Warren Barr Oak Lawn

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call lights were consistently within reach of residents (R23, R150, R64) and failed to ensure that wheelchairs were available for residents (R112 & R143) who were assessed to require them for mobility. This affected five residents (R23, R64, R150, R112, and R143) reviewed for accommodation of needs on the total sample of 43.

Inspectors wroteFailures at this level required more than one deficient practice statement:A. Based on observations, interviews, and record reviews, the facility failed to follow its infection prevention and control policy, including its COVID-19 policy. Specifically, the facility failed to place a resident with an indwelling medical device on transmission-based precautions upon admission; failed to don appropriate personal protective equipment (PPE) prior to entering an enhanced barrier precautions (EBP) resident room to provide direct care (R6); failed to place a COVID-19 positive resident in appropriate transmission-based (contact/droplet) precautions immediately upon return from the hospital and initiate the required monitoring protocol (R147); and failed to implement contact tracing for residents and staff exposed to a COVID-19 positive resident. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents are not verbally and mentally abused by facility staff. This affected one of three residents (R144) reviewed for staff to resident abuse on the total sample of 43.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide and document sufficient preparation/orientation to one resident to ensure a safe/orderly transfer from the facility to the hospital, failed to obtain a physician order for the transfer, and failed to document the transfer in the resident's medical record. This affected one resident (R130) out of three reviewed for transfer/discharge in a sample of 43.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide the bed hold policy to one resident or representative upon transfer to a local hospital. This affected one of (R130) three reviewed for bed hold in a sample of 43.

Inspectors wroteBased on interviews and record reviews, the facility failed to initiate a person-centered care plan for enhanced barrier precautions (EBP) and enteral nutrition for one resident admitted to the facility with a gastrostomy tube and receiving enteral nutrition. This affects one of three (R6) residents reviewed for comprehensive care plan in a sample of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its incontinence care policy and failed to ensure that a resident identified as requiring assistance with toileting was assessed and provided incontinence care at least every two hours. This affected one of three residents (R135) reviewed for incontinence care on the total sample of 43. Findings Includes: R135's minimal data set dated [DATE] section C (cognitive pattern) brief interview for mental status documents a score of twelve which indicate moderate cognitive impairment. Section GG (functional ability) documents: lower extremities impairment on both sides. R135 requires substantial maximal assistance rolling left to right and partial/moderate assistance for toilet hygiene. Section H (bladder and bowel) documents urinary continence always incontinent. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their physician order to ensure compression wraps were applied as prescribed (R78) and failed to ensure the old Scopolamine transdermal patch was removed before applying a new patch (R148). This affected two of three residents (R78 & R148) reviewed for quality of care on the total sample of 43. Findings Include: R78 was diagnosis with Lyphedema. Brief interview for mental status dated 2/26/26 documents a score of fifteen which indicates cognitively intact. Physician order sheet dated 9/28/25 documents: wrap bilateral lower extremities with Compression wraps with Ace bandage at 0600 (6:00am) in the morning apply. On 4/14/26 at 10:36am, R78 who was assessed to be alert and orient to person place and time said, her ace wraps for her legs was not applied today. R78 was observed without her compression ace wraps in place. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow the ortho physician recommendations to complete physical therapy evaluation and treat, occupational therapy evaluation and treatment, and assist with passive range of motion including pendulum exercises for greater than 30 days for one of three residents (R7) reviewed for physicians' orders regarding therapy and range of motion on the total sample of 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their intravenous therapy policy by failing to ensure one resident's Peripherally Inserted Central Catheter (PICC) dressing was changed every 7 days. This affects one of one residents (R121) reviewed for intravenous therapy on the total sample of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an opened insulin vial was properly labeled with the date opened and/or expiration date, in accordance with medication storage policy. This affected one of one resident (R61) reviewed for medication storage on the total sample of 43. Findings Includes: R61 was diagnosed with type two Diabetes Mellitus with Diabetic Autonomic (Poly) Neuropathy. Physician order sheet dated 4/2026 documents: Insulin Lispro Injection Solution 100unit/ milliliter On [DATE] at 10:51AM, during medication cart audit with V45 (nurse), R61 lispro insulin vial was open and not dated. V45 (nurse) confirmed there was no open date or expiration date on the insulin bag or vial. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow doctor orders to order a stat lab draw for one resident(R142) for one of one reviewed for lab services on the total sample of 43.

