Inspection·September 27, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify resident's Responsible Party of pressure ulcer changes for 1 (R8) of 4 (R1, R2, R3) residents reviewed for pressure ulcers. Findings Include: R8 was admitted to the facility on [DATE] with diagnosis not limited to Cardiac Arrest due to Underlying Cardiac Condition, Encephalopathy, Tracheostomy, Gastrostomy, Anoxic Brain Damage, Essential (Primary) Hypertension, Retention of Urine, Chronic Kidney Disease, Stage 3, Hyperosmolality and Hypernatremia, Adult Failure to Thrive, Dysphagia, Oral Phase, Monoclonal Gammopathy, Type 2 Diabetes Mellitus with Hyperglycemia, Specified Anemias, Abdominal Aortic Aneurysm, Multiple Myeloma, Vascular Implants and Grafts, Acute on Chronic Diastolic (Congestive) Heart Failure, Acute and Chronic Respiratory Failure with Hypoxia, Contracture, Right Hand, Contracture, Left Hand, Muscle Wasting and Atrophy, Reduced Mobility, Restlessness and Agitation. R8's Care Plan documents in part: R8 has actual impairment to skin integrity related to PMH (Past Medical History): Anoxic Brain Injury, Respiratory Failure Trach dependent, Gastric Tube, Impaired Mobility, Incontinence, and a Braden score places her at high risk for future skin impairment. Date Initiated: 08/07/24. Sacrum: Cleanse w/NSS (with normal saline) or wound cleanser and pat dry, apply Medi honey & Calcium Alginate to wound bed and cover w (with)/dry dressing once daily/PRN (as needed). Date Initiated: 08/30/24. Educate the resident and/or family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date Initiated: 08/08/24 High Risk-Skin Inspection: The resident requires Skin inspection (every shift/PRN). Observe for redness, open areas, scratches, cuts, bruises, and report changes to the Nurse. Identify/document potential causative factors and eliminate/resolve where possible. Date Initiated: 08/07/24 Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to MD (Medical Doctor). Date Initiated: 08/30/24. R8 has an ADL Self Care Performance Deficit and Impaired Mobility r/t (related to): Right- and left-hand contracture, encephalopathy, anoxic brain damage Bed Mobility: I require x2 staff participation to reposition and turn in bed. R8 is at risk for alteration of bowel and bladder functioning related to: indwelling urinary catheter (sacral wound), Anoxic brain damage, urine retention, CKD (Chronic Kidney Disease). R8 is at risk for malnutrition related to inability to meet nutritional needs orally as evidenced by NPO (Nothing by mouth) with EN (Enteral nutrition) dependence, complicated hospital course. Skin Evaluation dated 08/08/24 document in part: R8 is unable to reposition self-requiring total staff assistance with repositioning and ADL (Activities of Daily Living) care. No skin impairment (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 4 Event ID: 145632 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 145632 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr South Loop 1725 South Wabash Chicago, IL 60616 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)