Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Libertyville during CMS and state inspections, most recent first.
A resident with dysphagia and cognitive impairment was on a mechanical soft diet when she choked during breakfast and the LPN obtained an order to downgrade her to puree. The next morning, the resident was still served a mechanical soft tray with regular pancakes instead of the ordered puree diet, and she choked again, required CPR, was transported to the hospital, and later died. Staff reported the kitchen had not received a written diet change slip, and the facility had no policy guiding diet order changes.
A resident with morbid obesity and osteoarthritis, dependent on staff for bed mobility, was injured when a CNA, unable to safely manage the resident's weight during morning care, lost control and both fell from the bed to the floor. The resident sustained fractures to both femurs and required hospitalization. Staff interviews and records confirmed the CNA was physically unable to safely reposition the resident during the incident.
A resident with morbid obesity and osteoarthritis fell from bed while being assisted by a CNA, resulting in bilateral femur fractures. The resident's pain increased significantly after the fall, but the physician was not promptly notified of this change in condition, as required. Documentation shows the nurse practitioner was not informed of the resident's escalating pain prior to receiving X-ray results.
The facility failed to ensure CNAs were certified after training, affecting all residents. A CNA-in-training worked without certification, and records showed discrepancies in certification status. The facility lacked evidence of a policy on Health Care Worker Registry checks.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents. Unlabeled containers and uncovered frozen pizza were found in the freezer. A cook used a spatula on soiled surfaces before reusing it for food preparation. The Dietary Director confirmed the need for proper labeling and covering of food, and the facility's policies emphasize the importance of preventing contamination.
The facility failed to obtain weights as ordered for residents with CHF, affecting four residents. Orders for weekly or daily weights were not followed, with missing records for several weeks or days. Staff confirmed the importance of weights for monitoring fluid retention in CHF residents, acknowledging that weights should be done as ordered to detect potential exacerbations.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring such measures. Staff did not consistently wear gowns and gloves during high-contact care activities, such as administering medication via PEG tube, providing catheter care, and repositioning residents with wounds or indwelling devices. These actions were contrary to the facility's infection control policies, risking cross-contamination and transmission of resistant organisms.
The facility failed to ensure pressure relieving interventions were in place for two residents at risk for pressure injuries. One resident had an air mattress pump with the standby light on but not functioning, while another resident's air mattress pump was unplugged. Both residents' care plans included interventions to check the air mattress for proper functioning, which were not followed.
A facility failed to provide proper catheter care to a resident, leading to a deficiency. A CNA did not cleanse the catheter tubing or the frontal/genital area during care, only wiping the perineal area and applying a new brief. The DON confirmed that thorough incontinence care, including catheter tubing cleansing, is necessary to prevent infections. The resident has a history of UTIs.
A resident with severe cognitive impairment due to dementia was not provided with individualized activities as per their care plan. Despite being observed wandering aimlessly, staff repeatedly redirected the resident back to their room without offering meaningful engagement. The facility's activity calendar showed activities on another floor, and staff confirmed no activities were provided to the resident. The resident's interests, as noted by their spouse, were not reflected in their activity assessment.
Failure to Follow Ordered Diet After Choking Incident
Penalty
Summary
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. The resident had diagnoses including metabolic encephalopathy, osteoarthritis, and dysphagia, and the facility assessment showed moderate cognitive impairment and a need for set-up assistance with meals. The resident was initially on a mechanical soft diet. After the resident was observed coughing and gagging while eating breakfast, the nurse performed the Heimlich maneuver and food was expelled. The on-call provider was contacted and ordered the diet downgraded to puree. A physician order for a pureed texture diet was entered that same day. However, the next morning the resident was served a mechanical soft breakfast rather than the ordered puree diet. Staff reported that the breakfast tray and diet slip still reflected mechanical soft, and the kitchen staff stated they had not received a written diet change slip showing the downgrade. During the second choking event, staff observed the resident coughing while eating breakfast in bed. Abdominal thrusts were attempted, a mouth sweep was performed, 911 was called, CPR was initiated when the pulse could not be obtained, and the resident was transported by EMS to the hospital. The emergency room record states large amounts of pancakes were found in the airway, intubation could not be completed in the field, and the resident died at 8:30 AM. The report states the Immediate Jeopardy began when the diet was changed to puree but the resident was still served mechanical soft food the next morning.
