Avantara Lincoln Park

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were kept free from involuntary seclusion when staff tethered a bedsheet from the resident's room door handle to a hallway handrail, physically trapping the resident inside the room. This deficient practice affected one of four residents (R1) reviewed for abuse. A reasonable person reviewing these actions would conclude that tying a door shut with a bedsheet is a punitive, non-therapeutic mechanism used to involuntarily confine a resident. A reasonably prudent caregiver would recognize that blocking an exit in this manner completely strips the resident of their freedom of movement, creates an immediate fire and entrapment hazard, and serves strictly as a measure of staff convenience to manage the resident's whereabouts.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents are free from physical abuse for one of four residents (R2) reviewed for abuse in the sample of four.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by failing to ensure that one of four residents (R1) was protected by failing to immediately report an allegation of involuntary seclusion to the State Survey Agency within the required two-hour timeframe for one of four (R1) residents reviewed for abuse in the sample of four.

Inspectors wroteBased on interviews and records reviewed the facility failed to complete an accurate fall risk assessment to identify a newly admitted resident (R2), with a history of falls, unsteady gait, and Dementia with confusion was at high risk for falls and provide 1 person assistance for safe transfers and ambulation. This failure affected 1 of 3 residents reviewed for falls. R2's diagnoses include but are not limited to Polyneuropathy, Peripheral Vascular Disease, Hypertension, Dementia, Osteomyelitis of the Left Ankle and Foot, and Cellulitis of the Left Lower Limb. According to admission assessment R2, [AGE] year-olds, was admitted to the facility on [DATE] at approximately 2:21PM. According to Incident Report dated 2/25/25 at approximately 3:10AM R2 fell in the hallway. R2 was transferred on 3/25/25 to the hospital for evaluation and did not return to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that fall interventions were in place for one resident (R1) who was a high risk for falls. These failures resulted in R1 sustaining a fall which required R1 to go the local hospital due to sustaining an intracranial subdural hematoma.

Inspectors wroteBased on interview, and record review, the facility failed to administer covid 19 vaccine to one resident (R5) that consented for the covid 19 vaccine. The facility also failed to document the administration or declination of covid 19 vaccine for the same resident. This failure affected one resident (R5) in a sample of four residents reviewed for covid 19 vaccine administration. R5 admitted to facility on 11/17/2025 with diagnosis that documents in part; Cerebral infarction, hyperlipidemia, essential hypertension, chronic atrial fibrillation, insomnia, protein calorie malnutrition, covid 19 (12/1/25). On 12/29/25 at 3:15pm, V2 (Director of Nursing) stated that she expects the infection control nurse to obtain consents for resident vaccinations and schedule a vaccine clinic to ensure that vaccinations are administered and recorded in the immunization tab in chart. [...]

Inspectors wroteBased on interviews and record reviews, the facility [A] failed to provide adequate supervision for 1 cognitive impaired resident (R1) who is a high fall risk with a history of falls, and [B] failed to follow their fall prevention policy to ensure fall interventions were put into place for each fall, and failed to implement the interventions that were in place, for one [R1] of two residents reviewed for falls. Findings Include:R1's clinical record indicates the following in part: R1 with medical diagnoses of hydrocephalus, repeated falls, type II diabetes, dementia, history of falling, and essential hypertension. Minimum data set [MDS] Brief Interview Mental Status Score Indicates R1 is cognitively impaired. R1's Clinical Electronic Record indicates:R1 sustained 11 falls on: 3/31/25, 4/10/25, 5/12/25, 5/16/25, 5/30/25, 6/28/25, 7/15/25, 7/17/25, 8/4/25, 8/15/25, and 8/27/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the development of individualized, comprehensive care plans had appropriate and measurable goals with target dates to address the resident(s) needs related to weight loss, difficulty swallowing and medical decline. This deficient practice was identified for 1 (R1) resident. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide one resident (R1) with food that accommodates R1's food allergies and intolerances. This failure affected one resident (R1) out of three residents reviewed for food accommodations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a fall intervention was in place for one resident (R2) who is high risk for falls; and failed to provide adequate supervision for five residents (R2, R3, R4, R6 and R7) who are high risk for falls. These failures resulted in R2 sustaining a fall which required R2 to go to the local hospital due to sustaining a acute right femoral fracture; R3 sustaining a fall which required R3 to go to the local hospital due to sustaining a left femur intertrochanteric fracture; R4 sustaining a fall which required R4 to go to the local hospital due to sustaining an acute fracture of T12 vertebral body; R6 sustaining a fall in the bathroom which required R6 to go to the local hospital due to sustaining a T12 (Thoracic) superior endplate fracture and acute nasal septal fracture; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient staffing to ensure staff is monitoring residents (R2, R7, R8) every two hours and to ensure ADL (Activities of Daily Living) needs are met in a timely manner. The facility's short staffing has the potential to affect all 212 residents residing in the facility as of census 02/02/25.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide grooming assistance for one resident (R9) out of a total of 3 residents reviewed .

