Warren Barr Buffalo Grove

In the surveyor’s words

From the most serious findings on record at Warren Barr Buffalo Grove, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 24, 2021

  Based on interview and record review, the facility failed to perform a safe transfer with a mechanical lift for a resident (R1), failed to train staff on mechanical lift emergency procedures and the facility failed to ensure the safety of a resident during a pivot transfer for 2 of 3 residents (R1, R3) reviewed for falls in the sample of 3. These failures resulted in R1 sustaining a right clavicular fracture, right femoral fracture, and a humeral (upper arm) fracture and expiring 48 hours after her fall, and R3 sustaining a tibia and fibula fracture of her leg. The Immediate Jeopardy began on [DATE] when staff failed to perform a safe transfer with a mechanical lift. The Immediate Jeopardy was identified on [DATE]. […]

• Actual harm, isolatedF684Oct 30, 2023

  Based 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. The findings include: R1's face sheet shows he is a [AGE] year-old male with diagnosis including cerebral infarct, hemiplegia and hemiparesis following cerebral infarct affecting left non-dominant side, muscle weakness, unspecified dementia, history of falling, atrial fibrillation, type diabetes, chronic embolism and thrombosis, presence of cardiac pacemaker and hypertension. […]

• Actual harm, isolatedF695Apr 11, 2023

  Based on observation, interview, and record review the facility failed to ensure a resident on oxygen had an oxygen supply, failed to ensure a resident with a recent hospitalization for pulmonary edema (buildup of fluid in the lungs leading to shortness of breath) followed physician orders, failed to have a policy and procedure for weaning a resident off oxygen, failed to ensure oxygen tubing was dated, and failed to ensure oxygen tubing not in use was stored in a bag for 6 (R1, R2, R3, R5, R6, R7) of 6 residents reviewed for oxygen in the sample of 9. […]

• Actual harm, isolatedF689Jul 6, 2022

  Based on observation, interview, and record review the facility failure to ensure residents were safely transferred with a mechanical lift for 2 of 3 residents (R1, R3) reviewed for safety in the sample of 6. These failures resulted in R1 sliding from the mechanical lift and sustaining a subdural hematoma (brain bleed); left temporal hematoma with a skull fracture; left clavicle fracture; and left humerus fracture. R1 is currently hospitalized and was transitioned to hospice care. Findings include: 1. The facility's Final Incident Report dated 6/28/22 showed that R1 was being transferred by Certified Nursing Assistant (V11) from the bed to the chair when R1 slipped from the lift sling and onto the floor. R1 hit her feet first then hit her head on the floor. […]

• No harm, potential for more than minimal, widespreadF812Jan 29, 2025

  Based 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. Findings include: The CMS 671 dated 1/26/25 show there were 153 residents residing at the facility. 1. On 1/26/25 at 9:10 AM, V5 (Dietary Manager-DM) was in the dishwashing area loading dish racks eight (8) times . […]