Inspectors wroteBased on record review and interviews, the facility failed to ensure contracted diagnostic services were provided within 24 hours, as required under the terms of its contractual agreement, for one resident with a history of pulmonary embolism and acute embolism. This affected one of one resident (R143) reviewed for diagnostic services on the total sample of 43.

Inspectors wroteBased on the interview and record review, the facility failed to follow its fall occurrence policy by not conducting a post-fall investigation to determine the reasonable cause of the fall and reviewing the fall care plan with new interventions. This applies to one of three residents (R2) reviewed for falls in a sample of 14.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow physician orders to ensure as needed pain medication (oxycodone) was administered to one resident as prescribed. This affected one of three residents (R1) reviewed for pain management. This failure resulted in R1 being admitted to this facility on 9/24/25 and requested narcotic pain medication, rated pain as 6 out of 10, but was informed by nurse R1's medication was not available until the next morning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize an acute change in condition for a resident. This failure applied to one (R5) of three residents reviewed for nursing care and resulted in a delay in care for R5 who was hospitalized for respiratory failure.

Inspectors wroteBased on interview and record review, the facility failed to implement turning and repositioning to prevent the development of new pressure injuries and complete treatment orders. This failure affected two residents (R4 and R5) who were at high risk of developing pressure ulcers and resulted in R4 and R5 developing deep tissue injuries to the sacrum.

Inspectors wroteBased on interview and record review, the facility failed to provide timely incontinence care assistance for one of three residents (R8) reviewed for incontinence care.

Inspectors wroteBased on interview and record review, the facility failed to offer Influenza and Pneumococcal immunization as required for four of five residents (R25, R,27, R73 and R265) reviewed for immunization in a sample of 20 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the urine collection bag was covered for two of two residents (R261, R264) reviewed for resident's rights in a sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure privacy was maintained while applying a pain patch for one of one residents (R54) reviewed for privacy in a sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the fall care plan by failing to implement a fall intervention by not ensuring a resident's call light was in reach for a resident (assessed to be risk for fall and history of fall at the facility). This failure affected one resident (R57) of three reviewed for call lights in a total sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to place a urine collection bag below the bladder for one of two residents (R261) reviewed for catheter use in a sample of 20.

Inspectors wroteBased on observation, interview and record review, the facility failed to date and label the enteral tube feeding bottle for one of one resident (R264) reviewed for tube feeding management in a sample of 20 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow their covid 19 testing policy by not testing residents and staff following a covid 19 outbreak on 9/8/23 which had the potentially to affect all the 103 residents. In addition, the facility failed to test residents and staff for covid 19 for 14 days with no new positives during an outbreak that started on 2/5/24 which had the potential to affect all 96 residents at the facility reviewed for infection control.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify attending doctor of an outside consultant order/recommendations. This deficient practice affects one resident (R18) of three residents reviewed for physician notification. Findings Include: R18 is a [AGE] year old with diagnoses but not limited to: Acute Diastolic Congestive Heart Failure, Arteriosclerotic Heart Disease of Native Coronary Artery, Multiple Sub segmental Pulmunary Emboli, Acute Embolism and Thrombosis Deep Vein of Right Lower Extremity. R18 hospitalized on [DATE] for chest tightness and was diagnosed with bilateral proximal pulmonary artery emboli with right heart stain, underwent thrombectomy. Returned in the facility on 1/23/23, and was place on anticoagulant medication. R18 went to see Cardiologist on 6/1/23 and returned with an order of: [...]

Inspectors wroteBased on interview and record review the facility failed to follow physician orders by not applying an antifungal cream to one resident. This affected one of three residents (R3) reviewed for medication.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the attending physician of one resident's urine culture and sensitivity results noting the antibiotic the resident was receiving for UTI (urinary tract infection) was ineffective in treating resident's UTI. This affected one of three residents (R10) reviewed abnormal labs on the sample list of 49.