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedures by not checking in on and/or provide incontinence care every two hours for 3 (R2, R7, R8) dependent residents out of a total of 6 residents reviewed for improper nursing care. Findings Include: On 2/2/25 at 10:25 AM, Surveyor entered R2's room with V7 (Licensed Practical Nurse). R2 was lying in bed alert and able to verbalize needs. R2 stated that [R2's] incontinence brief was soiled and needed to be changed. R2 was unable to verbalize when was the last time R2's incontinence brief was changed. R2 stated, I can't tell you how long, but I've been uncomfortable for a while. Surveyor and V7 checked R2's incontinence brief and noted to be saturated with urine and feces. R2's incontinence under pad was also wet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure wound care dressing was in place and intact for 1 (R2) out of 3 residents reviewed for wound care. Findings Include: On 2/2/25 at 10:25 AM, Surveyor entered R2's room with V7 (Licensed Practical Nurse). R2 was lying in bed alert and able to verbalize needs. R2 stated that R2's incontinence brief was soiled and needed to be changed. R2 was unable to verbalize when the last time R2's incontinence brief was changed. R2 stated, I can't tell you how long, but I've been uncomfortable for a while. Surveyor and V7 checked R2's incontinence brief and noted to be saturated with urine and feces. R2's incontinence under pad was also wet. R2's sacral open wound had no dressing in place. V7 stated that the wound is open to air. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food at an appetizing temperature for three (R7, R8, R9) of three residents reviewed food temperatures.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that admission fall risk assessments are completed and include a score with actual risk, failed to ensure that Nursing staff are aware of residents at risk for falls, failed to ensure that Nursing staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, failed to ensure that alarms (in use) are functioning properly, failed to ensure that predisposing factors which contributed to a fall are included on the incident report, and/or failed to provide supervision to three of three residents (R2, R3, R4) reviewed for falls. These failures have the potential to affect 224 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly assess, monitor, and evaluate one (R2) resident after a fall incident on 3/13/24 and 5/18/24. These failures could potentially affect one (R2) of three residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that one resident (R3) had the proper equipment for a daily CPAP (Continuous Positive Airway Pressure) machine as ordered by a Medical Doctor. This failure has affected one of four residents reviewed for improper nursing care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their policy on Sanitation & Safety Operations by (a) failing to maintain proper food temperatures, (b) failing to date opened food items with open and use by date, (c) failing to store kitchen cleaning supplies/chemicals away from food items and silverware, (d) falling to monitor and make sure dishwasher temperatures reached at least 160 degrees F during the wash/rinse cycle of the dish washer These deficiencies have the potential to affect 204 residents who are on an oral diet and receiving meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to encourage and assist residents with cognitive impairments to dress in their own clothes, rather than hospital type gowns for 22 (R165, R184, R58, R86, R133, R46, R51, R59, R56, R63, R15, R98, R67, R124, R54, R158, R23, R99, R158, R13, R176, R16) residents, b.) Assist residents in maintaining and enhancing his or her quality of life, by providing equal access to quality care regardless of diagnosis and severity of condition for 3 (R58, R133,R165) residents reviewed for resident rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four (R43, R53, R131, R135) residents had access to the call light system in a total sample of 35 residents reviewed.

