Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Barr Buffalo Grove during CMS and state inspections, most recent first.
A cognitively impaired resident with dementia and multiple sclerosis, whose care plan directed that all information be given to her advocate, was started on Losartan for newly diagnosed HTN without prior notification of her health care POA. The POA, who visited frequently and had repeatedly requested to be informed of any changes including medications, only learned of the new antihypertensive from a cardiology NP months later. Documentation showed the new medication was discussed with the resident but contained no evidence that the representative was notified, and staff, including social services and the DON, acknowledged the resident’s confusion and the expectation that the representative should have been contacted before initiating the medication.
A resident with dementia and mobility issues was found in bed with a thick mattress propped upright along one side, held by a chair, while the other side of the bed was against the wall. The setup, confirmed by LPNs and the administrator, restricted the resident's movement and was acknowledged as an inappropriate restraint, contrary to facility policy that prohibits such use except for medical treatment.
A resident's tablet computer was reported missing after being last seen on the nightstand by a CNA and later tracked to a local hotel. An agency CNA, who worked a single night shift and was assigned to the resident, was observed entering the resident's room multiple times during that shift. Attempts to contact the CNA were unsuccessful, and the police confirmed the CNA had checked out of the hotel where the tablet was located. The facility did not prevent the misappropriation of the resident's property.
The facility failed to maintain proper kitchen sanitation and food safety practices, including a dishwasher not reaching the required sanitizing temperature, improper storage of meat products, and unsanitary conditions. A cook was observed handling food without a beard covering, and the kitchen had dust and debris in several areas, potentially affecting all residents.
The facility failed to maintain resident dignity during feeding assistance, as staff members were observed standing over residents while assisting them with meals. This practice contradicts the facility's policy, which requires staff to be seated to ensure resident comfort and dignity. The issue affected five residents who needed assistance during meals, and the DON confirmed the importance of seated feeding assistance.
The facility failed to provide proper restorative care and documentation for residents with contractures and mobility issues. A resident with a hand contracture was observed without a necessary palm protector, and quarterly restorative assessments were not updated for several residents. The Restorative Nurse admitted to performing but not documenting these assessments, contrary to the facility's program requirements.
The facility failed to adhere to infection control protocols, including improper cleaning of shared equipment and inadequate hand hygiene during incontinence care. A CNA did not sanitize equipment after use by a resident on contact isolation, and multiple CNAs failed to change gloves and sanitize hands when moving from dirty to clean tasks. Additionally, a resident with a nephrostomy was not placed on Enhanced Barrier Precautions, as required by the facility's policy.
The facility failed to ensure privacy for two residents during personal care. A resident with antistrophic lateral sclerosis was exposed to the hallway during incontinence care, and another resident with major depressive disorder was exposed to a roommate due to an improperly closed privacy curtain. The facility's policy requires full visual privacy during such care, which was not followed.
The facility did not request Level II PASSAR screenings for two residents who developed psychiatric disorders after admission. Initially, both residents had Level I screenings indicating no need for further assessment, but later MDS assessments showed psychotic disorders. The admissions staff was initially unsure about the need for rescreening, which was later confirmed as necessary. The facility's policy did not address rescreening for new psychiatric diagnoses.
A resident was admitted to the facility without the required PASARR screening, despite having diagnoses of unspecified dementia and schizophrenia. The facility's policy mandates preadmission screenings, including PASARR, for individuals with mental or intellectual disorders. The deficiency was identified when the administrator confirmed the absence of the screening, and the facility was in the process of conducting it during the survey.
Two residents in an LTC facility did not receive adequate ADL assistance. One resident, with cognitive impairment and incontinence, was found with a saturated brief, indicating a lapse in the required two-hourly checks. Another resident, dependent on staff for hygiene, reported not receiving scheduled bed baths due to staffing issues, with documentation confirming missed care. Facility policies for perineal and hygienic care were not followed.
