Avantara Lake Zurich
Inspection history, citations, penalties and survey trends for this long-term care facility in Lake Zurich, Illinois.
- Location
- 900 South Rand Road, Lake Zurich, Illinois 60047
- CMS Provider Number
- 145816
- Inspections on file
- 23
- Latest survey
- August 26, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Avantara Lake Zurich during CMS and state inspections, most recent first.
A resident with a pelvic fracture, who was alert and oriented, was unable to locate her call light when she needed to use the bedpan. After waiting for assistance and not being checked on by staff, she urinated in her brief and remained soiled, leading her to call 911 for help. Staff later found her wet and upset, with the call light tied to the bed rail and not visible to her.
A resident with severe cognitive impairment and multiple medical conditions exited the facility through an unsecured front entrance during the night, undetected by staff due to a non-functioning door alarm. The resident was found across a major highway, confused, hypothermic, and injured, and was subsequently hospitalized with an acute subdural hematoma, hypothermia, and injuries from an unwitnessed fall.
A cook at the facility was observed handling food with contaminated gloves, failing to follow proper handwashing and glove application procedures. Despite having a designated handwashing station, the cook washed hands in a food prep sink and applied gloves with wet hands, leading to potential cross-contamination. The Food Service Director acknowledged these improper practices, which violate the facility's hygiene standards.
The facility failed to maintain proper infection control measures, including inadequate isolation precautions for residents with influenza and improper use of PPE by staff. Residents with feeding tubes and catheters were not managed with enhanced barrier precautions, and staff did not consistently follow hand hygiene protocols, leading to potential cross-contamination.
A facility failed to provide least restrictive interventions before using a physical restraint on a resident with a history of falls and cognitive deficits. The resident was observed with a lap belt restraint during supervised activities, which was not released as required. Staff interviews revealed the restraint was used due to the resident's fall risk and agitation, but the facility did not consistently follow its policy to release the restraint during supervised activities.
A resident with congestive heart failure was not weighed daily as ordered, with only two weights documented in January. The facility's policy requires daily weight monitoring for such residents, but staff interviews confirmed this was not done, despite the resident's condition necessitating close monitoring.
A resident with a suprapubic catheter experienced issues with catheter drainage and pain due to the absence of a required dressing, leading to skin redness and discomfort. The facility failed to follow physician orders for catheter site care, and the facility's policy lacked specific instructions for suprapubic catheter care.
Two residents with indwelling catheters in a facility experienced inadequate catheter care, leading to hospitalizations for urinary tract infections. The facility failed to document catheter care, monitor urine output, and prevent cross-contamination. Catheter bags were mixed up between residents, and catheter tubing was found kinked, preventing proper drainage. The facility's policy on catheter care was not followed, resulting in significant health risks for the residents.
A resident with multiple health conditions was left unsupervised while taking medications, resulting in pills being scattered on the floor. The resident, who was shaky and unable to take medications independently, did not have water available initially and accidentally knocked over the medication cup. RNs and the DON confirmed the need for supervision during medication administration, which was not provided, violating the facility's medication pass policy.
A long-term care facility failed to accurately assess and supervise residents at risk of elopement, leading to incidents where one resident left the facility unsupervised and another wandered to a different floor. The facility did not maintain accurate elopement risk records, and there were delays in updating care plans and notifying family members. Staff interviews revealed issues with securing exit doors and using alarm systems.
A resident with a history of aggressive behavior hit another resident in the face, highlighting a failure in the facility's abuse prevention measures. Despite known behavioral issues, the resident's care plan lacked updated interventions, and non-pharmacological strategies showed no change in outcomes. The facility's policy on abuse was not effectively implemented, as evidenced by the incident and the lack of contact information for the nurse on duty.
Resident Left Unattended and Unable to Access Call Light
Penalty
Summary
A resident with a recent pelvic fracture, who was alert and oriented, reported that on her first night in the facility she was unable to locate her call light when she needed to use the bedpan. The resident stated that no staff came to check on her, resulting in her urinating in her brief and remaining in a soiled state. She described feeling frustrated, humiliated, and eventually scared due to the lack of assistance, which led her to call 911 for help. When staff responded after being notified by the police, the resident was found wet and upset, and the call light was discovered tied to the bed rail, though the resident had not seen it. Staff interviews confirmed that the resident was alert, oriented, and able to communicate her needs, but had not received timely assistance. The LPN and CNA involved acknowledged the resident's distress and the delay in care. The facility's policy requires staff to respect residents' privacy and dignity at all times, but this was not upheld in this instance, as the resident was left unattended and in a state of discomfort for an extended period.
