Above 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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Barr Lieberman during CMS and state inspections, most recent first.
A facility failed to return trust fund balances for 6 residents after discharge or death within the required 30 days. The BOM stated she was responsible for closing RFMS accounts and notifying AR, but she did not do so for these residents, and another staff member said checks were not distributed because she had only just been notified. Record review showed each resident had a remaining balance, including amounts over $7,000, and the facility policy required conveyance of funds and final accounting within 30 days.
A nurse left a medication cup with multiple pills in a resident’s room and documented the meds as given on the eMAR without staying to observe the resident swallow them. The resident did not have a physician order or self-administration assessment for bedside meds, and facility staff stated nurses are expected to remain with residents until meds are swallowed.
Several residents were found with medications at their bedsides or in personal storage without physician orders or proper assessment for self-administration. Staff allowed residents to self-administer medications and share house stock creams, contrary to facility policy, and did not document or assess residents' ability to safely manage their own medications.
Staff did not consistently use required PPE when entering the rooms of residents on contact isolation, and failed to disinfect vital sign equipment before and after use between residents. Dedicated disposable equipment was not provided or kept inside the rooms of residents on transmission-based precautions, including those with active COVID-19 infections. These actions were contrary to facility policy and were acknowledged by staff and nursing leadership.
Staff failed to accurately document controlled medication administration and did not consistently follow physician orders, resulting in discrepancies in medication counts and administration of incorrect medication dosages. Lapses in medication security were also observed, including an unlocked medication cart and unattended MAR screen.
A resident who was unable to perform personal hygiene independently was not assisted by staff in shaving or removing facial hair, despite repeated observations and the resident's verbal requests for help. The resident had multiple medical conditions and required supervision or assistance with self-care, but her care plan lacked interventions for grooming, and staff did not provide the necessary ADL support as required by facility policy.
A resident with a gastrostomy tube was observed receiving enteral feeding from a bag that was not properly labeled as required by facility policy. The bag was missing key information such as the resident's name, formula, rate, and nurse's initials, despite staff confirming these details are necessary for safe administration.
A medication refrigerator containing controlled medications was found unlocked during a survey. An LPN confirmed the presence of controlled drugs and stated the refrigerator should always be locked, noting that another nurse had left it open. The DON also confirmed the requirement for the refrigerator to be locked, in accordance with facility policy.
Failure to Return Resident Trust Fund Balances After Discharge or Death
Penalty
Summary
The facility failed to return resident trust fund balances for 6 residents who had been discharged or had expired, and the balances were not conveyed within 30 days. During interview, the Business Office Manager stated that she is responsible for closing residents’ RFMS accounts when a resident discharges or expires and for notifying Corporate Accounts Receivable so a check can be issued to the resident, the resident’s appointed person, or the state. She stated she did not complete this process for residents R5 through R10, and that more than 30 days had passed for each of those residents. The other staff member interviewed stated that trust fund checks are distributed when the address of the recipient is known, and that she had not distributed checks for these residents because she was only notified by the Business Office Manager on the date of interview. Record review showed that each of the 6 residents had a remaining RFMS balance after discharge or death. R5 expired with a balance of $3,432.40. R6 expired with a closing interest balance of $1,274.66. R7 expired with a closing interest balance of $969.33. R8 was discharged with a closing interest balance of $7,724.64. R9 expired with a closing interest balance of $1,538.68. R10 expired with a closing interest balance of $1,904.33. The facility policy stated that upon discharge, eviction, or death, the facility must convey the resident’s funds and a final accounting within 30 days to the resident or, in the case of death, to the individual or probate jurisdiction administering the estate.
Medication Left at Bedside and Documented as Given Without Observation
Penalty
Summary
The facility failed to obtain a physician order for a resident to keep medication at the bedside and failed to complete self-administration medication assessments for that resident. During observation and interview, a medication cup containing multiple pills was seen in the resident’s room on the bedside table. The nurse stated she had left the medication cup in the room, acknowledged she was not supposed to leave medication there, and said she should have stayed to watch the resident swallow the medication but did not remain in the room. The nurse also stated she did not watch the resident take the pills but still documented the medications as given on the electronic MAR. The surveyor and nurse counted 11 pills in the medication cup during the observation. The nurse manager stated nurses should not leave medications in residents’ rooms and are expected to stay with the resident until the medication is swallowed. The record review showed the resident did not have self-administration orders or assessments in place, and the facility’s medication pass competency and policy both required observing residents after medication administration and signing the MAR after the medication is given.
Failure to Ensure Safe Medication Storage and Self-Administration Procedures
Penalty
Summary
The facility failed to ensure that medications were not left at residents' bedsides without a physician's order and did not follow its own policy regarding resident self-administration of medication. Multiple residents were observed with various medications, including eye drops, calcium supplements, artificial tears, albuterol inhalers, analgesic creams, and prescription medications, stored at their bedsides or in personal storage areas. In several cases, residents reported self-administering these medications because nursing staff either forgot to provide them or were too busy, and there was no documentation of physician orders or assessments for self-administration. Staff interviews confirmed that medications should not be left at bedside without a physician's order and that an interdisciplinary team (IDT) assessment and care plan are required for residents to self-administer medications. However, staff allowed residents to keep and use medications at bedside without following these procedures. In one instance, a nurse provided a resident with house stock Voltaren cream that was shared among multiple residents, contrary to policy. Another resident had multiple over-the-counter and prescription medications stored in her closet and bedside dresser, which she accessed and used independently. Review of facility policies indicated that residents may only store medications at bedside with a physician's order and after an assessment of their ability to self-administer. Despite these requirements, the facility did not conduct the necessary assessments or obtain physician orders for the residents observed with medications at bedside. The facility's Director of Nursing and other staff acknowledged that these practices were not in compliance with facility policy or regulatory requirements.