The facility failed to obtain daily weights for a resident with congestive heart failure and did not apply protective arm sleeves for another resident as ordered. The resident with heart failure was not weighed on several days, contrary to physician orders, and the resident with fragile skin was observed without the required protective sleeves. Staff acknowledged these oversights, which were against the facility's policy to follow physician orders.
A facility failed to ensure fall interventions for a resident at high risk for falls. The resident, with a history of Parkinson's disease and unsteadiness, had a wheelchair pressure sensor alarm that did not activate when needed. Observations showed the alarm was not turned on, contrary to the care plan requiring bed and chair alarms to alert staff. The facility's policy mandates assessment and implementation of fall risk interventions.
Two residents in the facility experienced improper positioning of nephrostomy and urinary drainage bags, leading to potential risks of infection. One resident's nephrostomy bag was repeatedly observed on the bed, causing urine to back up into the tubing, while another resident's urinary drainage bag was lifted above bladder level during care. These actions were contrary to the facility's policy and the residents' care plans, which require drainage bags to be positioned below bladder level to prevent backflow.
A resident with a new gastrostomy diagnosis experienced improper care when an LPN administered medications without verifying the tube's placement, contrary to facility policy. The resident reported discomfort during the procedure, and further review showed that the type of tube used required placement verification by aspirating gastric content, which was not performed.
A resident receiving oxygen via nasal cannula had tubing and a bubble humidifier bottle that were not changed as ordered, with the bottle found empty on two consecutive days. The resident reported sinus pain and a dry nose. An LPN confirmed the tubing and bubblers should be changed weekly and the humidifier bottle should not be empty. The facility lacked an oxygen administration policy.
A resident receiving medications through a G-tube experienced a 20% medication error rate due to improper administration. An LPN crushed and mixed multiple medications together, contrary to the facility's policy requiring separate administration with water flushes between each. An RN confirmed the correct procedure, highlighting the deviation from standard practice.
A facility failed to securely store a resident's medication, as a capsule was found on the resident's bedside table. The resident was unsure of the medication, and an LPN later identified it as PhosLo 667 mg, prescribed for end-stage renal disease. The LPN confirmed that medications should not be left at the bedside, as it poses a risk of being forgotten or taken by another resident.
The facility failed to ensure call light accessibility for four residents, including those with cognitive impairments and physical limitations. Residents were unable to reach their call lights due to improper placement, despite care plans and facility policies requiring accessible call systems. This deficiency was observed in residents with severe and moderate cognitive impairments, leading to situations where residents had to call out for assistance.
A resident with severe cognitive impairment and fragile skin, on blood thinners, was found without protective bandages despite being at high risk for bruising. The facility failed to implement physician's orders for protective measures, as confirmed by staff interviews and observations.
A facility failed to notify the doctor and family when a resident's oxygen saturation dropped significantly during a therapy session. Despite the significant change in condition, the doctor was not informed until hours later, and the family was not notified at all. Staff interviews confirmed that the facility's policy on notification procedures was not followed.
A facility failed to ensure accurate medical records for a resident, with discrepancies in admission dates, consent forms, and daily nurse's notes. The resident's daughter raised concerns about the poor charting, and the administrator acknowledged the errors.
Failure to Notify Resident Representative of New Antihypertensive Medication
Penalty
Summary
The facility failed to notify a cognitively impaired resident’s health care power of attorney (POA) prior to initiating a new antihypertensive medication. The resident’s care plan dated 6/6/25 documented cognitive impairment related to dementia and multiple sclerosis, noted that she was very forgetful, and directed that all information be provided directly to her advocate. A POA form dated 9/12/24 identified a family member (V7) as the resident’s POA. Physician progress notes and a physician order dated 8/8/25 showed the resident was started on Losartan 25 mg daily for a new diagnosis of hypertension, and the physician documented that the new medication was discussed with the resident. However, there was no documentation that the POA was notified of the resident’s elevated blood pressures or the initiation of Losartan. On interview, the POA stated she was not informed that the resident had high blood pressure or that Losartan had been started until she spoke with a cardiology nurse practitioner on 12/17/25, despite being in the facility at least twice a week and having repeatedly requested to be notified of any changes, including medications. A cardiology note dated 12/17/25 confirmed that the nurse practitioner contacted the POA, who reported she was unaware the resident was taking Losartan. During observation on 1/5/26, the resident was awake but confused to place and time, unable to state the month, and did not know if she was on a medication for high blood pressure, stating that staff talk to her family member about all her medications. Social services staff described the resident as confused and forgetful with impaired short-term memory and confirmed that the POA was very involved and had requested to be informed of any changes. The DON stated that when a resident is started on a new medication, the resident and/or representative should receive education and consent prior to administration, and acknowledged that the cognitively impaired resident’s representative, who had requested notification of all changes, was not notified prior to starting Losartan.