Failure to Provide Safe Bed Mobility Assistance Resulting in Resident Fractures
Penalty
Summary
A deficiency occurred when staff failed to provide safe bed mobility assistance to a resident diagnosed with morbid obesity and generalized osteoarthritis, who was dependent on staff for bed mobility. The resident required assistance due to general weakness, immobility, and decreased activity endurance. During morning care, a CNA attempted to assist the resident in rolling to her side, but the resident's leg fell off the bed. The CNA, who was physically smaller than the resident, was unable to safely reposition the resident and attempted to lift her leg back onto the bed. This resulted in both the resident and the CNA falling from the bed to the floor, with the resident's legs crossing during the fall. As a result of the fall, the resident sustained fractures to both the left and right femur, requiring hospitalization. Multiple staff interviews and progress notes confirmed that the CNA was not able to manage the resident's weight and size during the transfer, and the incident occurred while the resident was being prepared to get out of bed. The resident was subsequently admitted to the hospital with closed fractures of the proximal left femur and distal right femur, as well as a left urethral stone. The incident was witnessed by the resident's roommate and corroborated by nursing staff and the nurse practitioner.
Failure to Notify Physician of Resident's Change in Condition After Fall
Penalty
Summary
The facility failed to notify the physician of a significant change in condition for a resident who required dependent care. The resident, who had morbid obesity and osteoarthritis, needed staff assistance for bed mobility. During morning care, as a CNA assisted the resident to roll, the resident's leg fell off the bed. The CNA attempted to reposition the resident, but due to the resident's large size and the CNA's small stature, both the resident and the CNA fell from the bed to the floor. The resident's legs crossed during the fall, and the impact resulted in fractures to both femurs. Following the fall, the resident initially denied pain but later reported increasing pain, which was documented as 2/10 and then 8/10 on the pain scale. The LPN provided acetaminophen and informed the nurse practitioner of left thigh pain, leading to an X-ray order. However, the nurse practitioner later stated she was not notified of the resident's increased pain level of 8/10. The deficiency centers on the facility's failure to promptly notify the physician of the resident's significant change in condition, specifically the escalation in pain following the fall and prior to the X-ray results.
Failure to Ensure CNA Certification
Penalty
Summary
The facility failed to ensure that nursing assistants were certified after completing their training program, affecting all 114 residents. A Certified Nursing Assistant-in-training (CNA) was observed working on the 2nd floor, claiming to have completed her training and having her own resident assignment. However, it was revealed that she did not pass her certification test and was scheduled to retake it. The Director of Nursing (DON) and Human Resources confirmed that staff in the CNA program have 120 days to pass their test after completing their class, during which they can perform CNA duties under supervision. Despite this, the CNA in question continued to work without certification. The facility's records showed discrepancies in the certification status of two CNAs. One CNA, who had not passed her test, was still working as a CNA for 11 out of 14 days in the observed period. Another CNA, who also failed her test initially, was placed in a different role until she passed. The facility did not provide evidence of a policy on Health Care Worker Registry checks, nor did they provide a schedule showing when the second CNA was removed from direct care. This lack of oversight and adherence to certification requirements led to the deficiency noted by the surveyors.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner, potentially affecting all 122 residents. During an observation, small white circular containers were found unlabeled in the freezer, and frozen pizza was seen uncovered and open to air. Additionally, a cook was observed using a spatula to scoop taco meat into a blender, then placing the spatula in a visibly soiled strainer pan over the sink before using it again to scoop rice into the blender. The Dietary Director confirmed that foods should be prepared, labeled with the date, and covered in the freezer, and that a spatula that has touched a dirty surface should not be placed back into food for residents. The facility's Kitchen policy requires refrigerated food to be covered, dated, labeled, and shelved to allow air circulation, while the Food Handling policy recognizes contaminated equipment as a critical factor in foodborne illness.