Failure to Follow Infection Control Protocols and Equipment Disinfection
Penalty
Summary
Staff failed to follow established infection prevention and control protocols during resident care, particularly for those on contact isolation precautions and when taking vital signs. In multiple observed instances, staff entered the rooms of residents on contact isolation without wearing the required personal protective equipment (PPE), such as gowns and gloves, and only wore masks. Staff acknowledged forgetting to use the appropriate PPE when entering these rooms, despite facility policy requiring full PPE for contact isolation. Additionally, staff did not properly disinfect medical equipment, such as blood pressure (BP) machines and pulse oximeters, before and after use between residents. In several cases, staff took portable BP machines from the hallway, used them on residents without prior disinfection, and returned them to the hallway without cleaning. This practice was observed with multiple staff members, including LPNs and RNs, who admitted to forgetting to disinfect the equipment as required by facility policy. For residents on transmission-based precautions, such as those with active COVID-19 infections, the facility failed to provide dedicated disposable vital sign equipment inside the resident's room. Instead, vital sign equipment was removed from isolation rooms and used elsewhere, contrary to facility policy that mandates dedicated equipment remain in the room until isolation is discontinued. These lapses were confirmed by interviews with the infection preventionist, DON, and ADON, who all stated that staff should follow proper PPE and disinfection protocols, and that dedicated equipment should be used for residents on isolation precautions.
Failure to Accurately Document and Administer Controlled Medications per Physician Orders
Penalty
Summary
The facility failed to maintain accurate records and proper administration of controlled medications, as well as to follow physician orders for medication administration. During review of controlled drug administration record sheets, it was observed that nurses did not consistently sign out controlled medications after administration, resulting in discrepancies in medication counts for several residents. In one instance, a nurse admitted to giving medications but forgetting to document them in the controlled drug administration record. Additionally, a nurse was observed preparing and administering a different dosage of cranberry supplement than what was ordered, due to unavailability of the prescribed strength, without a corresponding physician order. Multiple staff members acknowledged that medication administration should follow physician orders and that documentation should occur immediately after medication is removed from the medication card or packet. Further observations revealed lapses in medication security, including an unlocked medication cart with keys left on top and the medication administration record (MAR) computer screen left open and unattended. Staff confirmed that these actions were not in accordance with facility policy. The facility's own policies require accurate and immediate documentation of controlled medication administration and strict adherence to physician orders, but these procedures were not followed as evidenced by the findings.
Failure to Provide Assistance with Personal Hygiene for Dependent Resident
Penalty
Summary
A deficiency occurred when a female resident who required assistance with activities of daily living (ADLs), specifically personal hygiene and grooming, was not provided with necessary care to remove or shave her facial hair. The resident, who is alert, oriented, and able to verbalize her needs, was observed on multiple occasions with visible facial hair on her jawline and chin. She reported to staff that she could not shave herself and needed assistance, but this care was not provided. Staff, including LPNs and the unit manager, acknowledged that CNAs are responsible for shaving or removing facial hair during ADL care, yet the resident's facial hair remained unaddressed over several days. Review of the resident's medical records revealed diagnoses including Type 2 Diabetes Mellitus, Morbid Obesity, Glaucoma, and Osteoarthritis. Her assessment indicated a need for supervision or touching assistance with personal hygiene. Despite this, her care plan did not include specific interventions for personal hygiene and grooming related to facial hair. Facility policies require that ADL care, including grooming and hygiene, be provided daily based on comprehensive assessment and care plans, but these were not followed in this instance.
Improper Labeling of Enteral Feeding Bag
Penalty
Summary
A deficiency was identified when a resident receiving enteral (tube) feeding was observed with a feeding bag that was not properly labeled according to facility policy. The feeding bag was only labeled with the date and time it was started, but was missing the resident's name, formula name, rate of administration, and the nurse's initials. Interviews with the MDS/CP Coordinator and the Director of Nursing confirmed that the facility's policy requires the feeding bag to be labeled with the resident's name, formula, rate, start date and time, and the nurse's initials. Record review showed the resident had a gastrostomy tube due to dysphagia following a cerebral infarction and was receiving a prescribed enteral feeding regimen. The facility's policy and care plan also emphasized the importance of proper labeling to reduce infection risk and ensure correct administration, but this was not followed in the observed instance.
Failure to Secure Controlled Medications in Locked Refrigerator
Penalty
Summary
Surveyors observed that a medication refrigerator containing controlled medications was left unlocked in one of the medication rooms. During the inspection, an LPN confirmed that controlled medications were stored in the refrigerator and acknowledged that it should always be locked, attributing the oversight to another nurse who left it open. The Director of Nursing was informed of the situation and also confirmed that the medication refrigerator should be locked at all times. The facility's policy requires that all medications be secured in locked storage areas, and specifically that Schedule II medications requiring refrigeration be stored in a locked refrigerator within a locked medication room.
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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 Skokie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Citadel Of Skokie, The | 0.3 mi | ★★★★★ | 4 | 0 |
| Alden Estates Of Skokie | 0.5 mi | ★★★★★ | 0 | 0 |
| Alden Estates Of Evanston | 0.6 mi | ★★★★★ | 4 | 0 |
| Westminster Place | 0.7 mi | ★★★★★ | 0 | 0 |
| Grove Of Skokie, The | 1.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.