Warren Barr South Loop

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 25, 2024

  Based on interviews and record reviews, the facility failed to follow care plan interventions to provide adequate supervision as per facility policy, to avoid fall accidents for 1 (R2) out of 3 residents, in a total sample of 3 residents reviewed accidental hazards. This failure resulted to R2 sustaining a frontal lobe hematoma which led to intraparenchymal hemorrhage. Findings include: R2's MDS Section C (10/4/2024) documents in part: R2 has BIMS (Brief Interview for Mental Status) score of 11. R2 is moderately impaired cognitively. […]

• Actual harm, isolatedF695Aug 27, 2024

  Based on record reviews, interviews, and observation the facility fails as follows: to provide respiratory care as per physician's order; to provide interventions for plan of care that would help prevent tracheostomy dislodgement; to provide close monitoring of tracheostomy for a resident with history of multiple incidents of decannulation or dislodgement by following physician's order and/or plan of care. These failures apply to 1 out of 4 residents (R1) reviewed for respiratory care via tracheostomy. These failures that include not closely monitoring, not following physician orders and/or care plan interventions resulted in facility staff not being aware of decannulation or dislodgement of tracheostomy that provides oxygenation essential for 1 resident's (R1) airway. […]

• Actual harm, isolatedF684Aug 15, 2024

  Based on observation, interview, and record review the facility failed to follow policy procedures, failed to assess wounds timely, failed to ensure that wound care orders are transcribed as directed, failed to implement care plan interventions (monitor dressing, report loose dressing, report signs/symptoms of infection), failed to ensure that Nurse's Notes were documented - as indicated on the TAR (Treatment Administration Record) and/or failed to follow physician orders for three of three residents (R1, R2, R3) reviewed for wound care. These failures resulted in R1 sustaining Staph (Staphylococcus) Bacteremia (presence of bacteria in the bloodstream which can occur due to tissue infection) on or about 8/2/24 which was treated with Vancomycin (Antibiotic) until 8/5/24. […]

• Actual harm, isolatedF686Jul 19, 2024

  Based on record reviews and interviews the facility failed as follows: failed to follow preventive measures in placing intervention of skin moisture barriers as per facility policy; failed to follow Wound Nurse Practitioner recommendation for dietitian to consult and assess in a timely manner; failed to provide interventions of multivitamin and zinc sulfate per Wound Specialist Assessment; failed to provide protein supplement due to delay of nutritional assessment; and failed to ensure orders by Wound Nurse Practitioner for laboratory testing and antibiotic therapy was carried out. All failures apply to 1 out of 4 residents (R1) in a total sample of 4 residents reviewed for prevention and treatment of pressure injuries. […]

• Actual harm, isolatedF600Jan 31, 2024

  Based on observation, interview and record review, the facility failed to ensure that two (R1, R2) residents remain free from abuse. This failure resulted in R1 and R2 being sexually abused by V3(CNA). Findings include: R1's current face sheet documents R1 is a [AGE] year-old individual first admitted on [DATE]. R1's medical conditions include but not limited to: acute and chronic respiratory failure with hypoxia, anxiety disorder due to known physiological condition, muscle wasting and atrophy, not elsewhere classified, right upper arm, left upper arm, right thigh, left thigh, dysphagia, oropharyngeal phase, dysphagia following cerebral infarction. […]