Resident Restrained in Bed by Improper Use of Fall Mat
Penalty
Summary
A resident with diagnoses including aphasia, restlessness and agitation, dementia, lack of coordination, abnormalities of gait/mobility, and a need for assistance with personal care was found restrained in bed. The resident was observed by his daughter lying in bed with a thick mattress positioned upright along one side of the bed, held in place by a chair, while the other side of the bed was against the wall. The daughter reported this to nursing staff, who confirmed the presence of the fall mattress in an upright position. Interviews with LPNs revealed that fall mats are intended to be placed on the floor next to the bed to prevent injury, not upright along the bed, as this would restrict the resident's movement and effectively trap them in bed. The administrator and staff acknowledged that positioning the fall mat in this manner constituted a restraint, which is not permitted by facility policy except for medical treatment. The facility's restraint policy defines a physical restraint as any device that is attached or adjacent to the resident's body, cannot be easily removed by the individual, and restricts freedom of movement.
Failure to Protect Resident Property from Misappropriation
Penalty
Summary
A resident's tablet computer was reported missing after it was last seen on the resident's nightstand, plugged in, by a CNA at the end of the evening shift. The resident regularly used the tablet, and its absence was first noticed by another CNA the following morning when assisting the resident. The resident's daughter later used a tracking application to locate the tablet at a local hotel. The facility's administrator confirmed that an agency CNA, who worked only one night shift and was assigned to the resident, was seen on camera entering the resident's room multiple times during that shift. Attempts to contact this CNA by both the facility and local police were unsuccessful. The facility's abuse and neglect policy prohibits misappropriation of resident property, including deliberate misplacement or exploitation. Despite this policy, the resident's tablet was not protected from wrongful use or theft. The police were notified and investigated the incident, confirming that the agency CNA in question had checked out of the hotel where the tablet was located. The facility failed to ensure the resident's belongings were safeguarded, resulting in the misappropriation of the resident's property.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to ensure proper sanitation and food safety practices in the kitchen, which could potentially affect all residents. The dishwasher did not reach the required temperature of 160 degrees Fahrenheit for sanitizing dishes, as observed during multiple cycles where the final rinse temperature remained at 130 degrees Fahrenheit. Despite being aware of the issue, the Dietary Manager allowed the use of regular silverware and some dishware that had been washed in the malfunctioning dishwasher. Additionally, the facility's dishwashing log showed inconsistencies in the final rinse temperatures, indicating a lack of adherence to the facility's policy. Further deficiencies were observed in the storage and handling of food and kitchen hygiene. Boxes of frozen meat products were found open, unlabeled, and undated in the walk-in freezer, contrary to the facility's policy requiring food to be covered, dated, and labeled. A cook with a thick beard was seen handling food without a facial hair covering, which is required to prevent contamination. The kitchen also had unsanitary conditions, with dust and debris found in the bin holding the ice scooper and on a rack above the meal service assembly. These observations highlight a failure to maintain sanitary conditions in the kitchen.
