Warren Barr Orland Park

Inspectors wroteBased on interview and record review, the facility failed to maintain confidentiality of resident's record by failing to ensure that resident's medications were secured at the facility and not sent home with another resident. This failure affected one (R172) of two residents reviewed for confidentiality of records.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff conducted appropriate discharge instruction prior to discharging a resident and failed to ensure a resident was discharged home with the right medications. This failure affected one (R236) of one resident reviewed for discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 2 medication errors out of 30 medication opportunities resulting in a 6.67% medication error rate. This failure affected one (R195) of three residents reviewed for medication administration. R195's face sheet documents R195 is an [AGE] year-old resident admitted on [DATE] with diagnoses including but not limited to Type 2 diabetes mellitus without complications, supraventricular tachycardia, and acute gastroenteropathy due to Norwalk agent, and Alzheimer's disease with late onset. R195's Minimum Data Set documents a Brief Interview of Mental Status (BIMS) summary score of 5, indicating R195 has severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were aware of required LALM (Low Air Loss Mattress) settings and failed to ensure the LALM settings were set to the correct settings (while in use) for two of three residents (R3, R6) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining environment for one resident (R10) and failed to accommodate one (R3) request during dining in a sample of 10 residents reviewed for resident rights.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician for one resident (R1) in a sample of 10 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely turn a resident in bed for cares. This failure resulted in R1 rolling off the bed and sustaining a right femur fracture. This applies to 1 of 3 residents (R1) reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from theft. This applies to 1 of 3 residents (R3) reviewed for abuse/theft in the sample.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 162 residents in the facility receiving dietary services.

Inspectors wroteBased on interview and record review, the facility failed to have documentation that staff were educated and offerred the Covid-19 immunization. This applies to all 168 residents in the facility reviewed for immunizations in the sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or their representatives written notification of the reason for transfer to the hospital, and failed to notify the Ombudsman of the transfers. This applies to 5 of 5 residents (R29, R33, R37, R54, and R80) reviewed for discharge in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who require assistance with their ADLs. This applies to 7 of 7 residents (R23, R29, R33, R68, R75, R96, R116) reviewed for personal hygiene in a sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to obtain vital information regarding residents' pacemakers, and ensure it was readily available in the resident's medical record. This applies to out 5 of 5 residents (R20, R81, R96, R136, R529) reviewed for pacemakers in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired items from resident refrigerators. This applies to 4 of 4 residents (R36, R38, R47, R84) reviewed for refrigerators in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures. These failures apply to 5 of 5 residents (R27, R5, R529, R383, & R63) reviewed for infection control practices in a sample of 33 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or their representative of the facility's policy for bed hold in writing. This applies to 3 of 3 residents (R33, R54, and R80) reviewed for discharge in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident beds were kept at a safe height. This applies to 2 of 4 residents (R167 and R173) reviewed for accidents in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications securely. This applies to 3 of 3 residents (R125, R119, R379) reviewed for medication storage in a sample of 33.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's orders for obtaining a urinalysis in a timely manner. This applies to 1 of 3 residents (R1) reviewed for care delay.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADLs (Activity of Daily Living) care to residents. This applies to 4 of 16 residents (R8, R9, R14 and R19) reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly answer resident call lights. This applies to 3 of 16 residents (R3, R6, R7) reviewed for call lights in a sample of 17.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food services in a manner that prevents food borne illness. This applies to all 166 residents that receive food services from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for self-administration of medications, and failed to obtain physician order for resident to self-administer medications and to have medications stored in resident rooms. This applies to 5 of 5 residents (R3, R10, R17, R123 and R388) reviewed for medications in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have call lights accessible to dependent residents. This applies to 4 of 4 residents (R8, R21, R77 and R147) reviewed for accommodation of needs in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have thermometers and complete temperature logs for residents' personal refrigerators. They facility also failed to remove expired items, label food, and clean refrigerators. This applies to 5 of 5 residents (R1, R2, R53, R62, R94) reviewed for refrigerators in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents were free from physical restraints. This applies to 2 of 2 residents (R77, R86) reviewed for restraints in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to administer medications timely as per the physician's orders. This applies to 1 resident (R82) in a sample of 34 residents reviewed for medication pass timing. R82's MDS (Minimum Data Set), dated 2/14/24, shows her cognition is intact. R82's POS (Physician Order Sheet) shows order, dated 3/14/24: Maintain at all times: Strict contact isolation precautions due to an active infection (ESBL urine) single room. R82's Care Plan, dated 3/14/24, shows resident is on contact isolation precautions related to positive ESBL in urine. Interventions include provide antibiotic therapy per the physician's orders. On 3/19/24 at 3:27 PM, R82 said she had been at the facility for 5-6 weeks, and on 2 occasions, the staff did not bring her medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed adjust the mattress and bed frame so the exposed metal frame was not a hazard. This applies to 1 resident R63 reviewed for accidents hazards in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident nutritional status and monitor weights as ordered. These failures resulted in R33 experiencing a significant weight loss. This applies to 1 resident (R33) reviewed for weight loss in a sample of 34.