Inspectors wroteA. Based on observations, interviews, and review of records the facility failed to follow policy to accurately account residents' narcotic medication for 2 out of 6 medication carts for a total of 11 medication carts reviewed for controlled substance or narcotic storage accuracy. These failures have the potential to affect R12 and R95 narcotic medication improperly accounted. B. Based on observations, interviews, and review of records the facility failed to follow policy on labeling and dating insulin vials opened for residents use. Failed to ensure tuberculin vials stored in the refrigeration are not expired. Failed to maintain medication cart free from expired house stock medication. And failed to ensure medication for topical use are in proximity to supplement taken by residents orally. Failure applies to 2 out of 3 medication rooms for a total of 5 medication room. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to accurately complete Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process for 2 (R59, R133) residents reviewed for resident assessment in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to refer three residents with newly evident or possible serious mental disorders to the appropriate state-designated authority for review. This failure affects three residents (R73, R125, R166) reviewed for PASSR (Preadmission Screen and Resident Review) in a total sample of 35 residents.

Inspectors wrote2. On 06/06/2024 at 11:41AM, surveyor located inside of R37's room and observes R37's bed in a high position, R37's bed observed to not be in the lowest position. R37 observed in a supine position with head of bed at 45 degrees. R37's bed observed in a high position that reaches surveyor's mid upper thigh measuring approximately 2 feet, 8 inches in height. R37 states she is not sure why her bed is positioned so high. R37 states she doesn't want to fall again because she fell in the facility sometime last year and broke her knee cap. R37 states she is still healing from her injuries. On 06/04/2024 at 11:45AM, surveyor makes V9 (Licensed Practical Nurse/LPN) aware of R37's bed being in a high position. V9 located inside of R37's room and observes R37's bed position and states R37's bed should not be this high. V9 observed operating R37's bed and lowering R37's bed to the lowest position. [...]

Inspectors wroteA. Based on observations, interviews, and review of records the facility failed to follow policy to accurately account residents' narcotic medication for 2 out of 6 medication carts for a total of 11 medication carts reviewed for controlled substance or narcotic storage accuracy. These failures have the potential to affect R12 and R95 narcotic medication improperly accounted. B. Based on observations, interviews, and review of records the facility failed to follow policy on labeling and dating insulin vials opened for residents use. Failed to ensure tuberculin vials stored in the refrigeration are not expired. Failed to maintain medication cart free from expired house stock medication. And failed to ensure medication for topical use are in proximity to supplement taken by residents orally. Failure applies to 2 out of 3 medication rooms for a total of 5 medication room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer the right medication as ordered and failed to administer intended medication dose as ordered per policy. There were 28 (twenty-eight) opportunities with 3 errors resulting in 10.71% (percent) error rate. This applies to 2 (two) residents (R118 and R68) of 8 (eight) residents observed for medication administration. These failures have the potential to affect 2 residents (R118 and R68) in receiving the right medicine and the right dose as ordered by physician.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff and family follow recommended isolation guidelines consistent with current standard of practices to prevent cross contamination for 3 of 4 residents (R499, R500, R168,) observed for infection control in the sample of 35.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow their hot food policy by failing to provide hot food to one (R172) of 5 residents in a sample of 35 reviewed.

Inspectors wroteBased on interviews and records review, the facility failed to keep one resident (R4) free from abuse in a sample of three reviewed. This deficiency resulted in R4 being hit by R5 with a walker, and R4 sustained a laceration to the forehead requiring five sutures.

Inspectors wroteBased on interview and record review the facility failed to recognize, monitor, and provide needed services for a resident who had been noted with swelling of right leg and decline in activity for one resident (R2) out of three residents reviewed for quality of care, causing R2 to continue with a swollen leg for several days. R2 sustained an acute right hip fracture and underwent surgery to fix the fracture.