Failure to Maintain Dignity During Feeding Assistance
Penalty
Summary
The facility failed to assist residents with feeding in a dignified manner, as observed during a dining session. Staff members, including the Activity Director, CNAs, and an LPN, were seen standing over residents while assisting them with their meals, which is contrary to the facility's policy that emphasizes the importance of staff being seated to ensure resident comfort and dignity. This issue was noted for five residents who required varying levels of assistance during meals. The Director of Nursing acknowledged that staff should be seated when feeding residents to maintain their dignity, as per the facility's Privacy and Dignity policy.
Failure to Ensure Proper Restorative Care and Documentation
Penalty
Summary
The facility failed to ensure proper restorative care for residents with contractures and mobility issues. One resident with a left hand contracture was observed without a palm protector, which is necessary to prevent further decline and maintain skin integrity. The resident's care plan required the use of a palm protector post-range of motion exercises, but it was not in place during observations. The Restorative Nurse confirmed that the palm protector should be worn at all times except during hand hygiene and passive range of motion exercises. Additionally, the resident's restorative assessment had not been updated since December 2023, despite the requirement for quarterly assessments. The facility also failed to conduct and document quarterly restorative assessments for other residents requiring restorative services. One resident, who required extensive assistance with activities of daily living and was on a passive range of motion program, had not had an assessment since September 2023. Another resident's last assessment was in December 2023, and the Restorative Nurse admitted to performing but not documenting the quarterly assessments. The facility's Restorative Nursing Program mandates quarterly evaluations, but these were not consistently documented or updated, leading to deficiencies in the care provided to residents.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed, as evidenced by multiple instances of improper handling and cleaning of equipment and personal protective equipment. A certified nursing assistant (CNA) was observed transporting a resident on contact isolation for Norovirus without sanitizing shared equipment such as a dialysis chair, table, and grab bar after use. Additionally, the CNA placed soiled linens on public surfaces without cleaning them afterward, which is against infection control protocols. In several instances, CNAs did not follow proper hand hygiene and glove-changing procedures during incontinence care. For example, a CNA was observed placing soiled linens and incontinence briefs on the floor and then proceeded to touch clean items and the resident without changing gloves or sanitizing hands. This was observed with multiple residents, including those with urinary tract infections and pressure injuries, increasing the risk of cross-contamination and infection spread. Furthermore, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a nephrostomy, as there was no signage indicating isolation precautions. The Infection Control Registered Nurse confirmed that residents with indwelling medical devices should be on EBP, but this was not adhered to, indicating a lapse in following the facility's infection control policies.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy during personal care for two residents, leading to a deficiency in maintaining residents' privacy and dignity. Resident R81, who was admitted with diagnoses including antistrophic lateral sclerosis and adult failure to thrive, was observed receiving incontinence care with the door open, exposing the resident's perineal area to the hallway. Similarly, Resident R121, admitted with major depressive disorder and a pressure injury, was exposed when a CNA provided incontinence care without fully closing the privacy curtain, allowing a roommate to see the resident's buttocks. The facility's policy mandates that privacy curtains be drawn fully to ensure visual privacy during such care, which was not adhered to in these instances.
Failure to Rescreen Residents for PASSAR After New Psychiatric Diagnoses
Penalty
Summary
The facility failed to request a Level II Preadmission Screening and Resident Review (PASSAR) for two residents who developed psychiatric/mood disorders after admission. Initially, both residents had Level I PASSAR screenings indicating no need for Level II assessments. However, subsequent Minimum Data Set (MDS) assessments revealed that both residents had developed psychotic disorders. The admissions staff, V19, acknowledged that PASSAR screenings are conducted prior to admission to ensure appropriate services are provided but was initially unsure if a rescreening was necessary when new psychiatric diagnoses are added. It was later confirmed that both residents should have been rescreened, but the facility's policy did not address the need for rescreening when additional psychiatric diagnoses are identified during a resident's stay.
