Health inspection·November 18, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a comprehensive and individualized care plan for a Stage IV pressure for one (R3) of four residents reviewed for improper nursing care. The findings include: R3's face sheet's showed admit date on 4/18/25, with diagnoses not limited to Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue, Pressure ulcer of sacral region stage 4, Type 2 diabetes mellitus, Essential (primary) hypertension, Disorder of prostate, Unspecified dementia. R3's health record showed discharge date on 8/1/25. MDS (Minimum Data Set), dated 7/7/2025, showed R3's cognition was intact. He needed Substantial / maximal assistance with eating, oral and personal hygiene; Dependent with toileting hygiene, shower / bathe self, upper and lower body dressing, chair / bed transfer. R3 was always Incontinent of bowel and bladder. MDS showed 1 Stage IV pressure ulcer that was present upon admission / entry.On 9/26/25 at 10:01 AM, V7 (Wound Care Coordinator, LPN / Licensed Practical Nurse) stated she has been working in the facility for almost a year. V7 stated R3 had no skin breakdown upon initial admission. V7 said R3 went to the hospital several times and came back to the facility with Stage IV pressure ulcer on sacral area. SR3 was followed up by wound Nurse Practitioner/NP. V7 said skin breakdown / pressure ulcer should be care planned. The care plan is a document that needs to be known for the resident so staff would be able to know how to care for the resident. V7 said care plan will show what needs to be done or it is the plan of the care of the resident that would include goals and interventions. She said she is responsible in doing the care plan for skin impairment.Survey resumed on 11/14/25 due to Federal Government Shutdown that began on 10/1/25.On 11/14/25 At 12:41pm, V2 (DON / Director of Nursing) stated care plan should be person centered and individualized. It includes problem / concerns, goals, and interventions. V2 said plan of care would direct staff on how to care for the resident. Surveyor reviewed R3's care plan with V2; no care plan found for R3's stage IV pressure on Sacrum. She said there should be a care plan for Stage IV pressure ulcer done by wound care nurse. On 11/14/25 At 12:51pm, V7 (Wound Care Coordinator) stated Care plan should be done for residents with skin impairment including pressure ulcer. She said care plan should be individualized and includes concern/ comorbidities, type of wound and stage of pressure ulcer, goals and interventions. V7 said care plan is the plan of care of the resident that would direct staff what to do. Surveyor reviewed R3's care plan with V7, no care plan found for R3's stage IV pressure ulcer to sacrum.V26 (Wound Nurse Practitioner / NP) notes, dated 7/28/25, showed: R3 with Stage 4 pressure ulcer on sacral. Wound size: 8cm x 12.5cm x 1.3cm. Wound base: 60% granulation, 40% slough. Exposed tissues: Subcutaneous, muscle / fascia, tendon/ligament, Bone. Exudate: Heavy amount of serous. R3's skin / wound evaluation, dated 7/5/25, showed: Community acquired Stage IV pressure ulcer to sacrum. Measurement: 10.5 x 6.5 x 1.6cm. R3's POS (Physician Order Sheet), order date 7/29/25, showed: Clean sacrum with normal saline pat dry apply Betadine-soaked gauze cover with dry dressing secure with a border dressing daily and PRNR3's hospital records, dated 8/1/25, showed: R3 presented on (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 11/18/2025 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)