Avantara Lake Zurich

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 12, 2025

  Based on observation, interview, and record review, the facility failed to ensure the front entrance to the facility was safely supervised and/or secured to prevent 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6 from exiting the facility unbeknown to the staff. This failure resulted in R1 leaving the facility in the early morning hours and crossing four lanes of a major east-west arterial road where the speed limit is 50 miles per hour (MPH) wearing only a hospital gown, a brief, and shoes. R1 became hypothermic and was admitted to the hospital with an acute subdural hematoma, hypothermia due to cold environment, and unwitnessed fall. The Immediate Jeopardy began on [DATE] when staff could not find a resident in the facility. […]

• Actual harm, isolatedF689Mar 4, 2024

  Based on interview and record review the facility failed to ensure a resident with a history of falls and right sided weakness was safely transferred. This failure resulted in R1 sustaining a fall, hitting her head on the bedside table, and falling on her left side during a transfer. R1 was sent out to the local hospital and CT showed acute displaced fracture of the right ilium and right acetabulum. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 5. The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE]. […]

• Actual harm, isolatedF689Nov 2, 2022

  Based on observation, interview and record review the facility failed to ensure R1 was transferred in a safe manner to prevent an injury. This failure resulted in R1 being transferred to bed and sustaining a skin tear that resulted in 35 staples and 9 sutures to his right lateral/back leg. R1's skin tear has turned into a large wound on his right leg that has not healed and requires additional wound care management. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3. […]

• No harm, potential for more than minimal, widespreadF812May 6, 2026

  Based on observation, interview, and record review the facility failed to ensure dishes were air-dried prior to stacking. This has the potential to effect all residents receiving food from the kitchen. The findings include: Centers for Medicare and Medicaid Services form 671 dated 5/4/26 shows there are 143 residents residing in the facility. Facility Diet Type Report dated 5/4/26 shows only one resident has an order of NPO (nothing by mouth) and does not receive food from the kitchen. On 5/4/26 at 10:55 AM, V11 (Dietary Aide) was on the clean, outfeed side of the dish machine. V11 was removing trays from the dish racks immediately out of the dish machine without allowing it to air dry. V11 would place the trays on an adjacent cart in a manner that allowed them to air dry. […]

• No harm, potential for more than minimal, widespreadF812Jan 16, 2025

  Based on observation, interview, and record review the facility failed to ensure food was handled in a manner to prevent cross-contamination and failed to ensure a cook performed hand hygiene in a manner to prevent cross contamination. This affects all the residents residing in the facility. The findings include: The facility's CMS Form 671 dated 1/14/25 showed there were 138 residents residing in the facility. On 1/14/25 at 12:35 PM, V6 (Cook) washed his hands, walked with dripping hands to the box of gloves, near the steam table, and applied gloves with wet hands. V6 touched the exterior surfaces of the gloves with his dripping hands numerous times, in an attempt to apply the gloves. […]