Failure to Conduct PASARR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident was screened prior to admission, as required by the PASARR process, for one of the five residents reviewed for preadmission screenings. The deficiency was identified during an observation and interview process. On January 27, 2025, the resident was observed sitting in a reclining chair in his room, sleeping. The following day, the facility's administrator confirmed that no PASARR screening had been conducted for the resident, who had been admitted with diagnoses of unspecified dementia and schizophrenia. The facility's policy, dated August 16, 2024, mandates that no admission from the hospital should occur without a preadmission screening, including PASARR screening for those with mental or intellectual disorders. Despite this policy, the resident was admitted without the required screening, and the facility was in the process of conducting the screening at the time of the survey.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for two residents, R25 and R1, who are dependent on staff for care. R25, who has a history of dysphagia, cognitive impairment, and incontinence, was found with a saturated incontinence brief containing dark urine and soft stool. The care plan for R25 requires checking and changing every two hours, but it was noted that R25 was last changed during the night shift, indicating a lapse in care. The facility's policy mandates perineal care every two hours to prevent infection and skin irritation, which was not adhered to in this instance. R1, diagnosed with dementia and requiring assistance with personal hygiene, reported not receiving a bed bath as scheduled. R1's care plan specifies the need for two showers per week, but documentation showed only three showers in the last 14 days and no bed baths from January 23-28, 2025. A CNA confirmed that R1 was supposed to receive a bed bath but was unsure if it occurred, citing staffing issues. The facility's policy requires regular hygienic care to ensure cleanliness and comfort, which was not provided to R1 as required.
Failure to Follow Physician Orders for Daily Weights and Protective Arm Sleeves
Penalty
Summary
The facility failed to obtain daily weights for a resident with a history of fluid overload, as ordered by the physician. The resident, who has diagnoses including congestive heart failure and chronic kidney disease, was supposed to be weighed daily to monitor for fluid retention. However, records show that weights were not obtained on several days, and the resident confirmed that staff did not always weigh her daily. This oversight occurred despite the facility's policy to obtain weights as ordered by the physician. Additionally, the facility did not ensure that protective arm sleeves were applied as ordered for another resident. This resident, who has a history of fragile skin and is on blood thinners, was observed multiple times without the protective sleeves, which were intended to prevent bruising. The CNA acknowledged that the resident was supposed to wear the sleeves throughout the day but admitted to not applying them as required. The facility's policy mandates adherence to physician orders, which was not followed in this case.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident at high risk for falls. The resident, identified as R39, has a medical history that includes Parkinson's disease with dyskinesia, lack of coordination, unsteadiness of feet, and a history of falling. During an observation, it was noted that R39 had a wheelchair pressure sensor alarm attached to his wheelchair, but the alarm did not sound when the resident lifted his buttocks off the seat multiple times. The alarm's 'In Use' light was not on, indicating it was not activated. Later, a Certified Nursing Assistant (CNA) had the resident stand from the wheelchair, and again the alarm did not sound until the CNA manually turned it on. The resident's care plan specifies the use of bed and chair alarms to alert staff when the resident attempts to get up unassisted. The facility's Fall Occurrence Policy requires that residents are assessed for fall risk and that interventions are implemented and reevaluated as necessary.
Improper Positioning of Nephrostomy and Urinary Drainage Bags
Penalty
Summary
The facility failed to maintain proper positioning of nephrostomy and urinary drainage bags for two residents, R67 and R121, which is crucial to prevent urinary tract infections. For R67, observations on multiple occasions revealed that the nephrostomy drainage bag was placed on the bed, causing urine to pool at the opening of the bag and back up into the tubing. This improper positioning was noted despite the resident's care plan indicating the need for appropriate nephrostomy care due to an acute kidney injury and renal calculi. The Director of Nursing acknowledged that the drainage bag should be positioned to allow urine to flow into the bag, similar to the care required for an indwelling urinary catheter. For R121, the urinary drainage bag was observed to be improperly handled during peri care by a CNA, who lifted the bag above the bladder level and then placed it on the bed. This action contradicted the resident's care plan, which specified that the catheter bag and tubing should be positioned below the bladder level. The facility's Urinary Catheter Care Policy, revised in August 2024, clearly states that the drainage bag must be kept lower than the bladder to prevent backflow of urine, which was not adhered to in these instances.
