Inspection visit
Health 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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the
needs of 5 residents (R1-R5) reviewed for sufficient staffing in the sample of 8.
The findings include:
On 11/1/23 at 6:14 PM, R1 said the facility is short-staffed. Mostly on the overnight shifts and the
weekends. R1 said the weekend of 10/27/23-10/29/23, they had one CNA (Certified Nursing Assistant) for
68 residents. R1 said she told V3 (CNA) she had been waiting for over two and a half hours for assistance
and V3 said she was sorry, but there was not enough staff, and she could not get to everyone who had their
call light on. R1 said V3 told her that she had her light on earlier in the night and she tended to her needs,
however, she was trying to get to the residents that she had not gone to yet. R1 said she has heart disease
and is getting weaker. She needs staff to help her with getting up and walking with a gait belt and a walker.
On 11/2/23 at 10:42 AM, R1 was in her motorized wheelchair. R1 was alert and oriented. R1 said she put
her call light on one morning around 4:30 AM and was told by V15 (CNA) that she should put her light on
before 3:00 AM if she needs something, because he is busy getting other residents ready for dialysis
around 4:30 AM.
On 11/2/23 at 10:58 AM, R2 said the facility does not have enough staff, especially on the night shift. R2
said she had a fall one night and laid there yelling. No one came so she had to crawl over to her call light
and turn it on. R2 said she still had to wait a long time for help to come after turning on her call light. R2
said one time she put her call light on and it took 45 minutes for staff to come. R2 said she turned the light
on to let them know that her roommate was throwing up. R2 said she wheeled her wheelchair out into the
corridor because no one was coming. R2 said there was no one there to tell. R2 said one time she had to
wait around two hours for someone to come down and take her back to her floor after receiving dialysis.
On 11/2/23 at 9:40 AM, R3 said the facility does not have enough staff. R3 said she usually waits an hour
for help on the night shift. R3 said she has gone two weeks without a shower before, adding that was a
couple months ago. R3 said she spoke with V1 (Administrator) about it and in the last couple of weeks she
has received two showers a week. R3 said she has multiple sclerosis, and she needs assistance from staff
for everything. R3 said staff usually check and change her once in the morning and sometimes in the
afternoon. R3 said she has to call staff to have them reposition her because they do not usually do it on
their own. R3 said there is less staff on the night shift, and she has to wait longer for them to answer her
call light. R3 said it is aggravating.
(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:
145819
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
145819
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Warren Barr Buffalo Grove
150 North Weiland Road
Buffalo Grove, IL 60089
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 11/2/23 at 9:22 AM, R5 said the facility did not have enough staff, especially on the overnight shift and
she waits a long time for assistance. R5 said staff will tell you to wait a minute and then not return to take
care of you for a long time.
On 11/2/23 at 10:20 AM, V11 (R4's family member) said she came into the facility the other day at 5:45 AM
and R4's urinary drainage bag was full. V11 said R4 had a bowel movement and he had stool all over his
bottom and upper legs. V11 said staff came into R4's room after she arrived and cleaned him up and
emptied his urinary drainage bag. (R4 resides on the third floor of the facility).
On 11/2/23 at 1:55 PM, V9 (Clinical Certified Dialysis Technician) said it would not surprise her that a
resident reported waiting an hour to be taken back to their room after dialysis. V9 said she is not aware of
anyone waiting for two hours, however one of the other dialysis staff has had a resident wait for an hour and
a half for staff to come and get her.
On 11/2/23 at 2:20 PM, V3 (CNA) said she was the only CNA on the second floor on the third shift (11:00
PM-7:00 AM shift) on 10/27/23. V3 said she was pretty much on her own taking care of 68 residents. V3
said the two nurses tried to help when they could, however, they had their own work to do too. V3 said she
just did what she could, adding that she felt bad because she could not get to all of her residents. V3 said
she had to make sure she got to the residents that she knew were saturated. V3 said she was only able to
get to about half of the 68 residents.
On 11/2/23 at 11:35 AM, V1 (Administrator) said on the overnight shifts, the facility usually has two nurses
and two to three CNAs working on the second floor. V1 said on Friday, Saturday, and Sunday
(10/27/23-10/29/23) there were two Nurses and one CNA working the overnight shifts. V1 said they
struggled to find coverage after a CNA called off due to an emergency. V1 said they could not get anyone to
cover the call off. V1 said all management is available for support to help fill in and call staff to fill in if there
is a call off. V1 said if they cannot get anyone, then a manager can fill in.
On 11/3/23 at 9:14 AM, V2 (Licensed Practical Nurse-LPN) said she worked the overnight shift on
10/29/23. V2 said she was new to the facility, and it was pretty stressful with just one CNA working on the
second floor. V2 said the residents on the second floor require more care, so these residents need more
CNAs. V2 said she had quite a few things to get completed on her shift, but she tried to help the CNA when
she could. V2 said she was also not familiar with the residents due to being new. V2 said not having enough
staff can affect the residents. They have to wait for help, and if they are sitting in soiled incontinence briefs,
it can cause skin breakdown.
On 11/3/23 at 10:42 AM, V4 (CNA) said he was the CNA that worked on the second floor on 10/29/23,
during the overnight shift. V4 said he was the only CNA for 68 residents. V4 said there were two nurses, but
they had their own work to do. V4 said it was hard. There were a lot of call lights going off. One person can't
do everything. V4 said the nurses tried to help when they could. V4 said there were residents that were
complaining about the wait. V4 said there were only three CNAs for the whole building on Sunday 10/29/23.
