Health inspection·April 4, 2025

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure hemodialysis services were provided 3 times weekly as ordered by physician to a resident (R5). This failure has the potential to affect 1 (R5) of 3 residents reviewed for Quality of Care /Treatment. Residents Affected - Few The findings include: R5's admission record showed admit date on 02/18/2025 with diagnoses not limited to End stage renal disease, Dependence on renal dialysis, Arthritis due to other bacteria right knee, Acute and chronic respiratory failure with hypoxia, Gout, Benign prostatic hyperplasia, Type 2 diabetes mellitus, Chronic diastolic (congestive) heart failure, Unilateral primary osteoarthritis right knee, Essential (primary) hypertension. R5 was discharged to facility on 3/10/25. R5's order summary report dated 4/1/25 showed order not limited to: Hemodialysis MWF (Monday, Wednesday, Friday). On 4/1/25 at 2:22 PM V17 (LPN / Licensed Practical Nurse) stated she has been working in the facility for 2 years and is regularly assigned on the 1st floor. She said she had worked with R5 who was receiving HD (hemodialysis) 3x per week MWF (Monday, Wednesday, and Friday) as ordered by physician. She stated every dialysis day, dialysis assessment is printed out, given to resident including Face sheet and POS (Physician Order Sheet). V17 said dialysis resident would come back to facility with paperwork (dialysis assessment) filled out by dialysis center as a form of dialysis communication. V17 said if resident missed dialysis treatment, physician should be informed and documented. V17 stated R5 was scheduled for hemodialysis on 2/28/25 (Friday) but due to transportation issue, hemodialysis was rescheduled on 3/1/25. Reviewed R5's EHR (electronic health record) with V17 and was unable to find documentation that physician was informed regarding missed dialysis on 2/28/25. She said she does not know if R5 received dialysis on 3/1/25, no documentation found. V17 said she is always off every Monday and does not know if R5 received hemodialysis on 3/3/25. On 4/2/25 At 1:34PM V13 (Registered Nurse / RN) stated resident on hemodialysis is sent out to dialysis center to receive hemodialysis as ordered by physician. She said Dialysis assessment should be completed every dialysis day as a form of dialysis communication. V13 said usually she would do progress notes if resident is going out and had received hemodialysis. She said if resident missed or refused hemodialysis, inform physician. Surveyor reviewed R5's EHR with V13 and she confirmed that she worked with R5 on 3/3/25 (Monday), dialysis day. She said she is not sure if R5 received hemodialysis that day. V13 unable to find documentation if R5 received hemodialysis on 3/3/25. No dialysis assessment, no progress notes or documentation found in R5's EHR (electronic health record) on 3/3/25 that R5 received hemodialysis as ordered by physician. (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: 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 04/04/2025 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)