Avantara Palos Heights

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 3, 2025

  Based on observation, interviews and record reviews, the facility failed to implement intervention related to use of bed alarm; and failed to follow manufacturer's recommendation for safety use of reclining chair in preventing fall for one (R1) of three residents reviewed for accidents. This deficiency resulted in R1 who is cognitively impaired fell out of bed and sustained a large bruise on the left side of neck and jaw. Findings include: R1 is a [AGE] year-old, male, originally admitted in the facility on 06/21/23 with diagnoses of Unspecified Dementia, Unspecified Severity, with Psychotic Disturbance; Psychotic Disorder with Delusions due to known Physiological Condition; and Delusional Disorders. […]

• Actual harm, isolatedF689Oct 9, 2024

  Based on observations, interviews, and record reviews, the facility failed to prevent an accident by not ensuring R1 was adequately supervised based on his history of behaviors and accidents, mobility limitations, and health status which resulted in R1 self-transferring and sustaining multiple fractures. This failure applies to one (R1) of three residents reviewed for accidents/supervision. Findings include: R1 is an [AGE] year-old male with a diagnoses history of Parkinson's Disease, Dementia, Major Depressive Disorder, Muscle Wasting and Atrophy, Psychotic Disorder with Delusions, Diverticulitis, Cardiomegaly, Atherosclerotic Heart Disease, Encephalopathy, Malignant Neoplasm of Spinal Cord, and chronic kidney disease who was admitted to the facility 01/27/2020. […]

• Actual harm, isolatedF689Jan 29, 2024

  Based on observation, interview and record review the facility failed to have effective interventions in place to monitor/supervisor a resident identified to be high risk for falls. This affected one of four residents (R1) reviewed for fall prevention. This failure resulted in R1 falling from wheelchair on 12/31/23 while in dining/group room, R1 complained of right-hand pain. On 1/2/24 R1 Xray showed 5th metacarpal fracture with mild displacement, R1 sent to hospital for evaluation and treatment. […]

• Actual harm, isolatedF686Mar 2, 2023

  Based on observation, interviews, and record reviews, the facility failed to conduct a thorough wound assessment, obtain wound treatment orders from physician, implement interventions and ensure proper functioning of low air loss mattress in preventing the development and deterioration of pressure ulcer for two (R13 and R273) of eight residents reviewed for pressure ulcers. This failure resulted in R13's intact skin to develop a facility acquired stage 2 pressure ulcer on the sacral area which deteriorated to unstageable pressure ulcer; and R273's intact skin to develop a facility acquired stage 3 pressure ulcer on the sacrum. […]

• Actual harm, isolatedF689Mar 2, 2023

  Based on interview and record review, the facility failed to have effective interventions in place to adequately supervise a resident with a diagnosis of dementia and a history of wandering and falls. This failure resulted in one resident (R98) having a fall that resulted in (R98) sustaining a subdural hemorrhage. The facility also failed to transfer a resident in a safe manner, consistent with the assessed needs of the resident. This failure applied to one (R59) of one resident and resulted in (R59) sustaining a fracture to the left clavicle after being transferred to bed. […]