failure to identify fall and incomplete documentation |
| V5 | Certified Nursing Assistant (CNA) | Provided information about resident's behavior with toys |
| V6 | Restorative Director | Responsible for fall investigations and care plan updates; unaware of unreported fall |
| V7 | Certified Nursing Assistant (CNA) | Provided information about resident's need for supervision and behavior |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 8, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident dignity, care, safety, infection control, medication administration, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during personal care, failure to obtain weights as ordered, unsafe storage of razors accessible to residents with dementia, improper catheter care, failure to administer oxygen as ordered, medication administration errors, failure to offer bedtime snacks consistently, and lapses in infection prevention and control practices.
Deficiencies (8)
Failed to provide dignity during personal cares for residents by exposing them unnecessarily and not ensuring privacy.
Failed to obtain weights as ordered by a physician for a resident at risk for fluctuating weights.
Failed to ensure residents with dementia did not have access to razors, creating accident hazards.
Failed to ensure indwelling urinary catheter drainage bag was kept below the level of the bladder to prevent infection.
Failed to administer oxygen as ordered by a physician for multiple residents, with oxygen concentrators set incorrectly.
Failed to ensure physician prescribed medications were administered as ordered; resident self-administered medications without required assessments or orders.
Failed to ensure bedtime snacks were consistently offered to residents as ordered.
Failed to implement contact isolation precautions for a resident with MRSA, failed to wear appropriate PPE for residents on enhanced barrier precautions, and failed to perform glove changes during incontinence care.
Report Facts
Residents reviewed: 32
Residents affected: 2
Residents affected: 1
Residents affected: 10
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 4
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding privacy, medication administration, catheter care, infection control |
| V4 | Certified Nursing Assistant | Observed handling catheter drainage bag improperly and razor safety concerns |
| V6 | Licensed Practical Nurse | Provided statements about razor safety and catheter care |
| V11 | Clinical Care Coordinator | Provided statements regarding privacy, weights, oxygen therapy, bedtime snacks |
| V12 | Registered Nurse Supervisor | Provided statements regarding oxygen therapy and isolation precautions |
| V13 | Certified Nursing Assistant | Observed providing incontinence care without gown |
| V15 | Certified Nurse Aide | Observed catheter care without gown |
| V16 | Certified Nursing Assistant | Observed incontinence care without gown and improper glove use |
| V3 | Infection Preventionist | Provided statements regarding isolation signage and PPE use |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 14, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide timely assessment and treatment for a resident (R1) with eczema on her scalp.
Complaint Details
The investigation was complaint-related, triggered by concerns from R1's power of attorney regarding untreated eczema on the resident's scalp. The complaint was substantiated as the facility failed to timely assess and treat the condition.
Findings
The facility failed to ensure that R1's eczema was assessed and treated in a timely manner. The resident's scalp condition worsened over several months without appropriate treatment, and staff were unaware or delayed in responding to the issue until recently.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals for a resident with eczema.
Report Facts
Residents reviewed for quality of care: 6
Residents affected: 1
Braden score: 12
Dates of bed baths with no skin alterations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 Certified Nursing Assistant | Certified Nursing Assistant (CNA) | Reported R1's head condition and care provided |
| V5 | Power of Attorney of Financial | Brought medicated shampoo for R1 and reported concerns |
| V7 | Wound Care Nurse Practitioner (WCNP) | Recommended medicated shampoo and commented on treatment |
| V8 | Wound Care Nurse | Unaware of R1's scalp condition until recently |
| V9 | Registered Nurse (RN) | Day shift nurse unaware of R1's eczema |
| V10 | Social Services | Received report of concerns from R1's POA and inquired about treatment plan |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide oxygen therapy according to professional standards for a resident experiencing low oxygen levels.
Complaint Details
The complaint investigation found that the resident was on a non-rebreather mask at 4LPM with oxygen saturation at 54%, which was inadequate. EMS increased oxygen to 15LPM, improving the resident's condition. Staff admitted to placing the mask at 15LPM but failed to document it. The facility policy requires non-rebreather flow rates of 8-12LPM.
