Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Park Health & Living Ctr during CMS and state inspections, most recent first.
Staff failed to prevent and address incidents of unwanted sexual contact between residents and between staff and residents. A resident with a history of mental illness was reported to have groped a female resident who had expressed her discomfort, and a staff member was observed patting the same resident on the rear. The care plan lacked updated interventions, and staff minimized or failed to recognize the seriousness of the behaviors, contrary to facility policy.
The facility's pest control program was ineffective, as evidenced by mouse droppings found in multiple rooms on the 2nd and 3rd floors. Residents confirmed the presence of mice, with one resident reporting having killed a mouse. The Maintenance Director was unaware of the issue, despite regular pest control services, and facility policy requires the environment to be pest-free.
The facility failed to discard expired food, label food items with use-by dates, and sanitize cooking equipment per manufacturer's directions. A container of tuna salad was found past its discard date, and sliced deli turkey lacked a use-by date. Additionally, the Quaternary solution used for sanitizing was below the recommended concentration, indicating improper disinfection of kitchen items. These deficiencies could affect the safety of food served to 123 residents.
The facility failed to ensure reusable cloth incontinence briefs were in good condition, as observed by a surveyor who found a stained brief on a linen cart. The Laundry Aide assumed it was acceptable for use since it was not torn, despite washing it twice. The Housekeeping Director confirmed the stains were from urine and feces, and stated the aide is responsible for discarding such linens. This failure potentially affects 40 incontinent residents.
The facility did not refer four residents with serious mental illness for a PASARR Level II evaluation, despite their diagnoses indicating a need for further assessment. The facility's policy requires such referrals when a Level I screen suggests potential mental disorders, but the Social Service Director stated that the facility only conducts PASARR screenings when instructed by an outside agency.
A medication cart was found unlocked and unattended in an LTC facility, with keys left inside the lock. An RN responsible for the cart admitted to forgetting to secure it due to being busy. The cart contained medications for residents on the 1st and 3rd floors, posing a risk of unauthorized access and potential adverse reactions. The DON confirmed the danger and the facility's policy requires medications to be locked when not in use.
A registered nurse in an LTC facility failed to sanitize a wrist blood pressure cuff device between uses on multiple residents during medication administration. The nurse admitted to forgetting to clean the device due to nervousness. The DON confirmed that all shared equipment must be sanitized to prevent infection spread, as per facility policy.
Two residents were found without appropriate clothing or incontinence briefs, compromising their dignity. One resident was left exposed due to a lack of properly sized briefs, while another was found completely naked under a blanket. Staff acknowledged the dignity issue, and facility policies emphasize treating residents with respect, yet these standards were not upheld.
A resident's air loss mattress was incorrectly set for a weight range of 240-320 pounds, despite the resident weighing between 100-110 pounds. This error resulted in a firm mattress, unsuitable for pressure distribution, potentially worsening the resident's stage IV pressure wound. The resident, with a high risk for pressure wounds due to multiple health conditions, requires proper mattress settings to prevent further skin breakdown.
Two high fall risk residents experienced falls due to inadequate supervision in a facility. One resident fell in the bathroom without assistance, while another fell in the dining room with no staff present. Both residents had high Morse Fall Scale scores and required supervision, but staff were unaware of the incidents, indicating a lapse in communication and adherence to care plans.
The facility failed to offer pneumonia vaccines to three residents upon admission, as required by its policy. Despite consent being obtained, the vaccines were not administered, and there was no documentation in the residents' electronic health records. The Infection Preventionist and Director of Nursing acknowledged the oversight, which affected residents with chronic health conditions, increasing their risk for pneumonia.
A resident with a history of falls and complex medical conditions was not properly assessed or monitored, leading to a significant injury. Despite being a high fall risk, the facility did not conduct necessary fall risk assessments or update the care plan after previous falls. The resident was eventually hospitalized with a cervical vertebrae fracture and subdural hematoma, highlighting a failure in implementing adequate fall prevention measures.
A resident with a complex medical history was found with a new hematoma on her head, which was not reported to the state agency as required by the facility's policy. Despite the facility's protocol for reporting injuries of unknown origin, the administrator was unaware of the injury, and it was not documented or reported within the mandated 24-hour period.