Inspectors wroteBased on review of records and interviews the facility failures are as follows: Failed to maintain the right of every resident to be safe from accident and hazard. Failed to identify risks for prevention of fall. Failed to ensure adequate supervision and assistance were provided. Failed to place applicable patient centered and effective interventions to prevent fall for 2 out of 3 residents (R6 and R3) reviewed for hazards, incidents, and accidents. These failures resulted in 1 resident (R6) falling multiple times sustaining multiple injuries including right arm/shoulder (humerus) fracture, subdural hemorrhage, and subdural hematoma. And 1 resident (R3) fall resulted to closed fracture of the right wrist (distal radius).

Inspectors wroteBased on interview and record review the facility failed to ensure that a cognitively impaired resident's pain management regimen was followed in accordance with physician's orders as the resident was not assessed for pain consistently. This failure affects one (R2) resident out of three residents reviewed for pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who depends on staff's assistance for their ADL (Activities of Daily Living) care and grooming receive skin care and grooming. This affects one resident (R1) out of 3 residents reviewed for ADL care and grooming.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that sexual abuse allegation was reported to State Agency (SA) immediately or no later than 2 hours after the allegation is made. This failure resulted in the allegation not being reported timely.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure disposal of expired food items and follow proper cleaning and sanitation practices for the kitchen and dishes. This failure has the potential to affect 192 residents residing in the facility receiving meals from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed dispose of garbage and refuse properly. This failure has the potential to affect 195 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and review of records the facility failed as follows: Failed to properly position resident resulting to failure of giving the right dose to 1 resident (R5) during medication administration. Failed to follow guidelines for giving medication beyond scheduled time to residents. And failed to follow policy to account 2 residents (R133 and R146) controlled substance or narcotic for 2 out of 6 carts reviewed. These failures has the potential to affect residents on 3rd and 6th floors and 1 resident (R133) for a total of 85 residents to receive proper pharmaceutical services.

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their infection prevention and control program by failing to (a)date oxygen tubbing for two (R23, R168) of four residents reviewed in a sample of 35 resident. This deficiency has to the potential to affect two of four residents reviewed, (b)failed to follow policy related to cleaning between used blood pressure equipment used by 3 residents (R5, R49, R143 and R25) reviewed during medication administration. Findings Include: On 4/25/2023 at 11:30am, R23 was observed laying in bed with oxygen running via nasal cannula at O2 two liters per minute/ LPM. R23's oxygen tubbing was observed to have no date indicating when it was last changed or ehen it should be changed next. R23's medical diagnosis includes but not limited to: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized care plan for 1 resident (R333) on a high-risk medication out of 35 reviewed for care plans.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to maintain bed side rails in safe and stable working condition to a resident with left sided weakness that is using right side rail for bed mobility to change position for 1 resident (R83) out of 4 for a total sample of 35 reviewed for accidents and hazards. This failure has the potential to affect 1 resident (R83) in maintaining safety, free from hazards and prevention of accidents.

Inspectors wroteBased on observations, interviews, and review of records the facility failed to follow medication labeling of opened insulin for 2 out of 6 medication carts for 3 residents (R82, R147 and R168). Failed to ensure medication cart is free from expired insulin and insulin for resident that was already discharged . These failures have the potential to affect 3 residents (R82, R147 and R168) in managing diabetes via insulin administrations.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow their policy to ensure call lights are answered as soon as possible due to defective call light functioning for 1 (R38) out of 10 residents reviewed for call lights in a sample of 36.

Inspectors wroteBased on observation, interview and record review facility failed to follow policy as it relates to emergency food plan and did not have any (or enough) food resources to adequately manage and execute its food nutrition in the event of an emergency. These failures have the potential to affect 190 residents in the facility who is receiving an oral diet.

Inspectors wroteBased on observation, interview and record review the facility failed to follow multiple policies related to the following: Food storage area not maintained in clean sanitary condition, did not check dishwasher machine as required resulting to not reaching desired temperature, labeling of opened food and discarding food that are beyond best used by date, follow First-In-First-Out with evaporated can milk, perform hand hygiene before performing food preparation and after touching high touched area while performing food preparation, maintaining food sanitation by placing cheese sandwiches on stove platform without barriers and maintaining equipment (thermometer) clean when testing food temperatures. These failures have the potential to affect 190 residents in the facility who is receiving an oral diet.