Findings
The facility failed to provide appropriate oxygen therapy to a resident with chronic respiratory failure, as oxygen was administered at an ineffective flow rate of 4LPM instead of the required 12-15LPM, and documentation of oxygen adjustments was lacking. Staff interviews and policy review confirmed the deficiency in oxygen administration and monitoring.
Deficiencies (1)
Failed to provide oxygen therapy according to professional standards for a resident experiencing low oxygen levels.
Report Facts
Oxygen flow rate: 4
Oxygen flow rate: 15
Oxygen saturation: 54
Oxygen saturation range: 80
Oxygen saturation range: 82
Non-rebreather flow rate policy range: 8
Non-rebreather flow rate policy range: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Licensed Practical Nurse-LPN | Stated oxygen should be at 15LPM for non-rebreather mask and admitted placing the mask but did not document the oxygen flow rate. |
| V11 | Nurse Practitioner | Stated non-rebreather mask requires at least 12LPM for proper oxygenation and that oxygen levels should have been continuously monitored. |
| V5 | Licensed Practical Nurse-LPN | Stated oxygen levels should be increased and rechecked, and non-rebreather mask at 4LPM is ineffective. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to adequately supervise a resident with dementia and a history of wandering, following observed injuries and bruises on the resident.
Complaint Details
The complaint investigation found that the resident (R2) had bruises and injuries with no clear explanation. Staff reported no 1:1 supervision on the day the injuries likely occurred, despite the resident's known wandering behavior and need for supervision. The complaint was substantiated by observations and interviews.
Findings
The facility failed to provide adequate supervision for one resident (R2) with dementia and wandering behavior, resulting in unexplained bruises and injuries. Staff interviews revealed lapses in 1:1 monitoring, particularly on the weekend when no sitter was assigned.
Deficiencies (1)
Failure to supervise a resident with dementia and a history of wandering, leading to unexplained bruises and injuries.
Report Facts
Residents reviewed for safety: 9
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V6 Licensed Practical Nurse | Licensed Practical Nurse | Reported on R2's wandering behavior and supervision needs |
| V1 Administrator | Administrator | Provided information about supervision assignments and injury reports |
| V12 Certified Nursing Assistant | Certified Nursing Assistant | Observed R2 wandering without 1:1 supervision |
| V13 Licensed Practical Nurse | Licensed Practical Nurse | Nurse on duty during the weekend when injuries occurred, unaware of 1:1 assignment |
| V3 Licensed Practical Nurse | Licensed Practical Nurse | Reported ongoing 1:1 monitoring of R2 after moving to the unit |
Inspection Report
Annual Inspection
Census: 163
Deficiencies: 8
Date: Jun 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment, safety, and facility operations at Avantara Long Grove nursing home.
Findings
The facility was found deficient in multiple areas including cleanliness and maintenance of resident rooms, provision of care for activities of daily living, pressure ulcer prevention and care, aspiration precautions, fall prevention, perineal care to prevent infections, nutritional supplementation, and sanitary handling of cookware.
Deficiencies (8)
Failed to ensure resident rooms were clean and homelike for 4 of 32 residents reviewed.
Failed to provide care and assistance to perform activities of daily living for 2 of 32 residents reviewed.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for 2 of 5 residents reviewed.
Failed to ensure aspiration precautions were maintained and failed to provide thicken liquids for 1 of 32 residents reviewed for safety.
Failed to ensure fall interventions were in place for a resident at risk for falls.
Failed to ensure perineal care was provided in a manner to prevent infections for a resident with a history of urinary tract infections.
Failed to ensure a resident with significant weight loss was provided nutritional supplements at meals.