Failure to Protect Residents from Sexual Abuse and Inappropriate Contact
Penalty
Summary
The facility failed to follow its policy to ensure residents are free from sexual abuse, as evidenced by multiple observations and interviews involving inappropriate sexual contact between residents and between staff and residents. One resident, a man with schizoaffective and bipolar disorder who is moderately cognitively intact, was reported by another resident to have groped a female resident, who is cognitively intact, despite her expressing that she did not like the behavior and had told him to stop. Another resident and a staff member confirmed witnessing or hearing about these inappropriate interactions, with the staff member indicating that such behavior was sometimes consensual and sometimes not. The staff member also minimized the seriousness of the behavior, attributing it to typical male conduct rather than recognizing it as potentially abusive. Additionally, the surveyor observed a staff member, an activity aide, patting the same female resident on the rear in a playful manner, which the Director of Nursing acknowledged as inappropriate and unprofessional. The care plan for the male resident included counseling on appropriate sexual behavior and the need for consent, but interventions such as redirection were not documented in the care plan. The facility's abuse policy affirms residents' rights to be free from abuse, including sexual abuse, but the policy was not effectively implemented in these cases, resulting in residents being subjected to unwanted physical contact.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of mice on the 2nd and 3rd floors. Mouse droppings were observed in multiple rooms, including the toilet room floor of one resident's room on the 2nd floor and near the wardrobe dresser of another resident's room on the same floor. On the 3rd floor, over 100 mouse droppings were found next to a wardrobe cabinet in a resident's room. Interviews with residents confirmed the presence of mice, with one resident stating they had killed a mouse in their room. The Maintenance Director acknowledged the issue, despite pest control reports indicating no mouse activity, and stated that a pest control company regularly services the facility. The facility's policy mandates that it should be free of pests and rodents.
Food Safety and Sanitization Deficiencies
Penalty
Summary
The facility failed to adhere to proper food safety protocols, which included not discarding expired food, not labeling food items with use-by dates, and not sanitizing cooking equipment according to the manufacturer's directions. During a kitchen inspection, a container of tuna salad was found with a preparation date indicating it should have been discarded, yet it remained in the refrigerator. Additionally, sliced deli turkey was observed without a use-by date, which is against the facility's policy. These oversights in food labeling and discarding practices have the potential to compromise the safety of food served to the 123 residents receiving meals from the facility's kitchen. Furthermore, the facility did not ensure proper sanitization of kitchen equipment. The concentration of the Quaternary solution used for sanitizing was found to be below the manufacturer's recommended level, indicating that the items were not being disinfected properly. The dietary manager acknowledged that the concentration should be checked before cleaning items, but it was revealed that the dishwasher did not check the concentration that morning. This lapse in following sanitization procedures could lead to cross-contamination and foodborne illnesses among residents.
Facility Fails to Maintain Clean Incontinence Briefs
Penalty
Summary
The facility failed to ensure that reusable cloth incontinence briefs intended for resident use were in good condition. During a tour of the laundry room, a surveyor observed a cloth incontinence brief with multiple, permanent dark colored stains on a linen cart intended for resident use. The Laundry Aide, identified as V13, acknowledged awareness that stained incontinence briefs should be discarded when new ones are received. However, V13 assumed it was acceptable for residents to continue using the brief since it was not ripped or torn, despite washing it twice. The Housekeeping Director, identified as V14, confirmed the presence of permanent stains on the incontinence brief, attributing them to urine and feces. V14 stated that V13 is responsible for notifying him when incontinence briefs and other linens need to be reordered and for discarding old, stained, and worn linens. The facility's policies emphasize the importance of providing a safe, clean, comfortable, and homelike environment, with linens in good condition. The failure to adhere to these policies potentially affects 40 incontinent residents residing in the facility.
Failure to Refer Residents for PASARR Level II Evaluation
Penalty
Summary
The facility failed to refer four residents with serious mental illness to the appropriate state-designated authority for a PASARR Level II evaluation and determination. The residents involved had diagnoses including bipolar disorder, anxiety disorder, schizophrenia, schizoaffective disorder, panic disorder, and major depressive disorder. Despite the PASARR screenings indicating a reasonable basis to suspect mental illness, there was no documentation showing that these residents were referred for the necessary Level II evaluations. The facility's policy requires that all new admissions and readmissions be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASARR process. If a Level I screen indicates potential criteria for these conditions, a referral to the state PASARR representative for a Level II evaluation is mandated. However, interviews with the Social Service Director revealed that the facility does not conduct or repeat PASARR screenings unless instructed by the outside agency responsible for PASARR screenings, leading to the oversight in referring the residents for further evaluation.
