Avenora Elmhurst

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 5, 2024

  Based on interview and record review, the facility failed to protect R1, a resident with dementia from sexual activity from R2, another resident with dementia with known sexual behaviors and a history of wandering into other resident's rooms. This failure resulted in R1 experiencing sexual abuse at the facility when R2 went into R1's room at night and went into R1's bed and sexually assaulted her in her bed. R1 is unable to give consent to the sexual activity and a reasonable person would not want to be touched without consent. This applies to 1 of 3 residents (R1) reviewed for sexual assault in the sample of 3. […]

• Actual harm, isolatedF689May 9, 2026

  Based on observations, interviews and record review, the facility failed to provide adequate supervision to a resident with impaired upper extremity range of motion. This failure resulted in the resident spilling hot oatmeal on self and acquiring a burn. The facility also failed to follow their policy to ensure that immediate treatment procedures are followed after a burn incident.This applies to 1 of 1 resident (R1) reviewed for accidents and supervision in the sample of 3.The findings include:R1's face sheet showed that he was a [AGE] year old male admitted on [DATE], with multiple diagnoses including acute lymphoblastic leukemia, personal history of non-Hodgkin lymphomas, other pancytopenia, pressure ulcer of sacral region, stage 3, other symptoms and signs involving the musculoskeletal… […]

• Actual harm, isolatedF686Jan 8, 2026

  Based on observation, interview and record review the facility failed to develop and implement a plan of care to prevent the development of a pressure ulcer for a resident who was identified as being at risk for pressure ulcers. This failure resulted in R6 developing an infected eschar covered left heal pressure ulcer. This failure applies to 1 of 2 residents (R6) reviewed for pressure ulcers in the sample of 15.Findings Include:R6's admission record showed he was admitted to the facility on [DATE] with diagnoses that included vascular dementia with other behavioral disturbance, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and aphasia. […]

• Actual harm, isolatedF686Oct 10, 2024

  Based on observation, interview, and record review, the facility failed to identify a pressure injury prior to becoming unstageable, failed to implement offloading, and failed to develop and implement a care plan after the development of pressure ulcers for 1 of 5 residents (R14) reviewed for pressure in the sample of 16. This failure resulted in R14 developing two unstageable pressure injuries, one to each heel. The findings include: R14's face sheet showed a [AGE] year old female admitted to the facility on [DATE] from a local hospital. R14's 6/7/24 history and physical showed she was admitted post fall to a local hospital with a right distal femur fracture and surgical repair. R14 had significant weakness and deconditioning. […]

• Actual harm, isolatedF692Oct 10, 2024

  Based on interview and record review, the facility failed to identify a significant weight loss, failed to notify a resident's physician and/or dietician for a significant weight loss, failed to develop care plan interventions to address a resident's significant weight loss. These failures apply to 1 of 2 residents (R27) reviewed for nutrition in the sample of 16. This resulted in R27 sustaining a 5.87% weight loss in 1 week. The findings include: R27's electronic face sheet printed on 10/10/24 showed R27 has diagnoses including but not limited to hydrocephalus, hypertension, mood disorder, dementia with behaviors, and major depressive disorder. R27's facility assessment dated [DATE] showed R27 has severe cognitive impairment and has experienced no weight loss. […]