Avondale Estates of Elgin

In the surveyor’s words

From the most serious findings on record at Avondale Estates of Elgin, in the surveyor’s own words.

• Immediate jeopardy, patternF880Jul 3, 2023

  The facility failed to implement acceptable standard of infection control practices regarding the following: (due to two failures noted under this regulation, there are two deficient practice statements). A. Based on observation, interview, and record review, the facility failed to identify and ensure a resident (R362) with diagnosis of Candida Auris (highly contagious fungal rash infection) and with drainage from a non-contained open wound rash was placed on contact precautions, failed to prevent cross contamination during wound dressing change and while removing contaminated medications from the isolation room, failed to utilize dedicated medical equipment in an isolation room, and failed to educate staff and family regarding necessary contact precautions and use of protective… […]

• No harm, potential for more than minimal, widespreadF812Jul 3, 2023

  Based on observation, interview and record review, the facility failed to utilize chemical sanitizing solution at concentrations per manufacturer's instructions to sanitize food contact surfaces and sanitize equipment in the three compartment sink. This applies to all 77 residents residing in the facility. The findings include: Resident Census and Conditions of Residents form, dated 6/26/23, shows the facility census was 77 residents. Facility document, undated, shows there were two residents residing in the facility with physician orders that included NPO (nothing by mouth). On 6/26/23 at 10:20 AM during initial tour of the kitchen with V17 (Food Service Director), V23 (Cook) was swabbing his cook work station with a cloth from his chemical sanitizing solution bucket at his station. […]

• No harm, potential for more than minimal, patternF761Jun 27, 2025

  Based on observation, interview, and record review the facility failed to secure medications. This applies to 5 out of 5 ( R28, R49, R56, R269, R369) reviewed for medications in a sample size of 20. The findings include: 1. On 6/24/25 at 1:09 PM, R369 was sitting on the bed. Alert and well oriented. R369 stated that he was on Norco 1-2 pills every six hours as needed and that he had his own bottle of Norco with him. R369 stated he had a pill box full of his pills in his drawer. A weekly pill box with medications for three times a day dosing filled with pills was in R369's drawer. Also in his drawer was one bottle of acetaminophen (500 mg/325 caplets) almost full, and two boxes containing 15 patches of 4% Lidocaine gel. The drawer with medications was not locked. […]

• No harm, potential for more than minimal, patternF880Jun 27, 2025

  Based on observation, interview, and record review the facility failed to follow Enhanced Barrier Precautions (EBP) when caring for residents needing those precautions. This applies to 4 of 4 (R2, R27, R56 and R369) residents reviewed for infection control in a sample of 20. Findings include: 1. On 6/23/25 at 1:41 PM, R2 exited the washroom in her room and V18 (CNA-Certified Nursing Assistant) was still in the washroom tying up the garbage. V18 stated she helped R2 to clean up after using the toilet. V18 did not wear a gown. A sign outside R2's room door showed EBP and there was a bin with PPE (Personal Protective Equipment) outside R2's room. R2's Physician Order Sheet (POS) dated 6/10/25 showed EBP related to wound 2. […]

• No harm, potential for more than minimal, patternF881Jun 27, 2025

  Based on interview and record review, the facility failed to follow an Antibiotic Stewardship Program for residents receiving antibiotics. This applies to 5 of 5 residents (R216, R217, R167, R23, R24) reviewed for Antibiotic Stewardship in a sample of 20. The findings include: On June 25, 2025 at 2:03 PM, V2 (ADON/Assistant Director of Nursing) went over the Antibiotic Stewardship Program. V2 said the McGeers tool was used to determine whether the resident meets the requirement for the use of antibiotics. V2 said the tool should be used before the resident has started on the antibiotic. V2 said residents admitted from the hospital with antibiotics should also have the McGeers tool completed to ensure the antibiotics were appropriate to continue in the facility. 1. […]