Failure to Obtain Ordered Weights for CHF Residents
Penalty
Summary
The facility failed to obtain weights as ordered for residents diagnosed with congestive heart failure (CHF), affecting four residents in the sample reviewed for quality of care. Resident 38 had an order for weekly weights starting on a specific date, but there were no recorded weights for several weeks. Resident 66 had an order for daily weights, but multiple days were missing from the records. Resident 244, who was admitted with acute on chronic CHF, had an order for daily weights upon admission, but only two weights were recorded, and no daily weights were noted. Resident 11, with a diagnosis of chronic diastolic CHF, had an order for daily weights, but was only weighed once. Interviews with staff, including a Licensed Practical Nurse and a Registered Nurse, confirmed that weights are crucial for monitoring fluid retention in residents with CHF, as weight gain could indicate a CHF exacerbation. The staff acknowledged that weights should be done as ordered to monitor for fluid gain and notify the doctor if there is a significant weight change. The failure to obtain weights as ordered for these residents represents a deficiency in providing appropriate treatment and care according to the residents' medical needs and physician orders.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols, specifically regarding the use of Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). In one instance, a registered nurse (RN) entered a resident's room, who was on EBP due to multiple diagnoses including pneumonia and bacteremia, to administer medication via a PEG tube without wearing a gown. Another resident, with cellulitis and bilateral lower extremity wounds, was not properly attended to by certified nursing assistants (CNAs) who failed to change gloves or perform hand hygiene after providing peri care, thus risking cross-contamination. Additionally, a CNA did not wear a gown while providing catheter and incontinence care to a resident with an indwelling catheter, despite the care plan and signage indicating the need for EBP. Another resident with an intravenous access and leg wounds did not have EBP signage outside their room, and a CNA repositioned the resident without any PPE. These actions were contrary to the facility's policies on hand hygiene and EBP, which require the use of gowns and gloves during high-contact care activities to prevent the transmission of resistant organisms.
Failure to Ensure Proper Functioning of Pressure Relieving Devices
Penalty
Summary
The facility failed to ensure pressure relieving interventions were in place for two residents who were at risk for pressure injuries. On 09/23/24, one resident was observed in bed with an air mattress pump that had the standby light on, but the 'On' light was not lit, indicating it was not functioning properly. This resident's care plan indicated a risk for developing pressure injuries and included an intervention to check the air mattress for proper functioning. Another resident was also observed in bed with an air mattress pump that was not plugged into an outlet, and none of the lights on the pump were lit. This resident's care plan noted conditions such as cerebral palsy, paraplegia, and limited mobility, which increased the risk for skin alterations. The care plan also included an intervention to ensure the air mattress was functioning properly. The wound care nurse confirmed that both residents were at risk for pressure injuries and should have had working air mattresses.
Failure to Provide Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate catheter care to prevent urinary tract infections for one resident reviewed for catheter care. During an observation, a Certified Nursing Assistant (CNA) did not cleanse the catheter tubing or the frontal/genital area of the resident while providing catheter care. The CNA only removed the resident's incontinent pad, wiped the perineal area with disposable wipes, and applied a new incontinent brief. The Director of Nursing confirmed that staff should provide thorough incontinence care, including cleansing the catheter tubing, to prevent infections. The resident involved has a history of urinary tract infections.
Failure to Provide Individualized Activities for Dementia Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident diagnosed with dementia, identified as R76, who was observed to be severely cognitively impaired. Despite having a care plan that included interventions such as engaging the resident in activity-focused care and social interaction, R76 was repeatedly observed wandering and pacing aimlessly without any meaningful engagement or activities provided. Staff members, including a CNA Supervisor and an Infection Control Nurse, were noted to redirect R76 back to her room multiple times without offering any alternative activities or engagement. The facility's activity calendar indicated that all activities were conducted on the third floor, yet there was no evidence of staff facilitating R76's participation in these activities. Interviews with staff confirmed that no activities were provided to R76 during the observed period. Additionally, R76's activity assessment did not reflect her interests as reported by her husband, who mentioned her past work in beauty treatments. The facility's policy on dementia care emphasized providing therapeutic diversional activities consistent with residents' levels of functioning and interests, which was not adhered to in R76's case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Libertyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thrive Of Lake County | 2.8 mi | ★★★★★ | 3 | 0 |
| Libertyville Manor Ext Care | 3.5 mi | — | 0 | 0 |
| Serenity Estates Of Lincolnshire | 3.8 mi | ★★★★★ | 17 | 2 |
| Claridge Healthcare Center | 4.1 mi | ★★★★★ | 9 | 2 |
| Lake Forest Place | 4.2 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.