Inspection·June 16, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement physician's orders for a resident (R1) at risk for bruising. This applies to 1 of 3 residents reviewed for skin conditions in the sample of 9. Residents Affected - Few The findings include: R1's electronic face sheet printed on 6/16/24 showed R1 has diagnoses including but not limited to cerebral infarction, weakness, osteoarthritis, complete traumatic amputation of right hand at wrist level, and dysphagia. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment and is dependent on staff for bed mobility. R1's care plan dated 9/27/18 showed, Potential for skin bruising related to thin/fragile skin. Use caution during ADL (activities of daily living) care. Handle gently, observe for bruises. R1's progress notes dated 5/27/24 showed, Resident was noted to have a discoloration to right elbow measuring 9x5.5x0cm (centimeters). Skin remains intact with slight bogginess felt in the center. Periwound is intact with no swelling or erythema noted. Resident does not know how it happened. Denies pain or discomfort. ROM (range of motion) with no change from baseline. Resident is [AGE] years old, has thin fragile skin and is on Plavix daily. Resident is at high risk for bruising and skin breakdown related to blood thinners, age and fragile skin. Physician informed of findings with orders noted and carried out. Placed call to daughter but she was unavailable, voicemail was left requesting a call back. Will continue to closely monitor for any changes. R1's nurse practitioner visit note dated 5/28/24 showed, RN (Registered Nurse) requested follow up of right elbow hematoma. No recent fall per staff. (R1) is resting in bed. He is a poor historian and unable to provide history. Per patient mild soreness with palpating elbow. He is able to lift and bend arm. Denies pain. Plan of care reviewed with RN. #right elbow contusion secondary to Aspirin/Plavix and advanced age, fragile skin. Monitor hematoma, call if worsens. Addendum 5/29/24 Results reviewed with daughter via phone. Daughter verbalized patient reported bumping arm on side rail during repositioning on Monday. DON (Director of Nursing) aware and will discuss with daughter. (multipurpose bandage) or skin protector to be applied to provide additional barrier for skin . R1's physician's orders for June 2024 showed no physician's orders for (multipurpose bandage) or skin protectors to be applied to R1. On 6/16/24 at 10:52AM, R1 stated, I get bruising on my arms because my arms get bumped on the rails (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 06/16/2024 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)