Warren Park Health & Living Ctr

Inspectors wroteBased on interview and record review the facility failed to ensure their IDPH (Illinois Department of Public Health) Reportable initial and final Incident Report Form was transmitted correctly for 7 (R20, R28, R45, R50,R82, R86, R121) of 7 residents identified on four (4) Facility Reportable documents reviewed. This failure has the potential to affect 123 residents residing in the facility. Findings Include:On 12/10/25 during review of the facility Reportable Fax Transmittal Form document, it was observed that the facility transmittal sheet document in part: Result: No answer . IDPH did not receive the following reportable of 09/18/25, 10/27/25 (regarding R20 and R28), 10/28/25 (regarding R121), 11/19/25 (regarding R28 and R86), and 9/19/25 regarding R50, R45 and R82. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program. This has the potential to affect all 123 residents residing in the facility.

Inspectors wroteBased on observation, interviews and review of record the facility failed to maintain toilet rails inside the shower in safe working condition and they also failed to ensure that there is a shower head and shower curtain that covers entire shower area for all residents living on the 2nd floor. These failures have the potential to affect fifty-five (55) residents on their safety and comfort when using the shower room.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a home-like environment for three residents (R9, R133, and R134) out of a total sample of 26 residents.

Inspectors wroteBased on interview and record review the facility failed to ensure a Level II PASARR (Preadmission Screening and Annual Resident Review) yearly review was completed for 1 of 2 residents reviewed for PASARR in a sample of 26. Findings Include: R41 has diagnosis not limited to Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation, Ulcerative Colitis, Morbid (Severe) Obesity due to Excess Calories, Abnormalities of Gait and Mobility, Insomnia, Overactive Bladder, Age-Related Osteoporosis, Mood [Affective] Disorder, Solitary Pulmonary Nodule Right lower lobe Lung Nodule, Bilateral Primary Osteoarthritis of Knee, Bipolar Disorder, Pulmonary Embolism and Infarction, Heart Failure, Congestive Heart Failure, Idiopathic Scoliosis, Atherosclerotic Heart Disease of Native Coronary Artery, Hyperlipidemia and Essential (Primary) Hypertension. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their Change in Condition Policy to promptly notify the physician of skin rashes for three [R23, R97, R113] residents reviewed in a sample of 26. This failure resulted in a delay of treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure an enteral bolus feeding was administered per physician orders for one (R103) resident with an order of NPO (Nothing by Mouth) reviewed for g-(gastric) tube feedings in a sample of 26. Findings Include:R103 has diagnosis not limited to Chronic Systolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Asthma, , Gastrostomy, Essential (Primary) Hypertension and Hyperlipidemia. R103's Medication Review Report document in part: NPO (nothing by mouth) diet. Enteral Feed Order four times a day Enteral feeding G (gastric)-Tube: Jevity 1.2cal, Bolus: 2 cans. Flush g-tube with 120ml (milliliter) of water before & after each bolus feed. Enteral Feed Order one time a day for G-tube Care [Enteral] Change syringe daily. Oral /Enteral Syringe with Enfit Connector 60ml. R103's Care Plan document in part: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to (a.) follow the physician orders for a resident on continuous oxygen, (b.) failed to post oxygen in use signage at the entrance of R41's room, and (c.) failed to label and store oxygen tubing and a nebulizer set-up to prevent contamination for two (R41, R103) residents reviewed for respiratory treatments in a sample of 26.

Inspectors wroteBased on observations, interviews and review of records the facility failed to follow policy on accounting controlled or narcotic medications for residents on the 2nd floor. These failures have the potential to affect 2 residents (R121 and R133) and an unknown resident on inaccurate accounting of controlled or narcotic medication.

Inspectors wroteBased on observations, interviews and review of records the facility failed to maintain medication storage free from expired and/or discontinued medications for 1 out of 4 medication carts and 1 out of 2 medication rooms. These failures have the risk that can affect two (2) residents (R38 and R121) on receiving medication that are either expired and/or discontinued.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their Vaccination of Resident Policy. Failed to administer three [R23, R46, R113] residents their Covid Vaccine after consenting for the vaccine reviewed in a sample of 26.