Inspectors wroteBased on interview and record reviews, the facility failed to complete the annual and quarterly Minimum Data Set (MDS) assessments using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 4 (R4, R5, R6, R28 ) of 5 residents reviewed for resident assessment in a sample of 35.

Inspectors wroteBased on observations, interviews and records review the facility failed to follow their Smoking Policy and properly assess residents for safe smoking and supervise residents for proper storage of smoking materials. This has the potential to affect 5 of 5 residents (R166, R201, R84, R156, R97) reviewed for smoking material safe storage and smoking risk assessment.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to (a) properly discard expired medications on expiration dates that could potentially affect all 45 residents residing on the 6th floor; (b) properly date opened multi-dose inhalers, multi-dose insulin pens, and eye drops for 5 residents (R31, R37, R69, R84, R88); and (c) ensure opened multi-dose insulin pens were stored to prevent the potential for cross contamination for 8 residents (R84, R191, R66, R185, R159, R10, R88, R178) from four of six medication carts inspected for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review, facility failed to follow policy in maintaining urinary catheter drainage bag free from possible contamination by leaving it on the floor without any barrier. And failed to ensure isolation precaution signage was posted for 2 of 2 resident (R127 and R463) reviewed for infection control and prevention. These deficient practice has potential to affect 1 resident (R127) for recurrent urinary tract infection and 30 residents residing on the facility's fifth floor.

Inspectors wroteBased on observations, interviews and record review the facility failed to follow the facility policy on COVID-19 testing for 2 staff with waivers and 2 partially vaccinated, V32 (Certified Nursing Assistant/CNA), V33(CNA), V7 (Dietary Aide), and V10 (Licensed Practical Nurse/LPN) without the required testing. These failures have the potential to affect 193 residents for contacting COVID-19 infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents being discontinued from skilled therapy received both Medicare notices of non-coverage for the skilled therapy for 5 of 5 (R182, R175, R154, R200, R263) residents reviewed for non-coverage of Medicare services in the sample of 35 residents.

Inspectors wroteBased on record review and interviews the facility failed to ensure one resident (R193), considered at risk for abuse, remain free from abuse in the sample of 35 residents reviewed.

Inspectors wroteBased on record review and interviews, the facility failed to recognize and to internally report a potential abuse for one resident (R193) in the sample of 35 residents reviewed. This failure has the potential to allow abuse to continue, by preventing the facility from investigating and intervening to stop the abuse.

Inspectors wroteBased on record review and interview the facility failed to follow CMS's RAI guidelines on significant change in status assessment (SCSA) by not performing SCSA assessment for within 14 days after admission to hospice of 1 of 1 resident (R32) reviewed for resident assessment. This failure has the potential to affect 1 resident (R32) in receiving incorrect assessment that corelates to care of resident.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop a comprehensive resident centered care plan with goals and interventions for 1 (R185) of 2 residents reviewed for respiratory care in a sample of 35.

Inspectors wroteBased on record review and interviews the facility failed to discuss preference for code status upon admission for a resident who wants to be resuscitated, and instead documented code status as Do Not Resuscitate (DNR) in the resident profile. This failure affects one resident (R94) out of 35 residents reviewed and has the potential to prevent cardiopulmonary resuscitation to be provided to R94 in an event of cardiac or pulmonary arrest.

Inspectors wroteBased on observations, interview and record review, the facility failed to provide documentation to support the use of the anti-psychotic medications in dementia residents, failed to have documentation on the type of psychosis being treated and failed to provide documentation of non-pharmacological interventions prior and during the use of the anti-psychotic medications and failed to follow their psychotropic policy for 2 (R133, R156) of 2 dementia residents reviewed for anti-psychotic medication in the sample of 35 residents.

Inspectors wroteBased observation, interview and record review the facility failed to follow policy related privacy and dignity by not providing privacy curtain to 2 residents (R326 and R126) living in a single room. These failures have the potential to affect 2 residents on maintaining their respective privacy (R326 and R126) in a sample of 35 residents.