Failure to Secure Front Entrance Results in Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the front entrance was safely supervised and/or secured, resulting in a resident with severe cognitive impairment and multiple medical conditions exiting the building without staff knowledge. The resident, who was at high risk for falls and had a care plan indicating the need for a safe environment and supervision, was last seen in bed by a CNA during the night shift. Staff discovered the resident missing approximately 45 minutes later and began searching the facility, initially believing that door alarms would have sounded if the resident had exited. Upon checking, staff found that the front door alarm was not activated or not functioning, and the alarm did not sound when tested. The resident was eventually found by police across a four-lane highway, wearing only a hospital gown, a brief, and shoes, in cold weather conditions. The resident was confused, had sustained injuries including a missing tooth and abrasions, and was hypothermic with a body temperature of 93.2°F. Emergency department records confirmed an acute subdural hematoma, hypothermia due to cold environment, and an unwitnessed fall. The resident was admitted to the hospital for further care. Interviews with staff and review of video footage confirmed that the resident exited through the front door during the early morning hours, and that the door alarm system was not functioning as required. The facility's elopement policy required adequate supervision and a safe environment for all residents, but these measures were not effectively implemented, allowing the resident to leave the facility undetected.
Removal Plan
- Conducted a full house audit of all residents to identify those who are an elopement risk.
- Conducted in-services with all staff on the elopement policy.
- Evaluated and inspected the front door alarm system and found it to be in good working condition.
- Installed a lock box over the kill switch located in the ceiling, with access limited to supervisory/authorized staff.
- Installed a new code panel on the internal set of glass doors requiring a code to exit the facility.
- Checked all other exit doors and found them to be fully engaged and functioning.
- Checked all bed/chair/personal alarms and found them to be in good working condition.
- Checked doors equipped with the Wander Guard system and found them to be properly functioning.
- Initiated a QA audit tool for maintenance to check the alarmed doors and wander guard equipped doors for proper functioning.
- In-serviced all staff on the importance of immediately responding to exit door alarms.
- In-serviced all staff on ensuring that the front exit door alarm is consistently activated.
- Initiated a QA audit tool to ensure that the front alarm door is properly functioning.
- Held an emergency QAPI meeting attended by the Medical Director to develop and approve the plan of correction.
- Agreed to discuss all trends identified in the monthly QAPI meeting until resolution.
Improper Food Handling and Hygiene Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling and hygiene practices, leading to potential cross-contamination. During an observation, a cook, identified as V6, was seen washing his hands and then applying gloves with wet hands, which is against hygiene standards. V6 proceeded to handle food items, including frozen vegetables and carrots, with the same contaminated gloves. He also touched various surfaces, such as the trash can lid and freezer handle, without changing gloves, further increasing the risk of cross-contamination. The Food Service Director, V5, acknowledged the improper practices and stated that there is a designated handwashing station that should be used instead of the food prep sink. Despite this, V6 continued to wash his hands in the food prep sink and apply gloves with wet hands. V5 confirmed that hands should be dry before applying gloves to prevent bacteria from remaining on the hands and emphasized that touching food with contaminated gloves is unacceptable. The facility's hygiene standards and procedures, as well as the cook's job description, clearly outline the proper handwashing and glove usage protocols. These include washing hands with soap and warm water, drying them thoroughly before applying gloves, and changing gloves after handling garbage or dirty equipment. The failure to adhere to these standards poses a risk of foodborne illness due to cross-contamination, as highlighted by the Centers for Disease Control and Prevention (CDC).