Medication Security Lapse in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were locked and secured while unattended, as observed by a surveyor. On the first floor, a medication cart was found unlocked and unattended with the keys left inside the lock. A registered nurse (RN) acknowledged responsibility for the cart, which contained medications for residents on both the 1st and 3rd floors. The RN admitted to forgetting to lock the cart and retrieve the keys due to being busy with other tasks. This oversight left the medications accessible to residents, posing a risk of overdose, adverse reactions, or other life-threatening complications. The Director of Nursing (DON) confirmed the danger of leaving medication carts unlocked and unattended, acknowledging the potential for residents to self-administer the wrong medications and suffer adverse reactions. The facility's policy, dated April 2021, mandates that compartments containing drugs and biologicals must be locked when not in use and that unlocked medication carts should not be left unattended unless under visible supervision. The facility census indicated that 68 residents resided on the 1st and 3rd floors, all potentially affected by this deficiency.
Failure to Sanitize Shared Medical Equipment
Penalty
Summary
The facility failed to ensure that shared medical equipment, specifically a wrist blood pressure cuff device, was cleaned and decontaminated between uses for four residents during medication administration observation. On multiple occasions, a registered nurse used the same blood pressure device on different residents without sanitizing it before or after each use. This occurred during a medication pass observation where the nurse measured the blood pressure and heart rate of several residents consecutively without cleaning the device, which was then stored in the medication cart or placed on top of it without disinfection. The registered nurse acknowledged the oversight, attributing it to nervousness and forgetting to clean the device. The Director of Nursing confirmed that all shared medical equipment must be sanitized before and after each use to prevent the spread of infection. The facility's policy mandates that reusable resident care equipment be decontaminated between residents according to CDC recommendations and the manufacturer's instructions. The failure to adhere to these protocols was observed and documented by the surveyors.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to provide dignity for two residents, R226 and R41, as observed during a survey. R226 was found lying in bed with his buttocks exposed, wearing only a shirt and a blanket partially covering him. He reported that a staff member removed his incontinence briefs because they were too small, and the facility did not have any briefs in his size. R226, who is cognitively intact with a BIMS score of 13/15, has multiple diagnoses including unspecified dementia and chronic kidney disease. The CNA, V4, confirmed the lack of appropriate incontinence briefs and mentioned that the facility uses reusable briefs for mostly bed-bound residents, while some residents have disposable briefs purchased by their families. R41 was observed completely naked under a blanket, without a gown or incontinence briefs, and was not alert to make his needs known. R41 has a BIMS score of 09/15, indicating cognitive impairment, and requires moderate assistance with ADLs. The CNA, V7, acknowledged the dignity issue and stated she was instructed to use reusable briefs for R41. The Director of Nursing confirmed that leaving residents without clothing or briefs is a dignity issue. Facility policies emphasize treating residents with dignity and respect, yet these incidents demonstrate a failure to uphold these standards.
Improper Air Loss Mattress Setting for Resident
Penalty
Summary
The facility failed to correctly set the air loss mattress for a resident, identified as R75, based on their weight, which is crucial for pressure wound treatment services. During an observation, the air loss mattress was set for a weight range of 240-320 pounds, while R75 actually weighed between 100-110 pounds. This incorrect setting made the mattress hard and firm, which is not suitable for pressure distribution and could potentially worsen the resident's stage IV pressure wound on the sacrum. The Director of Nursing initially assumed the setting was correct based on the displayed weight range, but it was later confirmed by the Restorative Nurse that the setting was inappropriate for R75's actual weight. R75 has a medical history that includes dementia, adult failure to thrive, muscle weakness, and other conditions that contribute to a high risk for pressure wounds, as indicated by a Braden Score of 10. The resident is dependent on staff for most self-care activities and has a facility-acquired pressure ulcer on the coccyx. The facility's policy and the mattress owner's manual both emphasize the importance of setting the mattress according to the resident's weight to prevent skin breakdown and promote comfort, which was not adhered to in this case.
