Avantara Libertyville

In the surveyor’s words

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

• Immediate jeopardy, patternF880Jul 28, 2021

  Based on observation, interview, and record review the facility failed to implement infection control policies and recommendations from the Center for Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering a Person Under Investigation (PUI) for Covid-19 resident room, and failed to have the required PPE for airborne/droplet isolation available outside the resident room to prevent possible exposure to Covid-19, for 12 of 12 residents ((R299, R300, R301, R146, R297, R18, R302, R303, R59, R34, R305, and R304) reviewed for transmission based precautions in the sample of 22. This failure has the potential to infect high risk residents with Covid-19 and spread the disease of Covid-19 to negative residents. […]

• Immediate jeopardy, isolatedF805May 22, 2026

  Based on interview and record review the facility failed to provide a resident with the Physician prescribed diet, failed to have a policy in place regarding changes in dietary orders, and failed to implement a physician diet order change. This failure resulted in R1 choking on her food and expiring at the hospital. This applied to one of three residents (R1) reviewed for diets in the sample of three.The Immediate Jeopardy began on 5/17/26 when R1 received physician orders for a downgrade in diet to pureed and the next morning was served a mechanical soft diet rather than the Physician prescribed puree diet. R1 choked and expired at the hospital. V1 (Administrator) was notified of the Immediate Jeopardy on 5/22/26 at 9:58 AM. […]

• Immediate jeopardy, isolatedF684May 23, 2023

  Based on interview and record review, the facility failed to identify a resident's significant change in condition; failed to assess a resident with a significant change in condition; and failed to notify a resident's provider of a change in condition; resulting in delay of potential lifesaving care to 1 of 3 (R2) residents reviewed for death in the sample of 12. The Immediate Jeopardy began on [DATE] at 3:00 PM when R2 was unresponsive. V1, Administrator, was notified of the Immediate Jeopardy on [DATE] at 10:50 AM. […]

• Actual harm, isolatedF689Aug 25, 2025

  Based on observation, interview, and record review the facility failed to provide bed mobility in a safe manner for 1of 7 residents (R1) reviewed for safety/falls in the sample of 7. This failure resulted in R1 falling from R1's bed and sustaining left and right femur fractures requiring hospitalization.Findings include:R1's Care Plan initiated 04/10/2024 shows, R1 is diagnosed with morbid obesity and generalized osteoarthritis. R1 has an activity of daily living self-care performance deficit related to general weakness, immobility, and decreased activity endurance.R1 Minimum Data Set, dated [DATE] shows, R1 is dependent on staff to roll left and right. […]

• No harm, potential for more than minimal, widespreadF812Dec 17, 2025

  Based on observation, interview, and record review the facility failed to ensure kitchen staff were performing hand hygiene and utilizing gloves in a food safe manner. This has the potential to affect all residents receiving food from the facility. The findings include:On 12/15/25 at 10:10 AM, V5 (Cook) grabbed the lid of the garbage can, placed garbage into the garbage can, then proceeded to walk over to the steamer and grabbed a pan from the steamer and removed it. V5 was not wearing gloves and did not perform hand hygiene before grabbing the pan from the steamer. On 12/15/25 at 11:11 AM, V5 threw a disposable spoon into the garbage can by lifting the garbage can lid. […]