Warren Barr Lincoln Park

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise a resident with a history of falls. This failure affected one resident (R2)out of 3 residents reviewed for accidents and supervision in the facility. As a result, R2 fell and sustained a laceration of the head requiring sutures. Findings Include:On 11/29/25 at 8:24 pm, an initial Facility Reported Incident was submitted to Illinois Department of Public health (IDPH) that documented, Around 11:25 am, a resident (R2) was observed lying on his back on the floor in the bathroom of his room. (R2's) fall was unwitnessed and resulted in (R2) having a laceration to the right forehead, that required (R2) to get two sutures. (R2) can stand and ambulate with a walker, cues, and standby assist. Resident primarily uses a wheelchair for mobility. The final report was submitted to IDPH on 12/5/25 at 3:50 pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to display [NAME] information in a public and accessible location, informing residents of their right to explore or decline community transition, and their right to be free from retaliation, regardless of their decision on transition. These failures have the potential to affect all 85 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and store food. These deficient practices have the potential to affect all 85 residents receiving food prepared in the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to refer one resident with a known mental illness for a new level I Pre-admission Screening and Resident Review (PASRR) screening. This failure affects one (R64) out of eight residents reviewed in a total sample of eighteen. Findings Include:According to the admission Record, R64 is [AGE] years old, admitted to the facility on [DATE] with diagnosis of bipolar disorder with psychotic features, and major depression. On 11/20/25 at 10:55 AM, V28 (Admissions Director) stated R64's PASRR level I should be done prior to admission into the facility on 4/23/24 to determine if the nursing facility is able to meet R64's needs. V28 also stated R64's PASRR level I was incorrectly done in 2024 by the hospital, but the facility did not follow up until 11/18/25. The facility policy for PASARR Screening, dated 7/16/25, documents: [...]

Inspectors wroteBased on observation, interview, and record review, facility to ensure resident was receiving nutrition via G-tube according to physician orders for 1 (R8) out of three residents reviewed for tube feeds in a sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued medications are not administered and properly destroyed for 1 (R72) out of 5 residents reviewed for medication administration in a sample of 18. Findings Include:On 11/19/2025 at 10:34 AM during the medication pass, V24 (Registered Nurse, RN) opened the medication cart on the third floor, unlocked the narcotic medication bin, and dispensed a Tramadol 50 mg tablet. V24 was asked, What do the physician orders indicate as far as the medication dose, route and frequency? V24 logged in to the electronic medical record (EMR) and stated, I do not see an active order for (R72) to receive a Tramadol 50 mg tablet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure discontinued narcotics are removed and disposed of from the medication cart for one resident (R72) out of a sample of 3 resident's reviewed for medication storage and labeling on a total sample of 18 residents.

Inspectors wroteBased on record review and interview, the facility failed to offer vaccination to 3 out of 5 residents (R7, R86, R87) reviewed for vaccination related to infection prevention.

Inspectors wroteBased on interview and review of records, the facility failed to document offering vaccination to 1 out of 5 residents (R87) reviewed for vaccination

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and individualized care plan for a Stage IV pressure for one (R3) of four residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure narcotic medication or controlled substance were accounted correctly as to recording compared to the actual medication per policy; failed to separate each medication during gastronomy tube administration; and failed to ensure insulin is available per physician order to avoid delay of administration. These failures affect 6 residents (R23, R2, R53, R127, R69, and R11) reviewed for medication administration. These failures affect 6 residents (R2, R11 R23, R53, R69, R127) in receiving proper pharmaceutical services. On [DATE], at 10:25 AM, V10 (Registered Nurse / Agency) gave a folder that includes narcotic record documents. A document titled Shift Change Accountability Record for Controlled Substances, dated [DATE], was not signed/initialed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and label insulins and eye drops per policy; failed to maintain medication carts free from insulin that were expired; failed to store controlled substances inside a double locked storage; and failed to maintain medication storage area free from controlled substance that was discontinued. These failures affect 6 residents (R19, R30, R2, R1, R53, and R3) reviewed for drug storage.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are accurately documented for eight (R8, R16, R26, R33, R53, R61, R127, R277) out of eight residents reviewed for resident records.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete one residents (R29) comprehensive annual assessment.

Inspectors wroteBased on interview and record review, the facility failed to initiate a new Level I screen for one (R70) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to address a high blood sugar result for 1 out of 3 residents (R75) reviewed for blood sugar testing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pressure ulcer preventative measures were accurately applied for two residents (R4 and R62) in a sample of 18 residents reviewed for pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on resident food preferences for one (R70) resident in a total sample of 21 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate use of personal protective equipment (PPE) worn by staff caring for a resident with a known infectious disease (R50), and failed to ensure staff maintains clean technique/infection control practice while performing a bed bath (R3) for one resident. These failures affect 2 residents (R3 and R50) reviewed for infection prevention and control in a total sample of 21 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents right to be free from physical abuse by staff. This failure affected one resident (R1) who was handled roughly and was hit on the arm and the back by a facility CNA (Certified Nursing Assistant) as she attempted to redirect R1. This was identified as an Immediate Jeopardy which began on 06/30/24 when V20, Certified Nursing Assistant, physically abused R1. The immediacy was removed on 07/22/24. On 07/17/24, V1 (Administrator) was informed of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 07/17/24 at 2:41pm. The facility provided an acceptable removal plan on 07/22/34 at 5:34pm. On 07/23/24, through onsite observation, interviews, and record reviews, the surveyor confirmed the implementation of facility's removal plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication was locked up safely when not in visual proximity of the licensed nurses and not in use to prevent tampering and accidental hazard. This failure has the potential to affect all the residents residing on the 2nd and 3rd floor of the facility.