Inspectors wroteBased on interview and record review, the facility failed to evaluate for gradual dose reductions (GDR) for a resident receiving psychotropic medications. This applies to 1 of 1 resident (R68) reviewed for antipsychotic medications in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications in the appropriate form and as ordered per physician. There were 29 opportunities with 3 errors, resulting in a 10.34% error rate. This applies to 2 (R47 and R121) of the 5 residents observed in medication pass. 1. On 3/20/24 at 9:15 AM, V24 (Agency LPN/Licensed Practical Nurse) administered Norco 5/325 mg to R47. When V24 told R47 she was giving her Norco, R47 said, I already had Norco, didn't I? to which V24 replied, That was yesterday. V24 did not go check the computer to look at the doctor's order or see what time R47 last received Norco. R47 then swallowed the Norco pill. R47's POS (Physician Order Sheet) shows order: Norco oral tablet 5/325 mg give 1 tablet by mouth three times a day for pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply PPE (Personal Protective Equipment) and perform handwashing for a resident who was on contact isolation for C. Diff. (Clostridium Difficile). The facility also failed to This applies to 2 of 2 residents (R21, R147) reviewed for infection control in a sample of 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control guidelines provided by IDPH (Illinois Department of Public Health) after a resident tested positive for Legionnaire's Disease. The facility's policy for Legionnaire's Disease was also incorrect according to CDC (Centers for Disease Control and Prevention) guidelines. The facility also failed to ensure staff wore appropriate PPE (Personal Protective Equipment) in a COVID-19 positive resident's room. This applies to 2 of 4 residents (R3, R4) reviewed for infection control in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely ADL (Activities of Daily Living) care to residents that required staff assistance. This applies to 3 of 4 residents (R1, R2, R3) reviewed for activity of daily living in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide R1 adequate hydration resulting in R1 being admitted to the hospital for hypernatremia (high sodium). This applies to 1 of 6 residents (R1) reviewed for hydration. Findings Include: R1's September Physician's Order Sheet list the following diagnoses including: cerebral infarction, dementia, diabetes, hyperlipidemia, sleep apnea, atrial fibrillation, hyperlipidemia, dysphagia, and aphasia. Physician, order dated 9/26/23, documents enteral feeding Glucerna 1.2 at 65 ML/HR (Milliliters per hour) continuous to 1040 ML water flush 350 ML six times per day total volume 2100 ML in 24hour period. R1's MDS (Minimum Data Set), dated 9/17/23, show resident is completely dependent upon staff for (Activities of Daily Living). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow to ensure resident ADL (Activities of Daily Living) needs were met for residents who require assistance for transferring, incontinence care, and positioning. This applies to 4 of 8 residents (R27, R44, R70, and R324) reviewed for activities of daily living (ADL) in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place calls light within residents reach. This applies to 3 residents (R74, R117 and R159) in a sample size of 33. 1. On May 3, 2023, at 3:54 pm, R117 was on his bed, awake and dressed. R117's call light was clipped to itself between the nightstand and the wall. R117 stated he would like to have his call light, and thought it would be provided to him. R117's MDS (Minimum Data Set), dated April 10, 2023, indicates resident requires staff supervision with ADLs (Activities of Daily Living). R117's EHR (Electronic Health Record) care plan includes Resident is at risk for altered cardiovascular function related to hypertension, coronary artery disease and hyperlipidemia. Resident requires supervision to limited assistance with ADLs. At risk for falls related to unsteadiness on feet with impaired mobility. [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure resident's pain was assessed and managed. This applies to 1 of 4 residents reviewed for pain in a sample of 33.