One CNA on each floor. V4 said the second floor is the hard floor and three CNAs are needed. V4 said
there are usually only two CNAs on the second floor overnight. V4 said that means that each CNA would
have about 34 residents each. V4 said the facility is usually short-staffed on the weekends. V4 said when
there are not enough CNAs, the residents have to wait longer to be cleaned and changed. V4 said if the
CNAs do not change and clean the residents in time, it can cause skin problems. V4 said it could also be a
dignity issue, or the resident could get mad about having to wait and transfer themselves.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145819
If continuation sheet
Page 2 of 4
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
145819
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Warren Barr Buffalo Grove
150 North Weiland Road
Buffalo Grove, IL 60089
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 11/3/23 at 10:20 AM, V6 (LPN) said she worked Saturday 10/28/23 on the overnight shift. V6 said there
were call offs and only one CNA and two Nurses were working the second floor on 10/28/23. V6 said the
overnight nurses still have a lot to do on their shift. V6 said they each have about 34 patients that they have
to pass medications, they have to monitor the patients, obtain urinalysis samples if needed, and review
residents' labs, among other things. V6 said the Nurses help with the call lights when they can. V6 said it
was stressful on 10/28/23. Multiple call lights were going off. V6 said We help out but we can only do so
much. V6 said they needed another CNA. V6 said when there aren't enough staff, it affects the residents.
The residents wait to be changed. V6 said the second floor is a heavy hall, as far as residents' needs.
On 11/3/23 at 11:32 AM, V5 (CNA) said she was the only CNA on the overnight shift for the second floor on
10/28/23. V5 said she was not able to get everything done that she needed to. V5 said she tried to focus on
the residents that were wetter. V5 said she also tried to focus on the residents who had their call lights on.
V5 said there were a lot of call lights going off. V5 said if there is not enough staff, the residents have to wait
longer, and it could cause skin breakdown. V5 said a resident could self-transfer and then it is a safety
issue. V5 said it is also a dignity issue.
On 11/3/23 at 12:40 PM, V7 (CNA/Scheduler) said he does the schedules for the CNAs and the Nurses. V7
said normally he will try to schedule three CNAs and two Nurses for the second floor on the overnight shift.
V7 said the second floor is a heavier floor, and there is also a lot of residents that have dialysis that reside
on the second floor. V7 said one of the CNAs that were scheduled called off for 10/27/23-10/29/23 on the
overnight shift. V7 said there was only one CNA working them shifts to take care of 68-69 residents. V7 said
that is not enough. V7 said when there is a call off, he will try to get someone to come in or get someone to
stay over. V7 said he could not get anyone to cover. V7 said neither him, nor any management personnel
came in to cover the vacant spot. V7 said it is important to make sure there is enough staff for the safety of
the residents and to monitor for any change of condition. V7 said it is important to make sure the residents
are provided the care they need. V7 said if a resident is not feeling well, or is in critical condition, staff may
not notice when there is not enough staff. V7 said if the residents are incontinent, they could have skin
breakdown. V7 said it is also a dignity issue, having to sit in a soiled incontinent brief for a while.
The facility schedule, provided by the the facility on 11/2/23 showed one CNA for each floor on the
overnight shift on 10/27/23, 10/28/23, and 10/29/23.
The facility's Midnight Census Reports, provided by the facility on 11/3/23, showed:
On 10/27/23 there were 68 residents residing on the second floor.
On 10/28/23 there were 66 residents residing on the second floor.
On 10/29/23 there were 67 residents residing on the second floor.
R1's ADL (activities of daily living) care plan, dated 7/26/23, showed she had an ADL self-care deficit and
required assistance with transfers and was dependent on staff for toilet use. R1's 10/27/23 assessment
showed she was cognitively intact. R2's care plan dated 4/23/21 showed she had an ADL self-care deficit
and required extensive staff assist for transfers and staff assist with toilet use. R2's facility assessment
dated [DATE], showed she is cognitively intact. R3's care plan dated 7/3/23 showed she has an alteration in
neurological status related to multiple sclerosis.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145819
If continuation sheet
Page 3 of 4
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
145819
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Warren Barr Buffalo Grove
150 North Weiland Road
Buffalo Grove, IL 60089
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
R4's care plan dated 7/12/23 showed he had an ADL self-care deficit and was dependent on staff for
toileting and transfers. R4's facility assessment dated [DATE] showed he had severe cognitive impairment.
R1-R4's diagnoses, progress notes, care plans, facility assessments, and physician's orders were reviewed.
The facility's policy and procedure titled staffing, with a revision date of 7/28/23,showed It is the facility's
policy to provide adequate staff to meet the needs of the residents which is the requirement under the
federal regulations.
Event ID:
Facility ID:
145819
If continuation sheet
Page 4 of 4
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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.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
FAQ · About this visit
Common questions about this visit
What happened during the November 3, 2023 survey of WARREN BARR BUFFALO GROVE?
This was a inspection survey of WARREN BARR BUFFALO GROVE on November 3, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WARREN BARR BUFFALO GROVE on November 3, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each ..."
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.