F 0689
Level of Harm - Minimal harm
or potential for actual harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on interview and record review, the facility failed to follow their fall policy and R5's comprehensive
care plan to prevent further falls for 1 of 6 residents reviewed for falls.
Residents Affected - Few
Findings include:
R5's face sheet documents medical diagnoses of lack of coordination and abnormalities of gait and
mobility.
R5's Fall Risk Evaluation, dated 7/29/2023, documents R5 is at high risk for falls.
R5's Significant Change MDS (Minimum Data Set) Assessment, dated 10/28/2023, documents R5 requires
partial/moderate assistance with toileting hygiene and toilet transfer.
R5's comprehensive care plan contains a focus that documents R5 is at high risk for falls related to history
of falls, Parkinson's Disease, poor safety awareness, poor balance, coordination, limited mobility, and
decreased activity endurance. R5 also continues to over-estimate functional limitation. Intervention initiated
on 8/23/2022 documents in part: Staff to address [R5's] needs with a prompt response to all requests for
assistance.
V8's (Nurse) progress note, dated 11/05/2023 at 1:53 PM, documents: The resident fell on the floor and c/o
(complained of) pain to [R5's] mid back 7 out of 10. Prior to the fall the resident requested to be toileted. I
informed the resident that [R5's] CNA (Certified Nurse Aide) was on break and I would toilet [R5], but I had
to go to the bathroom first.
On 11/28/2023 at 3:40 PM, V8 stated R5 requires pivot assistance with going to the commode. V8 stated
R5 had loose stools prior to fall and needed to go to the commode frequently. V8 stated [R5] saw me and
said [R5] needed to go to the commode. I looked for [V14, CNA] but they said [V14] was on break. I told
[R5] before I take you to the commode, let me go to the bathroom because I've been holding it too long.
On 11/29/2023 at 10:09 AM, R5 was alert and oriented to person, place, and time. R5 stated falling a few
weeks ago while going to the commode. R5 stated, I told them that I had to go right away.
On 11/29/2023 at 10:34 AM, V11 (Physical Therapist) and V12 (Therapy Director) stated R5 is impulsive
and needs a lot of precautions. V11 stated while sitting down, R5 will sometimes just lunge up and not
follow safety precautions. R5 will forget to use proper walking techniques or forget to use the walker. V11
stated R5 needs to use the walker even for short distances to assist with getting up
(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:
145875
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
145875
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/30/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Warren Barr Lincoln Park
2732 North Hampden Court
Chicago, IL 60614
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and pivoting. V11 and V12 stated R5's impulsiveness and lack of safety awareness puts R5 at high risk for
falls.
On 11/29/2023 at 10:57 AM, V13 (Escort/Sitter) stated, [R5] kept saying [R5] had to go to the bathroom. I
told her that [R5's] CNA went on break. [R5] told me twice that [R5] had to go. V13 stated, I walked by [R5's]
room. [R5] stood up. I told [R5] to sit down. Soon as I turn back around [R5] was on the floor.
Facility's Fall Occurrence policy last revised 7/17/2023 documents: It is the policy of the facility to ensure
that residents are assessed for risk for falls, that interventions are put in place, and interventions are
reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall
interventions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145875
If continuation sheet
Page 2 of 2