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by multiple instances of non-compliance with contact and droplet isolation precautions. One resident, diagnosed with influenza, was observed outside of her isolation room in the group dining area without a mask, despite orders for strict droplet isolation. The infection control preventionist confirmed that the resident should have remained in her room and meals should have been delivered there. Additionally, staff were observed not wearing the required personal protective equipment (PPE) when entering the resident's room, which could lead to cross-contamination. Another resident with a gastrostomy tube did not have enhanced barrier precautions (EBP) signage or PPE available outside their room, which is necessary for residents with feeding tubes to prevent infection. The infection control preventionist acknowledged the oversight and noted that staff should ensure EBP signs and PPE are in place. Furthermore, a resident with influenza was not properly isolated, as staff entered the room without the required PPE and failed to perform hand hygiene, increasing the risk of spreading the infection. Additional deficiencies were noted in the handling of residents with catheters and during incontinence care. Staff did not adhere to proper PPE protocols, such as wearing gowns and changing gloves between tasks, which are critical to preventing cross-contamination. The facility's policies on hand hygiene and infection control were not consistently followed, as evidenced by staff not performing hand hygiene after glove removal and not wearing appropriate PPE during high-contact care activities.
Failure to Implement Least Restrictive Interventions Before Restraint Use
Penalty
Summary
The facility failed to ensure that least restrictive interventions were provided before implementing a physical restraint for a resident, identified as R90, who was observed with a lap belt restraint in place during supervised activities. On multiple occasions, R90 was seen with the restraint secured while sitting in his wheelchair, including during meal times and activities, without the restraint being released. Interviews with staff revealed that the restraint was used due to R90's history of falls and agitation, but it was noted that the resident could not consistently remove the restraint on command due to cognitive deficits. The facility's policy requires non-restraining interventions to be utilized first, and physical restraints should only be used as a last resort. However, the restraint was applied after R90's fall shortly after admission, and the staff did not consistently release the restraint during supervised activities as required. R90's care plan indicated a high risk for falls and included the use of a self-release belt, but the resident was unable to remove it consistently. The facility's failure to adhere to its restraint policy and ensure the restraint was released during supervised activities led to the deficiency.
Failure to Conduct Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure daily weights were conducted for a resident with congestive heart failure, as ordered by the physician. The resident, admitted with diagnoses including Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes, and hypertension, had a physician's order to monitor weight daily before breakfast and notify the physician of any significant weight gain. However, the electronic Medication Administration Record (eMAR) for January 2025 showed that only two weights were documented, with 14 out of 16 weights not completed. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the resident was not being weighed daily as required. The facility's policy for residents with congestive heart failure mandates daily weight monitoring to manage fluid balance, yet this protocol was not followed. The Director of Nursing acknowledged the oversight, noting that the Certified Nursing Assistants were responsible for taking daily weights and reporting them to the nurses for documentation and physician notification, which was not occurring as ordered.
Failure to Provide Proper Suprapubic Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to a deficiency. The resident, identified as R32, reported issues with his catheter not draining properly and experiencing pain. Upon inspection by a registered nurse (RN), it was observed that the resident did not have a dressing over the suprapubic catheter, and urine was leaking around the catheter tubing, causing skin redness. The catheter drainage bag showed no drainage, and sediment was present in the tubing. The nurse manager confirmed that the resident was supposed to have a dressing in place, as per the physician's orders, but it had not been applied. Further examination by a licensed practical nurse (LPN) revealed drainage around the catheter tubing and reddened skin at the urostomy site. The LPN cleaned the area with saline and applied a new dressing, although the resident experienced discomfort during the process. The physician's orders required wound care to the catheter site, including cleaning with normal saline, applying skin prep, and covering with a dry dressing twice daily and as needed. The facility's indwelling catheter policy did not include specific care instructions for a suprapubic catheter, contributing to the oversight in care.
