Avantara Joliet

In the surveyor’s words

From the most serious findings on record at Avantara Joliet, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 11, 2025

  Based on interview and record review, the facility failed to ensure a resident was transferred safely. This failure resulted in R1 sustaining a 10-12-centimeter laceration to left lower leg which required 18 sutures. This applies to one resident (R1) reviewed for injuries in a sample of four.The findings include: Resident Incident Report by V13 (LPN/Licensed Practical Nurse) dated 3/24/25 states R1 sustained a laceration to her left lower leg during transfer from wheelchair to bed. V13's Departmental Note dated 3/24/25 shows R1's laceration was reported by V12 (CNA/Certified Nursing Assistant) who performed R1's transfer. On 7/8/25, at 10:43 AM, V13 said she is unsure of R1's wheelchair footrests were on or off her wheelchair at the time of the incident. […]

• Actual harm, isolatedF692Jul 11, 2025

  Based on interview and record review, the facility failed to recognize a resident's significant weight loss of 17.8% in one month and implement timely interventions. This failure resulted in R1's continual weight loss of 24% in three months and eventual hospitalization. This applies to one resident (R1) reviewed for decreased oral intake.The findings include:R1's Weights and Vitals Summary show the following weights:1/6/25 165.2 lbs2/6/25 167.2 lbs3/7/25 169.3 lbs4/9/25 139.2 lbs (17.8% loss in 1 month)5/13/25 135.9 lbs6/13/25 128.6 lbs (24% loss in 3 months)7/7/25 113.2 lbsR1's Nutritional Status Notification written by V19 (Registered Dietician) dated 4/14/25 states, please obtain a new weight. April weight indicated a 30 pound weight loss 17.8% suspect may be in error. […]

• Actual harm, isolatedF684Feb 26, 2025

  Based on interview and record review the facility failed to adequately assess, administer medications, and notify the physician for a resident who had not had a bowel movement in over 3 days on several occasions. This failure contributed to (R1) developing a fecal impaction, pain and inflammation in her colon. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 7. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Parkinsonism and Constipation. R1's active Care Plan shows she has a cognitive impairment due to dementia, is incontinent of bowel and bladder, and is at risk for constipation due to impaired mobility. […]

• Actual harm, isolatedF580Jan 15, 2025

  Based on interview and record review, the facility failed to ensure a resident's Physician/Nurse Practitioner was immediately notified of a fall where the resident had hit his head. This failure resulted in an over six-hour delay in hospitalization and treatment. This applies to 1 of 3 residents (R3) reviewed for notification of changes. Findings include: The facility's 1/6/25 reportable Serious Injury Incident form for R3 showed Resident noted on his right side next to his bed. Resident was transferred to hospital. […]

• Actual harm, isolatedF689Jul 31, 2024

  Based on interview and record review, the facility failed to provide a safe transfer with a mechanical lift for 1 resident (R1). This failure resulted in R1 falling off the side of her bed and obtaining an 8cm (centimeter) laceration to her head requiring 15 staples. This past noncompliance occurred from June 23, 2024, to July 13, 2024. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 13. The findings include: R1's electronic face sheet printed on 7/31/24 showed R1 has diagnoses including but not limited to lymphedema, repeated falls, hypertension, cognitive impairment, and morbid obesity. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and requires substantial/maximum assistance with transfers. […]