Failure to Verify Gastrostomy Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure the proper checking of a gastrostomy tube placement before administering medication to a resident, identified as R39, who was readmitted with a new diagnosis of gastrostomy. On the specified date, an LPN administered medications to R39 without verifying the placement of the gastrostomy tube, despite the resident expressing discomfort during the procedure. The facility's policy requires checking the placement by observing the marker at the insertion site or aspirating gastric content if the marker is not visible. However, the LPN did not follow this protocol, leading to a deficiency in care. Further investigation revealed that the type of gastrostomy tube used for R39 did not have a visible line for placement verification, as confirmed by an RN. The RN demonstrated that the placement should be checked by aspirating gastric content, which was not done in this instance. The physician's order and the facility's medication pass policy both emphasize the importance of verifying tube placement before administering any tube feeding or medications, which was not adhered to in this case.
Failure to Change Oxygen Tubing and Maintain Humidifier
Penalty
Summary
The facility failed to provide proper respiratory care for a resident by not changing the oxygen tubing and bubble humidifier bottle as ordered and not keeping the humidifier bottle filled. The resident, who was receiving oxygen via nasal cannula, had tubing and a bubble humidifier bottle labeled with a date over a month old, indicating they had not been changed weekly as required. Additionally, the humidifier bottle was found empty on two consecutive days. The resident reported experiencing sinus pain and a dry nose, which could be related to the deficiency in care. A Licensed Practical Nurse confirmed that the tubing and bubblers should be changed weekly and that the humidifier bottle should not be allowed to run empty. The facility was unable to provide an oxygen administration policy to support their practices.
Medication Administration Error via G-tube
Penalty
Summary
The facility failed to administer medications according to standard practice for a resident receiving medications through a gastrostomy tube, resulting in a 20% medication error rate. The resident, identified as R39, was observed receiving multiple medications, including aspirin, omeprazole, multivitamins, tramadol, vitamin D3, and carbidopa-levodopa, all at once through a G-tube. The Physician's Order Sheet did not document that these medications could be given simultaneously. On a specific date, a Licensed Practical Nurse (LPN) prepared and administered these medications by crushing them together and mixing them with water, contrary to the facility's Medication Pass Policy, which requires medications to be given separately with a water flush between each. A Registered Nurse (RN) confirmed that medications should be crushed and administered individually to prevent interactions, with 10-30 ml of water given between each medication.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the secure storage of a resident's medication, specifically for one resident reviewed for medication storage. During an observation, a blue and white capsule was found in a medication cup on the bedside table of a resident. The resident was unsure of the medication's identity but believed it was something she was supposed to take at breakfast. Later, a Licensed Practical Nurse (LPN) brought the resident her medications and was also unsure of the capsule's identity. Upon verification, the LPN identified the capsule as PhosLo 667 mg, which was prescribed to the resident for end-stage renal disease to be taken with meals on dialysis days. The LPN acknowledged that medications should not be left at the resident's bedside, as the resident might forget to take it or another resident could take it.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that four residents had access to their call lights, which is a critical component for resident safety and communication. Resident 1, who has severe cognitive impairment and a right hand amputation, was found unable to reach or operate his call light, which was wrapped around the right side rail and hanging towards the floor. Despite the resident's care plan emphasizing the need for a reachable call light, the staff did not ensure its accessibility, as confirmed by a Certified Nursing Assistant and the Director of Nursing. Resident 2, with moderate cognitive impairment and a history of falls, was also unable to access her call light, which was similarly wrapped around the side rail and out of reach. Although a sign above her bed instructed staff to place the call light within reach, it was not followed, leaving the resident unable to locate it without assistance. Resident 3, who has moderate cognitive impairment and a history of behavioral issues related to call light use, was found yelling for help because he could not find his call light, which was also positioned out of reach. Resident 7, with moderate cognitive impairment and a history of falls, had her call light placed inside a basin on her bedside table, making it inaccessible. The facility's policy mandates that call lights be within reach of residents capable of using them, but this was not adhered to in these cases. The Director of Nursing acknowledged that call lights should be accessible to prevent residents from attempting to get up on their own, yet the facility did not ensure compliance with this policy, leading to the deficiency.