Inspectors wroteBased on observations, interviews, and record reviews facility failed to follow their policy to ensure residents are free from sexual abuse for 1 (R4) out of 3 residents reviewed for sexual abuse in a sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests. This has the potential to affect all residents residing on the 2nd and 3rd floor.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to discard expired food based on use by guidelines and labeled use by date, failed to ensure food items were labeled and dated with use by date, and failed to sanitize cooking equipment based on manufacturers' directions. These failures have the potential to affect all 123 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that reusable cloth incontinence briefs intended for resident use were in good condition, this failure has the potential to affect 40 incontinent residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to refer four (R41, R66, R72, R90) residents with serious mental illness to the appropriate state-designated authority for PASARR (Pre-admission Screening and Resident Review) level II evaluation and determination in a total sample of 25 residents reviewed. Findings Include: R41s' Face sheet documents that R41 was admitted to the facility on [DATE] with diagnoses not limited to: bipolar disorder and anxiety disorder. R41s' PASARR screening dated 05/25/2005 titled OBRA-1 Initial Screen documents that there is reasonable basis to suspect a mental illness for R41. There is no documentation to show that R41 was referred to the appropriate state-designated authority for a Level II PASARR evaluation and determination. R66s' Face sheet documents that R66 was admitted to the facility on [DATE] with diagnoses not limited to: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were locked and secured while unattended. This failure has the potential to affect all 68 residents residing on the 1st and 3rd floors. Findings Include: On 12/09/2024 at 11:15AM, surveyor located on the first floor of the facility. Surveyor observes a medication cart unlocked and unattended with medication cart keys left inside of the medication carts' lock. V6 (Registered Nurse/RN) states she is responsible for the unlocked and unattended medication cart. V6 states this medication cart stores medications for residents on the 1st and 3rd floors of the facility. V6 states she must have gotten busy with other things and forgot to lock the medication cart and retrieve the keys. V6 states that residents can potentially get access to the medications if the cart is left unlocked and unattended. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure shared equipment was cleaned and decontaminated between each use for 4 [R27, R92, R104, R116] of 6 residents reviewed for medication administration observation.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide dignity for two (R41, R226) residents in a total sample of 25 residents reviewed.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to correctly set air loss mattress based on weight for one (R75) of 8 residents reviewed for pressure wound treatment services in a total sample of 25 .

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate assistance and supervision to 2 (R50, R84) out of 2 high fall risk residents reviewed for accidents and hazards in a final sample of 25. Findings Include: On 12/09/24 at 12:05 PM, R50 was sitting in [R50's] wheelchair in the dining room alert and able to verbalize needs. R50 stated R50 has pain everywhere. R50 stated [R50] went to the bathroom by himself around 9:00 AM this morning, and while [R50] was washing [R50's] hands, R50 slipped and hit [R50's] head on the sink. R5 stated [R50] was able to lift himself back up and went back in bed. R50 stated [R50] notified the nurse but does not know the name of the nurse. On 12/9/24 At 12:10 PM, Surveyor notified V9 (Registered Nurse) of what was reported by R50. V9 stated that V9 was not made aware of R50's incident. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and offer pneumonia vaccines prior to or upon admission to the facility. This failure affects three (R9, R72, R75) out of five residents reviewed for pneumonia vaccines in a total sample of 25 residents.

Inspectors wroteBased on interview and record review, facility failed to follow their policy to report the appearance of suspicious bruise, lacerations, or other abnormalities as unknown origin as soon as it is discovered for one (R1) out of three residents reviewed for reporting of unknown injury.

Inspectors wroteBased on observation, interviews and record review the facility failed to establish and implement interventions for one resident (R5), with a behavior of urinating and defecating in a waste basket. This failure has affected two residents (R5 and R6) and has the potential to affect 54 other residents who reside on the second floor.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that two dependent residents (R4 and R8) received showers as scheduled. This failure has affects two of five residents reviewed for ADLs (Activities of Daily living).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was free from physical abuse which affected one (R70) in the sample of 58 residents reviewed for abuse. This failure caused harm to R70 who was physically struck, fell, and suffered a laceration to R70's left forehead which required 4 sutures as treatment in the hospital.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staffing. This failure has the potential to affect all 125 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label/date food items, failed to store food items/goods six inches off the floor, failed to dispose of food items after the use by date, and failed to ensure staff kept personal belongings in appropriate location in an effort to prevent food borne illnesses These failures have the potential to affect all 124 residents receiving oral nutrition at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the outside dumpster lid was closed to prevent pest and rodents from migrating into the dumpster. This failure has the potential to affect all 125 residents at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide room identifiers on residents' room in an effort to provide a safe environment to residents. This failure affected six (R24, R34, R43, R73, R101, and R323) residents reviewed for home like environment in the total sample of 58 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately don and doff personal protective equipment (PPE) for isolation rooms; failed to perform proper hand hygiene, failed to doff gloves in the hallway; failed to post the proper isolation sign for positive COVID 19 isolation rooms in efforts to prevent the spread of microorganism including COVID 19; failed to provide accessible PPE for isolation rooms; failed to properly transport COVID 19 isolation linen; and failed to follow the facility's COVID-19 policy and procedures. These failures affected R2, R16, R18, R30, R33, R38, R94, R105, R107, and R118 and has the potential to affect all 50 residents on the first floor, all 57 residents on the second floor and all 18 residents on the third floor at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure the facility is free of roaches. This failure has the potential to affect all 125 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's call light device was within reach for one resident (R107) to call for staff assistance. This failure affected one resident (R107) in the sample of 58 residents reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to perform a thorough physical abuse investigation which affected two (R49 and R70) residents in the sample of 58 residents reviewed for abuse.

Inspectors wroteBased on observation, interview and document review the facility failed to maintain its nurse call system in full functioning condition on 3 of 3 resident floors. This affects all 123 residents in the facility.