Health inspection·April 18, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few then went to 89%, 88% and 82% on room air. R1 had a concentrator at her bedside so she placed R1 on oxygen and got the nurse. V3 had her occupational therapy note with her and read it. The OT (Occupational Therapy) note dated 2/21/24 (no time) for R1 that V3 read during her interview showed, When patient (R1) was found, patient was breathing and it sounded labored slightly so O2 (oxygen saturation) was taken and it was 95% for the first 10 seconds and then it went down to 89%, then 88%, then 82%. Patient was given oxygen on 3 liters and patient nurse was notified. Patient nurse came into the room when OT was sitting at the end of the bed with 3 liters on and tested O2 and stated that it was 99% so she was okay to stay on 3 liters when she was on therapy and then put down to 2.5 liter when she was supine in bed. Patients nurse was told that the patients oxygen went down when she leaves the oxygen on her finger longer. The patients nurse stated to just keep oxygen on her. Patient was talking; however, was slow to respond like the previous days. On 4/18/24 at 11:19 AM, V5 RN (Registered Nurse/Nursing Supervisor) stated, a change in condition for a resident is anything different from their baseline. V5 stated if it wasn't normal for a resident to wear oxygen and then needed oxygen, that would be a change in condition. V5 stated therapy notified them that R1 was short of breath and had a decreased oxygen saturation. V5 stated the doctor should have been notified; this was a change in condition. V5 stated when the doctor is notified they would get oxygen orders and any other orders to see what is causing the oxygen to drop. V5 stated it is important to notify the doctor because we don't know what is causing the change in condition. This should have been done as soon as it was heard from therapy. V5 stated the family should be notified of the change in condition as soon as possible. On 4/18/24 at 11:45 AM, V6 RN stated, In the morning R1's vital signs were okay. R1's blood pressure was a little low so midodrine was given. V6 stated OT (Occupational Therapy) and PT (Physical Therapy were in R1's room and told her R1's oxygen saturation was dropping. V6 stated she did not see the oxygen saturation reading that OT?PT had checked. V6 stated she was told R1's oxygen was falling from high to low. V6 stated she checked R1's oxygen saturation and it was 90%. V6 stated R1 was on oxygen when she checked her and she thought R1 was on oxygen normally. V6 stated if R1 was not normally on oxygen then that would be a change in condition. V6 stated she did not notify the doctor immediately because R1's oxygen saturation was greater than 90% so that is normal blood oxygen level. V6 stated with any change in condition the doctor is to be notified first and then the family. On 4/18/24 at 12:35 PM, V8 NP (Nurse Practitioner) stated, R1's oxygen saturation dropping and the nurse having to put oxygen on would be a change in condition for the resident. V8 stated they are supposed to call him and the nurse did not call him. V8 stated the nurse did mention it when he came to the building at 12:45 PM. The Face Sheet dated 4/18/24 for R1 showed medical diagnoses including type 2 diabetes mellitus, cardiomegaly, peripheral vascular disease, diverticulosis, pressure ulcer, spinal stenosis, cellulitis of abdominal wall, end stage renal disease, hyperkalemia, morbid obesity, chronic pain, hypotension, hypothyroidism, hyperlipidemia, essential hypertension, dependence on renal dialysis, and other sequelae following unspecified cerebrovascular disease. The facility's Notification Procedures for Change in Resident Condition policy (1/12/23) showed, the facility shall promptly notify the resident, the attending physician and representative (POA) of changes in the resident's medical/mental and physical condition and/or status using the quality improvement program. The charge nurse or nurse supervisor will notify the resident's attending physician or covering physician when there has been: e. A significant change in the resident's physical, (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 04/18/2024 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 0580 Level of Harm - Minimal harm or potential for actual harm emotional/mental condition. Unless other wise instructed by the resident, the charge nurse of nurse supervisor will notify the resident's next of kin or representative when: c. There is a significant change in the resident's physical, mental, or medical status. Residents Affected - Few 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 04/18/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the information available in the resident's chart was accurate for 1 of 3 residents (R1) reviewed for medical records. The findings include: The Face Sheet dated 4/28/24 for R1 showed she was admitted to the facility on [DATE] with medical diagnoses including type 2 diabetes mellitus, cardiomegaly, peripheral vascular disease, diverticulosis, pressure ulcer, spinal stenosis, cellulitis of abdominal wall, end stage renal disease, hyperkalemia, morbid obesity, chronic pain, hypotension, hypothyroidism, hyperlipidemia, essential hypertension, dependence on renal dialysis, and other sequelae following unspecified cerebrovascular disease. The facility's admission Packet Information for R1 was dated 1/15/24 and R1 was admitted on [DATE]. The Consent for the Use of side rails, Fall Prevention Education Material, Informed Consent for Influenza Vaccination, Informed Consent for Pneumonia Vaccination, and Informed consent for Vaccination (RSV respiratory synctial virus), were dated 1/15/24 and signed by the resident on the same date. R1 was not admitted until 2/15/24 and these forms were part of the admission Packet for R1. The Daily Skilled Nurse's Notes for R1 dated 2/16/24 through 2/21/24 had it marked under section a, daily evaluation section that R1 had an ostomy. The Daily Skilled Nurse's Notes for R1 showed dialysis was not marked on 2/17/24, 2/18/24, and 2/20/24. R1 did not have an ostomy and was on end stage renal dialysis. On 4/18/24 at 7:08 AM, V9 (R1's daughter/power of attorney) stated, they have poor charting. They had R1 signs documents dated 1/15/24 and she was admitted on [DATE]. They should have caught that. How are you having her sign things for when she wasn't there. You don't care enough to make sure her chart was accurate then what else don't you care about. V9 stated most R1's teeth were missing and that was not documented. V9 stated R1 had a previous ostomy but did not have one now. V9 stated R1 had dysphagia and that was not on there. V9 stated they did not document that R1 had a previous stroke and that was not in her diagnoses. On 4/18/24 at 12:23 PM, V1 (Administrator) stated, staff are expected to chart accurately. I know R1 was on dialysis and she did not have an ostomy. When R1 was here in the past she had an ostomy. It must have pulled over in the chart but the nurse's are supposed to be aware of that. V1 stated R1 was not at the facility on 1/15/24 and the papers in the admission packet should not be dated that; they should be accurate. The facility's Electronic Medical Record Policy (7/28/23) showed, it is the policy of this facility to ensure that only authorized personnel shall complete appropriate entries, insure efficient monitoring of these records, maintain integrity, confidentiality and preservation of resident clinical information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145819 If continuation sheet Page 4 of 4