Failed to ensure cookware was handled in a sanitary manner affecting all residents.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents: 163
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V10 | Housekeeping | Reported cleaning schedule and staffing shortages |
| V11 | Housekeeping Director | Reported staffing shortages and cleaning procedures |
| V14 | Certified Nursing Assistant | Involved in incontinent care causing resident discomfort |
| V4 | Wound Care Nurse | Provided wound care assessment and comments |
| V5 | Restorative Nurse | Provided information on resident care and fall risk |
| V13 | Registered Dietitian | Provided dietary information and supplement recommendations |
| V7 | Certified Nursing Assistant | Provided incontinent care and fall risk information |
| V6 | Speech Therapist | Provided information on dysphagia and aspiration risk |
| V9 | Cook | Observed handling cookware in unsanitary manner |
| V8 | Dietary Manager | Provided policy on dishwashing and hand hygiene |
| V2 | Director of Nursing | Provided guidance on proper perineal care technique |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 10, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding resident room cleanliness, timely repairs, and medication administration practices.
Findings
The facility failed to maintain clean and well-repaired resident rooms for 11 of 13 residents reviewed, with issues including broken equipment, unclean floors, and walls with damage. Additionally, the facility failed to ensure proper medication administration for one resident, as pills were found on the floor and medication pass procedures were not fully followed.
Deficiencies (2)
Resident rooms were not clean and repairs were not performed timely, including broken siderails, dirty floors, unclean air conditioning units, and walls with multiple nicks.
Prescription medications were not administered according to standards of practice; two unidentified pills were found on the floor in a resident's room.
Report Facts
Residents affected: 11
Residents reviewed for cleanliness: 13
Residents reviewed for medication administration: 3
Residents affected by medication deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Reported short staffing and cleaning schedule | |
| Maintenance | Reported on repair requests and maintenance procedures | |
| V7 CNA | Certified Nursing Assistant | Assisted resident with breakfast and found pills on floor |
| V10 LPN | Licensed Practical Nurse | Nurse for resident with medication administration issue |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 14, 2023
Visit Reason
The inspection was conducted as an annual survey to assess the facility's compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to wound care, incontinence care, pharmaceutical services, medication storage, food preparation, and infection prevention at Avantara Long Grove nursing home.
Findings
The facility was found deficient in multiple areas including failure to change wound dressings as ordered, inadequate incontinence care, improper medication dispensing and storage, failure to provide properly pureed food, and lapses in infection control practices such as hand hygiene and glove use.
Deficiencies (6)
Failed to change a non-pressure wound dressing as ordered for 1 of 3 residents reviewed for wound care.
Failed to provide incontinence care in a manner to prevent infection for 1 of 3 residents reviewed for incontinence care.
Failed to ensure medications were dispensed according to standards of practice for 1 of 4 residents reviewed for pharmacy services.
Failed to ensure medications were secured for 2 of 35 residents reviewed for medications.
Failed to ensure the noon meal was thoroughly pureed for 21 of 21 residents reviewed for pureed diet.
Failed to wash hands and change gloves to prevent the spread of infection to 1 of 35 residents reviewed for infection control.
Report Facts
Residents reviewed for wound care: 3
Residents reviewed for incontinence care: 3
Residents reviewed for pharmacy services: 4
Residents reviewed for medications: 35
Residents on pureed diet: 21
Residents reviewed for infection control: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Wound Care Nurse | Confirmed wound dressing discrepancy and removal for resident R162 |
| V6 | Certified Nursing Assistant (CNA) | Provided incontinence care to residents R87 and R99; involved in infection control deficiency |
| V3 | Licensed Practical Nurse (LPN) | Provided guidance on incontinence care and infection control practices |
| V9 | Registered Nurse (RN) | Discussed medication administration practices |
| V8 | Licensed Practical Nurse (LPN) | Discussed medication administration and storage practices |
| V2 | Director of Nursing | Provided statements on medication administration policies |
| V4 | Licensed Practical Nurse (LPN) | Discussed medication storage and resident assessment |
| V12 | Dietary Manager | Commented on proper preparation of pureed foods |
Viewing
Loading inspection reports...
