Warren Barr Buffalo Grove

Inspectors wroteBased on observation, interview, and record review the facility failed to keep a resident free from physical abuse. This applies to 2 of 4 residents (R1 & R2) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to accommodate residents' food preferences and allergies for 3 of 5 residents (R1-R3) reviewed for food preferences and allergies in the sample of 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu for residents on a puree diet for 4 of 4 residents (R5, R55, R151, R165)reviewed for pureed diet in the sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff applied a gait belt to safely transfer a resident at risk for falls. This applies to 1 of 32 residents (R182) reviewed for safety in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nutritional supplements were provided for a resident with a history of weight loss. This applies to 1 of 10 residents (R70) reviewed for weight loss in the sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff donned the correct personal protective equipment (PPE) for residents on isolation which applies to 2 of 32 residents (R106, R182) reviewed for infection control in a sample of 32.

Inspectors wroteBased on observation, interview and record review the facility failed to notify a resident's representative prior to starting a cognitively impaired resident on a new medication for 1 of 3 residents (R1) reviewed for resident notification of changes and/or treatments in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was not restrained in bed for 1 of 3 residents (R1) reviewed for restraints in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's (Tablet Computer) was not misappropriated for 1 of 3 residents (R1) reviewed for misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the dishwasher reached the desired temperature to sanitize dishes to prevent the spread of food borne illness, failed to ensure meat products were covered, dated, and labeled, failed to ensure staff wore beard coverings in the kitchen to prevent cross contamination and failed to ensure the kitchen was maintained in sanitary conditions. This failure has the potential to affect all residents residing at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist residents with feeding in a dignified manner. This applies to 5 of 30 (R6, R53, R17, R69, R81) residents reviewed for dignity in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a palm protector was in place for a resident with a contracture and failed to ensure restorative assessments were done for 4 of 5 residents (R38, R62, R65, R57) reviewed for restorative services in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure multi-use resident equipment was cleaned after being used by a resident on contact isolation, failed to ensure incontinence care was performed in a manner to prevent the spread of infections, failed to ensure staff removed their gloves and washed their hands to prevent to spread of infection and failed to ensure a resident with an indwelling medical device was placed on enhanced barrier precautions. This applies to 6 of 30 residents (R54, R70, R45, R25, R67 and R121) reviewed for infection control in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provided residents with privacy during personal cares for two of 30 residents (R81, R121) reviewed for privacy in the sample of 30.

Inspectors wroteBased on interview, and record review the facility failed to request a level II PASSAR (Preadmission Screening and Resident Review) screening for residents with a psychiatric/mood disorder which was added after the resident was admitted to the facility. This applies to 2 of 5 (R99, R119) residents reviewed for PASSAR in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was screened prior to admission for 1 of 5 residents (R96) reviewed for preadmission screenings (PASARR) in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for residents that are dependent on staff for two of 30 residents (R25, R1) reviewed for ADLs assistance in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain daily weights on a resident with a history of fluid overload and failed to ensure protective arm sleeves were applied as ordered for two of 39 residents (R37, R70) reviewed for quality of care in the sample of 30.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure fall interventions were in place for a resident that is at high risk for falls. This applies to 1 of 30 residents (R39) reviewed for safety in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a nephrostomy and urinary drainage bag below the level of the bladder for 2 of 7 residents (R67, R121) in the sample of 30.

Inspectors wroteBased on observation, interview, and record review that facility failed to ensure placement of a gastrostomy tube was checked prior to administering medication for 1 of 4 residents (R39) reviewed for enteral nutrition in the sample of 30.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's oxygen tubing and bubble humidifier bottle was changed as ordered and failed to ensure a resident's oxygen humidifier bottle was kept filled for 1 of 8 residents (R32) reviewed for oxygen administration in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications according to standard of practice for a resident receiving medications through a gastrostomy tube. There were 25 opportunities with 5 errors resulting in a 20% error rate. This applies to 1 of 7 residents (R39) observed in the medication pass.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's medication was stored in a secure manner for 1 of 30 residents (R54) reviewed for medication storage in the sample of 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 residents (R1,R2,R3,R7) had access to their call lights. This applies to 4 of 9 residents observed and reviewed for call light accessibility in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician's orders for a resident (R1) at risk for bruising. This applies to 1 of 3 residents reviewed for skin conditions in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to notify the doctor and power of attorney/family when a change in condition occurred for 1 of 4 residents (R1) reviewed for change in condition.

Inspectors wroteBased on interview and record review the facility failed to ensure the information available in the resident's chart was accurate for 1 of 3 residents (R1) reviewed for medical records.

Inspectors wrote2. On 2/28/24 at 12:07 PM, V9 CNA (Certified Nursing Assistant) was sitting at a table feeding R71 while R56 sat at the same table without a food tray in front of her. R96 was brought over to the same table as R71 and R56 and did not have a food tray in front of her. V9 stated they have early trays for the residents that need to be fed and they feed those residents before other residents are given their food trays. At 12:18 PM, R56 was given her food tray and was able to feed herself. The food trays were removed from the food cart and were delivered to residents at different tables. Some residents were eating at the same table while others waited for their food trays. R96 was sitting at the table with R71 who had finished eating and R56 who had just received her tray. R96 stated she wanted her food and that she was hungry. R96 stated she needed to be fed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide oral care and failed to ensure a resident received a shower for 2 of 3 residents (R301, R1) reviewed for Activities of Daily Living (ADLs) in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure heels were off-loaded for a resident with contractures and history of pressure injury to her heels for 1 of 10 residents (R67) reviewed for pressure in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise a resident with dysphagia during meal time for 1 resident (R8) and failed to transfer a resident with a gait belt for 1 resident (R70). These failures apply to 2 of 10 residents reviewed for accidents in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform safe medication administration for one residents (R7) of seven residents reviewed for medication administration on the total sample list of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications at ordered times. There were 31 opportunities with 5 errors resulting in a 16.13% medication error rate. This applies to 2 of 7 residents (R7 and R84) reviewed in the medication pass on tthe total sample list of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to refrigerate and label open insulin vials with open and use by dates. This applies to 1 of 1 resident (R14) reviewed for Medication Storage in a sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide water/other liquids for a resident for one of five residents (R301) reviewed for hydration in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the needs of 5 residents (R1-R5) reviewed for sufficient staffing in the sample of 8.

Inspectors wroteBased on interview and record review the facility failed to provide necessary care and services to a resident exhibiting a change of condition after an initial fall. This failure resulted in R1 sustaining a second fall approximately 12 hours later that resulted in a subarachnoid hemorrhage (brain bleed). This applies to 1 of 3 resident (R1) reviewed for quality of care in the sample of 3.