Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and review of records the facility failed to provide planning of care related to oral/dental care for 1
(R1) of 3 residents reviewed for improper nursing care.
Findings include:
R1 is [AGE] years old, initially admitted on [DATE], with diagnosis of hemiplegia and hemiparesis following
cerebral infarction affecting left non-dominant side. R1 is cognitively intact as assessed on 8/27/2024 with a
BIMS (Brief Interview of Mental Status) of 15.
On 10/15/2024 at 1:07 PM, R1 was seen laying on bed in her room. R1 was alert and verbally able to
express her thoughts within topic during conversation. R1 stated that her tooth does not bother her as much
as before. R1 stated that her tooth problem is located at the top left area in her mouth and now she does
not chew on the left side where she used to chew and she knew that there was a problem on her tooth
when she felt a sharp end on her tooth. R1 said, At first it was terrible, and it was swollen. It started around
the second week of September. R1 had a food tray in front of her and was barely eating her food. R1 was
seen focusing on eating the dark green vegetable without touching the rest of her food.
Per review of R1's progress notes, R1's tooth problem was first noted on 9/11/2024 by V18 (Medical
Doctor) that R1 has a tooth pain and V18 ordered for R1 to be seen by a dentist. Per V3 (Registered Nurse)
notes dated 9/12/2024, R1 was seen by the dentist and documented that Social Worker team to follow up
for rescheduling. Progress notes dated 9/17/2024 by V4 (Registered Nurse) documented that R1 verbalized
pain 8 out of 10, with 10 being the highest rate of pain. Pain went down to 3 after giving Tylenol medicine.
Progress notes dated 8/19/2024 by V5 documents R1 enjoys eating as she finds this her only pleasure
being in the facility. Progress notes dated 9/19/2024 by V5 (Licensed Clinical Social Worker) documents
that R1 verbalized concern about tooth infection and how to cope with the situation. Progress notes dated
10/15/2024 by V5 (Licensed Clinical Social Worker) documents R1 anxiety persist due to tooth infection. R1
talked about how she needs to alter the way she chews her food. R1 also talks about more aches and pain
she has been having and this contributes to her depression.
On 10/15/2024 R1's care plan were reviewed and does not include identified problem of her tooth. On
10/16/2024 after request of full care plan, oral/dental health problems related to tooth pain was included
and dated 10/16/2024.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145336
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145336
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Warren Barr Gold Coast
66 West Oak Street
Chicago, IL 60610
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 10/16/2024 at 12:05 PM with V2 (Director of Nursing) stated that R1 has a tooth problem. V2 said, I
think her tooth was broken and she complained of pain. Per V2, R1 was seen by the dentist on 9/12/2024
and recommended tooth extraction. R1 was scheduled to go out to an outside dental clinic but was
cancelled due to transfer problem. R1 uses Hoyer lift for transfer and the dental clinic does not have
equipment to transfer R1 from the wheelchair or stretcher to dental chair. Dental clinic was concerned
about the safe transfer of R1. V2 said, that R1 has an appointment on 10/18/2024 for in-house tooth
extraction and that R1's diet was changed from regular to mechanical soft. R1's Tylenol medication
schedule was changed from as needed to every 8 hours. V2 was handed R1's full care plan to review. After
full review, V2 pointed and acknowledged the care plan for oral/dental health problems related to tooth pain
dated 10/16/2024. V2 stated that it was just done today and R1 did not have a care plan for oral/dental
health problem until today. V2 stated that R1's care plan needs to be comprehensive enough to address all
issues included in the interventions including pain, diet, and other areas that may be affected by R1's tooth
problem.
On 10/17/2024 at 11:24 AM, V1 (Administrator) explained that R1 was scheduled for an appointment going
to outside dental clinic but was unable to go due to transfer issue. Dental clinic cannot accommodate
because it is hard to transfer R1 from wheelchair or stretcher to the dental chair because R1 needs Hoyer
lift. V1 was made aware that care plan was not started until today (10/16/2024) to address these concerns
and contingencies such as the issue she (V1) just mentioned in case interventions by facility failed related
to R1's dental/oral care. V1 stated that she was aware and will address the issue.
Care Plan policy dated 7/26/2024, reads:
It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction
with federal regulations. Under procedures, after the comprehensive assessment is completed, the facility
will put in place person-centered care plans outlining care for the resident within 7 days. These will be
periodically reviewed and revised by a team of qualified persons after each assessment.
Per policy of the facility, care plans are in conjunction with federal regulation.
Under Code of Federal Regulation Title 42 dated 10/16/2024 on Care Plan, it reads:
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for
each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3),
that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and
psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan
must describe the services that are to be furnished to attain or maintain the resident's highest practicable
physical, mental, and psychosocial well-being as required by the regulation. The services provided or
arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of
quality.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145336
If continuation sheet
Page 2 of 2
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the October 18, 2024 survey of WARREN BARR GOLD COAST?
This was a inspection survey of WARREN BARR GOLD COAST on October 18, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WARREN BARR GOLD COAST on October 18, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.