Inspectors wroteBased on interview and record review, the facility failed to immediately report to IDPH (Illinois Department of Public Health) within required time, the allegation of abuse of one of four residents (R1) reviewed for abuse. This failure affected R1 who was handled roughly and was hit on the arm and back by a facility staff as an attempt to redirect R1.

Inspectors wroteBased on interview and record review, the facility failed to immediately initiate an investigation into an alleged physical abuse for one of four residents (R1) in the sample reviewed for physical abuse. This failure affected R1 who was handled roughly and was physically hit in the arm and back by a staff to redirect R1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication is administered as ordered for one resident (R3) for residents reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy on enteral tube feeding care by failing to label the date and time the feeding was started for two (R2, R3) residents of three residents reviewed for enteral feedings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a.) food items were properly stored per manufacturer guidelines, b.) expired foods were discarded, and c.) proper hand washing was done in between handling dirty and clean plate ware. These failures have the potential to affect all 77 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled and stored in 2 of 2 medication carts reviewed. This affects 4 residents (R54, R3, R64, and R68) reviewed for medication storage. Findings Include: 1. R54 has diagnoses of Asthma and Essential (Primary) Hypertension. R54's Order Summary Report, dated 12/13/23, documents: Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT 2 puff inhale orally every 12 hours. R54's Care Plan documents: Focus: R54 has Asthma. Intervention: Give medications as ordered (Budesonide Inhaler). Monitor/document side effects and effectiveness. 2. R3 has diagnoses not limited to Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Disorders of Electrolyte and Fluid Balance, and Urinary Tract Infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for infection prevention and control by: 1. Failed to ensure that proper PPE (Personal Protective Equipment) such as N95 mask is worn by staff during COVID outbreak in the affected area. 2. Failed to ensure that a sign will be provided outside the room for residents on transmission-based precautions indicating the type of the precaution for 5 residents (R9, R14, R60, R68, R274). 3. Failed to follow enhanced barrier precaution policy and procedures for resident (R68) with PICC (peripherally inserted central catheter) line. These failures affect 5 residents (R9, F14, R68, R274, and R60), and could potentially affect 23 residents residing on 3rd floor for facility's census, dated 12/12/23, reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed to: (1) provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal and Influenza vaccinations; (2) assess eligibility and offer Influenza vaccination to 2 (R9, R68) residents; and (3) assess eligibility and offer pneumococcal vaccinations to 4 (R9, R60, R68 and R274) residents. These failures affect 4 (R9, R60, R68 and R274) of 5 residents reviewed for pneumococcal / influenza vaccinations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were treated with respect and dignity by not passing out meals to residents sitting at a table at the same time. These failures affected 1 resident (R70) reviewed during dining in a total sample of 19 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 (R60) resident reviewed for accommodation of needs in a sample of 19. Findings Include: R60 has diagnoses not limited to Extended Spectrum Beta Lactamase (ESBL) Resistance, Major Depressive Disorder, Insomnia, Hallucinations, Dementia in other Diseases Classified Elsewhere, Mild, with other Behavioral Disturbance, Acute on Chronic Diastolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Chronic Kidney Disease, Stage 3, Anemia in Chronic Kidney Disease, Cognitive Communication Deficit, Lobar Pneumonia, and Acute Cough. R60's Care Plan documents: Intervention: Keep call light within reach when in bedroom or bathroom Date Initiated: 12/08/23. Focus: (R60) has an ADL (Activities of Daily Living) self-care deficits r/t (related/to) decline in ADL functions. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a Physician's order with the code status for 2 (R14, R66) of 2 residents reviewed for Advance Directives in a sample of 19. Findings Include: 1. R66 has diagnosis not limited to Acute on Chronic Systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrilelation, Acute Embolism and Thrombosis of Right Axillary Vein, Essential (Primary) Hypertension, Acute and Chronic Postprocedural Respiratory Failure, Personal History of Pneumonia, Cardiomyopathies, and Cognitive Communication Deficit. R66's Care Plan documents: Focus: (R66) Advance Directive Status (Code Status: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide physician ordered oral nutritional supplements. This failure affected 2 residents (R23, R34) of 6 residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the correct oxygen flow rate as ordered for 2 (R4, R66) of 2 residents reviewed for respiratory care in a sample of 19. Findings Include: 1. R66 has diagnoses not limited to Acute on Chronic Systolic (Congestive) Heart Failure, Paroxysmal Atrial Fibrillation, Acute Embolism and Thrombosis of Right Axillary Vein, Essential (Primary) Hypertension, Acute and Chronic Postprocedural Respiratory Failure, Personal History of Pneumonia, Cardiomyopathies, and Cognitive Communication Deficit. Order Review Report, dated 12/12/23, documents: Oxygen 2L (Liters)/min (Minute) via nasal cannula to maintain Oxygen Saturation level equal or above 92% as needed for SOB (Shortness of Breath). R66's Care Plan documents Focus: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their fall policy and R5's comprehensive care plan to prevent further falls for 1 of 6 residents reviewed for falls.

Inspectors wroteBased on observation, interview, and records review, the facility failed to follow their policy on resident food preferences for one (R6) of four residents reviewed.