Warren Barr Orland Park

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 3, 2025

  Based 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. The findings include: R1's Face Sheet showed she was originally admitted to the facility on [DATE]. R1's Face Sheet included diagnoses of functional quadriplegia, reduced mobility, muscle wasting and atrophy, morbid (severe) obesity, body mass index (BMI) 50-59.9, anxiety disorder, and need for personal care. […]

• Actual harm, isolatedF692Mar 22, 2024

  Based 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. The findings include: R33 was admitted originally admitted to the facility on [DATE]. R33 was readmitted on [DATE] per the Face Sheet. R33's MDS (Minimum Data Set), dated 03/13/24, showed no BIMS score for R33, but showed R33's cognitive skills for daily decision making were severely impaired. The same MDS showed R33 was dependent upon staff for most ADL's (Activities of Daily Living). The same MDS showed R33 received nutrition through a feeding tube. […]

• Actual harm, isolatedF692Sep 29, 2023

  Based 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. […]

• Actual harm, isolatedF689Jun 27, 2023

  Based on interview and record review, the facility failed to ensure that a resident did not fall out of bed during staff provision of care. This applies to 1 of 3 residents (R2) reviewed for fall incidents in the sample of 12. This failure resulted in R2 sustaining lacerations on the head, requiring emergency care treatment and staples at the hospital. The findings include: R2 was admitted to the facility on [DATE]. R2 has multiple diagnoses which includes encephalopathy, type 2 diabetes mellitus, fibromyalgia, muscle wasting and atrophy, lack of coordination, abnormal gait and mobility, abnormal posture, and history of falling, based on the face sheet. R2's fall risk evaluation, dated April 28, 2023, showed the resident was high risk for fall. […]

• Actual harm, isolatedF697Jul 1, 2021

  Based on interview and record review, the facility failed to provide narcotic pain medication to a resident as ordered by the physician. This failure resulted in R1 not receiving physician-ordered pain medication for more than 20 hours and causing R1 to experience severe pain. This failure also resulted in psychosocial harm as evidenced by R1 stating she felt great sadness, helplessness, and anxiousness due to her pain level and the lack of available pain medication. This applies to 1 of 3 residents (R1) reviewed for pain medication in the sample of 4. Findings include: The EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE] and was discharged to home on June 15, 2021. R1 had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]