Health inspection·September 29, 2023

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm Based on observation, interview, and record review, the facility failed to provide R1 adequate hydration resulting in R1 being admitted to the hospital for hypernatremia (high sodium). This applies to 1 of 6 residents (R1) reviewed for hydration. Residents Affected - Few Findings Include: R1's September Physician's Order Sheet list the following diagnoses including: cerebral infarction, dementia, diabetes, hyperlipidemia, sleep apnea, atrial fibrillation, hyperlipidemia, dysphagia, and aphasia. Physician, order dated 9/26/23, documents enteral feeding Glucerna 1.2 at 65 ML/HR (Milliliters per hour) continuous to 1040 ML water flush 350 ML six times per day total volume 2100 ML in 24hour period. R1's MDS (Minimum Data Set), dated 9/17/23, show resident is completely dependent upon staff for (Activities of Daily Living). R1 was hospitalized for hypernatremia due to dehydration from 9/17/23 to 9/26/23 per progress notes. R1's shows critical lab results indicating severe dehydration was reported to the facility on 9/16/23 at 3:55 PM. Blood Urea Nitrogen elevated at 102 MG/DL (Milligram per Deciliter) (Normal 7-28). Creatine elevated at 1.96 MG/DL (Normal 0.44-1.32), Sodium elevated at 177 mEq/L (Normal 138-147). Hospital progress note, dated 9/20/23 at 3:11 PM, physician assessment and plan identified sodium lab value related water deficit nearly 10L probably due to limited intake of water through the feeding tube. Dehydration and high sodium probably associated with worsening mental status and brain damage (encephalopathy). On 9/28/23 at 9:20 AM, R1 was gowned and in bed with feeding tube running. R1's feeding tube solution, Glucerna 1.2, was being delivered by pump at 65 ML/HR (milliliter per hour) with water flushes preset at 350 ML every four hours. The feeding pump showed 926 ML of feeding delivered and 350 ML of water flushes delivered. The volume of feeding that remained in the bag was approximately 300 ML. The amount of water flush that remained in the bag was approximately 800 ML. R1 lips appeared dry. The urine in R1's collection chamber was amber and cloudy. On 9/28/23 at 9:58 AM, V17 (Licensed Practical Nurse) observed R1 tube feeding, flush, and pump. Tube feeding total volume delivered at that time was 961 ML. Total water volume delivered 350 ML. V17, LPN, stated 350 ML of water should have automatically been delivered by the feeding pump since she last saw R1. V17, LPN, manually pushed a button to deliver 350 ML of water to R1. On 9/28/23 at 10:27 AM, V16, DON (Director of Nursing), stated by looking at the reading on R1's (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: 145899 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 145899 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/29/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Warren Barr Orland Park 14601 South John Humphrey Dr Orland Park, IL 60462 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)