Inadequate Catheter Care and Cross-Contamination Risks
Penalty
Summary
The facility failed to provide appropriate catheter care and prevent cross-contamination for two residents with indwelling catheters. Resident 1, who was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, had a suprapubic catheter in place. The facility's records showed no documentation of catheter care, urine output, or dressing changes around the catheter stoma site. During an observation, it was noted that Resident 1's catheter tubing was kinked, preventing urine from draining properly, and the catheter bag was placed above the bladder level, causing urine to back up into the tubing. Resident 1 was hospitalized with a urinary tract infection and acute kidney injury. Resident 2, who shared a room with Resident 1, also had an indwelling catheter and was admitted with diagnoses including obstructive reflux uropathy. The facility's records showed no evidence of catheter care or scheduled catheter changes as ordered. Resident 2 expressed concerns about the handling of catheters, noting that catheter bags were often mixed up between her and her roommate. She reported that catheter care was only performed during showers or when incontinent of stool. Resident 2 was hospitalized with a urinary tract infection and electrolyte imbalance, and her catheter was changed at the hospital. The facility's policy on urinary catheter care emphasized the importance of preventing catheter-associated urinary tract infections by ensuring proper catheter maintenance, including keeping the drainage bag below the bladder level and monitoring for kinks in the tubing. However, the facility failed to adhere to these guidelines, resulting in inadequate catheter care and cross-contamination risks for the residents involved.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure proper supervision of a resident during medication administration, leading to a deficiency in pharmaceutical services. The incident involved a resident who was admitted with multiple diagnoses, including Type 2 Diabetes, hypertension, and chronic congestive heart failure, among others. The resident, who had no cognitive impairment, was found with several pills scattered on the floor in her room. She reported that she did not have water to take her medications when they were initially brought to her, and due to shakiness, she accidentally knocked the cup of medications over. The Registered Nurse (RN) acknowledged that the resident was shaky and should have been supervised while taking her medications. Another RN confirmed that it is not acceptable to leave medications at a resident's bedside for safety reasons and that supervision is necessary to ensure medications are taken. The Director of Nursing (DON) stated that the resident is not capable of taking medications independently and should be supervised during administration. The facility's policy requires adherence to medication pass procedures, which were not followed in this instance.
Elopement Risk Management Failures in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments and adequate supervision for residents at risk of elopement, leading to two separate incidents involving residents R1 and R2. R1, who had severe cognitive impairment and was independently ambulatory, was initially assessed as not at risk for elopement. However, a subsequent assessment identified him as high risk. Despite this, R1 managed to elope from the facility by cutting off his wanderguard and exiting through an unlocked door without triggering the alarm. The incident report noted that R1 was found at a nearby gas station after being reported missing by another resident. The facility's policy required immediate notification of the resident's family and physician, but this was delayed by 24 hours. R2, another resident with a history of Alzheimer's disease and cognitive disorders, was found wandering on a different floor within the facility. Although R2 did not leave the building, the incident was not documented in her medical record, and there was a delay in updating her care plan to reflect her elopement risk. The facility's policy required regular elopement risk assessments, but R2's assessments were not conducted quarterly as required, with a significant gap between assessments. Staff interviews revealed that exit doors were not consistently secured, and there was confusion about the use of wander devices and alarm systems. Additionally, the facility failed to maintain accurate and up-to-date elopement risk signs and records. Discrepancies were found between the elopement risk signs posted at the nurse's station and those in the elopement binder, with some residents not listed or incorrectly listed. The facility's policy required these records to be updated regularly, but staff were unable to confirm when the last updates were made. This lack of accurate documentation and communication contributed to the facility's inability to adequately supervise and protect residents at risk of elopement.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident physical abuse, involving two residents. Resident R3, who has a history of Alzheimer's disease, dementia with moderate agitation, and other mental health conditions, was involved in an incident where they physically hit another resident, R6, on the face. This incident was witnessed by a Certified Nursing Assistant (CNA), who reported that R3 has a history of verbally aggressive behaviors and had previously exhibited physical aggression towards others. R3's care plan, which was initiated to address behavior problems related to dementia and adjustment issues, did not have any new or additional interventions added since its initiation. Despite R3's known history of aggressive behaviors, including verbal and physical aggression, the care plan remained unchanged. The facility's records show multiple instances of R3's aggressive behavior, including yelling, swatting at residents and staff, and threatening to hit them with a shoe, yet no pharmacological interventions were implemented, and non-pharmacological interventions showed no change in outcomes. The facility's policy on abuse and neglect emphasizes providing care in an environment free from abuse, yet the incident on 4/28/24 indicates a failure to adhere to this policy. The Director of Nursing acknowledged R3's known behaviors and stated that staff were to increase monitoring and keep R3 engaged in activities following the incident. However, the lack of updated interventions in R3's care plan and the absence of contact information for the nurse on duty during the incident suggest deficiencies in the facility's response to managing R3's behaviors and preventing further incidents of abuse.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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