F0689

G

Failure to Prevent Falls, Ensure Safe Transfers, Smoking Safety, and Maintain Exit Door Alarms

Nashville, Illinois Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards and to provide adequate supervision and assistance to prevent accidents, particularly related to falls, transfers, smoking safety, and exit door alarms. One resident with severe dementia, osteoarthritis, and high assistance needs for ADLs was admitted without a documented admission fall risk assessment, despite transfer paperwork indicating she was high risk for falls and required 1:1 observation. Her care plan later identified her as at risk for falls and wandering, but the fall risk evaluation and precautions were not initiated on admission. She experienced an unwitnessed fall in her room while attempting to toilet herself after removing her non-skid socks, complained of right hip pain, and was subsequently found to have a right hip fracture requiring hospital transfer and surgical repair. Later observation showed her call light attached to the bed sheet and out of her reach.

Another resident with vascular dementia, a history of falls, fractures, restlessness, and incontinence was care planned for multiple fall interventions, including bed pad and chair alarms, placement near the nurse’s station, and keeping her within staff’s visual field when up in a wheelchair. She had an unwitnessed fall from her wheelchair in a common bathroom, sustaining a laceration above her right eye that required repair in the ER. She later had another unwitnessed fall from her wheelchair in a dining area, with reported loss of consciousness and multiple forehead lacerations requiring ER treatment. Despite these events and her care-planned interventions, surveyors repeatedly observed her in her wheelchair without the chair alarm connected, with the alarm monitor left on the bed and the pull cord on the back of the wheelchair, and at times placed in her room out of staff view. Staff interviews confirmed that the alarm was not consistently used when family was present.

The facility also failed to provide safe mechanical lift transfers for multiple residents. One cognitively intact resident with a history of falls, fractures, weakness, and high fall risk was care planned to require two staff and a full-body mechanical lift for transfers, with a fall mat and other fall-prevention measures. During observation, CNAs transferred her from wheelchair to bed using a full-body lift while the wheelchair was left unlocked, and no fall mat was present or placed afterward. Another resident with severe cognitive impairment, dementia, and high fall risk was similarly transferred from a geriatric chair to bed with a full-body lift while the wheelchair remained unlocked.

Smoking safety practices and exit door alarm management were also deficient. A cognitively intact bilateral above-knee amputee with a documented history of smoking and burn concerns was care planned as a smoker, but her smoking safety risk assessments twice documented that she did not currently smoke, and one assessment concluded she was safe to smoke unsupervised. Observations showed CNAs assisting her into a wheelchair, providing her with a burn-marked smoking gown, handing her cigarettes and a lighter from her bedside, and the resident reporting that she could smoke whenever she wanted, usually without staff outside. At the same time, the facility’s smoking policy required a smoking safety assessment to determine supervision needs and noted that burning clothing or being generally careless while smoking jeopardizes independent privileges.

In addition, exit door alarms were not consistently activated or effectively audible. A surveyor opened the 200 hall exit door and found that the alarm did not sound until a CNA used a key to activate it; the CNA stated the alarm was often left off so residents could go out for fresh air and that keeping it on was considered a restraint. On another unit, an exit alarm sounded continuously for over ten minutes, and the administrator was unsure which door was alarming and acknowledged existing issues with door alarms, including a memory care unit exit alarm not functioning properly. The facility’s elopement device policy required regular inspection and documentation of exit door security systems and staff placement at malfunctioning doors, but survey findings showed alarms not being kept on and alarms that were difficult for staff in other areas to hear.