Failure to Implement Physician's Orders for Resident at Risk of Bruising
Penalty
Summary
The facility failed to implement physician's orders for a resident at risk for bruising, which was identified during a survey. The resident, who has severe cognitive impairment and is dependent on staff for bed mobility, was noted to have a discoloration on the right elbow, indicating a hematoma. The resident is on blood thinners and has fragile skin, increasing the risk of bruising. Despite the nurse practitioner's recommendation to apply a multipurpose bandage or skin protector to provide an additional barrier, there were no physician's orders for these protective measures in the resident's June 2024 orders. Observations and interviews revealed that the resident did not have any bandages or skin protectors on his arms at the time of the survey. A registered nurse stated that the bandages were not applied because they were in the wash, and new ones were eventually cut and applied. The Director of Nursing confirmed that the resident should have had the bandages on at all times due to the high risk of bruising. The facility's policy mandates that all treatments must be in accordance with physician's orders, which was not adhered to in this case.
Failure to Notify Doctor and Family of Change in Condition
Penalty
Summary
The facility failed to notify the doctor and the power of attorney/family when a change in condition occurred for a resident. On the morning of the incident, the resident's oxygen saturation dropped significantly during a therapy session, prompting the therapist to administer oxygen and notify the nurse. Despite this significant change in the resident's condition, the doctor was not notified until several hours later, and the family was not informed at all. The resident's daughter expressed concern that earlier notification might have led to different medical decisions, potentially improving the resident's outcome. Interviews with staff revealed that the nurse on duty did not recognize the need to notify the doctor immediately, as the resident's oxygen saturation was above 90% when she checked. However, other staff members, including the nursing supervisor and nurse practitioner, confirmed that the drop in oxygen saturation and the need for supplemental oxygen constituted a significant change in condition that warranted immediate notification of the doctor and family. The facility's policy on notification procedures for changes in resident condition was not followed in this instance. The resident had multiple medical diagnoses, including type 2 diabetes mellitus, cardiomegaly, peripheral vascular disease, and end-stage renal disease, among others. The failure to promptly notify the doctor and family of the resident's change in condition represents a significant lapse in the facility's adherence to its own policies and procedures, potentially impacting the resident's care and well-being.
Inaccurate Medical Records and Charting
Penalty
Summary
The facility failed to ensure the accuracy of the information available in a resident's chart. The Face Sheet for the resident showed an admission date with multiple medical diagnoses, but the Admission Packet Information was dated prior to the actual admission date. Additionally, several consent forms were signed and dated before the resident was admitted. The Daily Skilled Nurse's Notes contained inaccuracies, such as marking the resident as having an ostomy when she did not and failing to mark dialysis on certain dates, despite the resident being on end-stage renal dialysis. The resident's daughter, who is also the power of attorney, expressed concerns about the poor charting, noting that documents were signed before the actual admission date and that several important medical details were either incorrect or missing from the chart. The facility's administrator acknowledged these discrepancies, stating that staff are expected to chart accurately and that the errors should have been caught. The facility's Electronic Medical Record Policy emphasizes the importance of accurate and authorized entries to maintain the integrity and confidentiality of resident clinical information.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Buffalo Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Addolorata Villa | 1 mi | ★★★★★ | 8 | 0 |
| Avantara Long Grove | 1.9 mi | ★★★★★ | 0 | 0 |
| Elevate Care Riverwoods | 2.1 mi | ★★★★★ | 1 | 0 |
| Radford Green | 2.3 mi | ★★★★★ | 1 | 0 |
| Greek American Rehab Care Ctr | 2.3 mi | ★★★★★ | 18 | 0 |
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