Health inspection·May 6, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to follow their policy on enteral tube feeding care by failing to label the date and time the feeding was started for two (R2, R3) residents of three residents reviewed for enteral feedings. Findings include: 1. R2's medical diagnoses in current face sheet includes: cerebral infarction due to embolism of bilateral posterior cerebral arteries, encounter for attention to gastrostomy, and cognitive communication deficit. R2's Diet: NPO (Nothing by Mouth) diet, NPO texture, NPO consistency and her Brief Interview for Mental Status (BIMS) dated 5/3/24 is documented as 6/15, indicating R2 has severe cognitive impairment. R2's Physician's orders, dated 04/26/2024, document: Enteral Feed Order every shift Enteral feeding G-Tube feeds with Jevity1.5 at 75ml/hour. Start at 17:00 and infuse until 1575ml is reached per day. On 5/6/2024 at 10:20am, R2 was observed sleeping with head of bed elevated to about 75 degrees, and R2's nutritional supplement was observed running at a rate of 75mL/hour. The pump showed R2 had received 1025 ml, and the bottle of R2's nutritional supplement in the bottle still infusing was 300mL. The nutritional supplement bottle was labeled with R2's name, but there was no date or time when the nutritional supplement feeding was started. V12, Licensed Practical Nurse/LPNstated he found the G-tube feeding running this morning, and the nurse who hung and started the feeding should have labeled the bottle with the time and date to let the next nurse know when to change it to make sure R2 gets fresh feedings per orders. V12 stated he did not know when the tube feeding was started. 2. R3's medical diagnoses in current face sheet includes: moderate protein-calorie malnutrition, type 2 diabetes mellitus without complications, and dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance. R3's Brief Interview for Mental Status (BIMS), dated 4/30/24, is documented as 3/15, indicating R2 has severe cognitive impairment. R3's diet is documented as: NAS (No Added Salt) diet, Puree texture, thin liquids consistency. R3's Physician's orders, dated 01/15/2024, document: Enteral Feed Order every shift Enteral feeding G-Tube type(G-tube) Jevity1.2, Rate: 60ml/hr. Start at 5pm and infuse until (2pm: total volume 1260 cc) is reached per day. Turn off during ADLs(Activities od Daily Living) and PRN(As Needed). (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 05/06/2024 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)