Inadequate Supervision Leads to Falls for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate assistance and supervision to two high fall risk residents, leading to incidents where both residents experienced falls. One resident, identified as R50, reported slipping and hitting their head on the sink while in the bathroom alone, despite being at high risk for falls and requiring staff assistance for toileting and transfers. The incident was not immediately reported to the nursing staff, and the resident was able to return to bed without assistance. The staff, including a registered nurse and a certified nursing assistant, were unaware of the incident until informed by the surveyor, indicating a lapse in communication and supervision. Another resident, R84, also at high risk for falls due to impulsive behaviors and impaired cognitive function, fell in the dining room without any staff present to supervise. The fall was unwitnessed by staff, although other residents were present and called for help. The facility's fall coordinator confirmed that R84 requires supervision and touch assistance for mobility and that staff should be within eye distance to monitor and intervene as needed. The absence of staff in the dining room at the time of the fall suggests a failure to adhere to the facility's policy of providing adequate supervision for high-risk residents. Both residents had documented high fall risk scores on the Morse Fall Scale, and their care plans indicated the need for supervision and assistance to prevent falls. The facility's policies emphasize the importance of resident safety and supervision, yet the incidents involving R50 and R84 highlight deficiencies in implementing these policies effectively. The lack of staff presence and communication regarding the incidents contributed to the failure to prevent these falls, which could have been avoided with proper supervision and adherence to care plans.
Failure to Administer Pneumonia Vaccines Upon Admission
Penalty
Summary
The facility failed to adhere to its policy of offering pneumonia vaccines to residents prior to or upon admission. This deficiency was identified during a review of records and interviews, affecting three residents out of a sample of 25. The residents involved were an elderly male with chronic obstructive pulmonary disease, anemia, and other conditions; an elderly female with stage 4 chronic kidney disease, diabetes, and other health issues; and another elderly male with adult failure to thrive, muscle wasting, and dementia. None of these residents had documentation in their electronic health records indicating that they had been offered or administered the pneumonia vaccine upon admission. Interviews with facility staff revealed that the Infection Preventionist acknowledged the residents had consented to the vaccine but had not yet received it. The Director of Nursing stated that the facility's procedure is to offer the vaccine upon admission, obtain consent, and then order the vaccine from a contracted pharmacy, which should arrive within three days. However, the vaccines had not been administered as expected. The facility's policy, dated October 2022, mandates that all residents be assessed for eligibility and offered the pneumococcal vaccine series upon admission unless contraindicated or previously vaccinated, with detailed documentation required for those who receive the vaccine.
Failure to Assess and Prevent Falls in High-Risk Resident
Penalty
Summary
The facility failed to appropriately assess and evaluate a resident who was at high risk for falls, leading to a significant injury. The resident, a female with a complex medical history including schizophrenia, bipolar disorder, and seizures, had previously fallen on two occasions. Despite these incidents, the facility did not conduct fall risk assessments after the falls on February 19th and April 18th, 2024, nor did they update the resident's care plan with new interventions to prevent further falls. On May 21st, 2024, the resident was sent to the hospital with a diagnosis of a fracture of the cervical vertebrae and an acute subdural hematoma. Prior to this, the resident had refused to go to the hospital after a fall in April, despite sustaining a head injury. The facility's nurse practitioner noted a new hematoma on the resident's head on the day she was sent to the hospital, but no one knew how the injury occurred. The resident was described as impulsive and not adhering to fall precautions, yet no additional measures were implemented to address these behaviors. Interviews with facility staff revealed that the resident was considered a high fall risk upon admission, but the necessary assessments and interventions were not completed following her falls. The Director of Nursing acknowledged that more specific interventions could have been added after the resident's fall in April. The facility's policy on falls and fall risk management requires re-evaluation and potential changes to interventions if a resident continues to fall, which was not adhered to in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its policy for reporting injuries of unknown origin, as evidenced by the case of a resident who sustained a new hematoma on her head. The resident, who has a complex medical history including schizophrenia, bipolar disorder, and seizures, was found with a new hematoma on her forehead by a nurse practitioner and a licensed practical nurse during an assessment. Despite the facility's policy requiring immediate reporting of suspicious bruises or injuries of unknown origin, the administrator was not informed of the new injury, and it was not reported to the state agency within the required 24-hour timeframe. The resident had a history of falls, with documented incidents occurring earlier in the year. On the day the new hematoma was discovered, the resident was sent to the hospital due to altered mental status and low oxygen saturation, where she was diagnosed with a fracture of the cervical vertebrae. The facility's abuse prevention program mandates that any injury of unknown source be reported and documented, but this protocol was not followed in this instance, leading to a deficiency in the facility's compliance with its own policies and state regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ryze At The Ridge | 0.3 mi | — | 1 | 0 |
| Elevate Care Chicago North | 0.9 mi | — | 5 | 0 |
| Westwood Vlge Nrsg And Rhb Ctr | 0.9 mi | — | 2 | 0 |
| Atrium Health Care Center | 0.9 mi | — | 2 | 0 |
| Clark Manor | 1 mi | — | 1 | 0 |
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