Nursing Home Spotlight: Warren Barr Pavilion, Chicago, Illinois

Nursing Home Spotlight: Warren Barr Pavilion

Warren Barr Pavilion is a large 221 bed nursing home facility located in the near north side of Chicago.  According to the government’s Medicare website , the facility received only two out of five stars, which is a below average rating.  This is in large part to the facility’s high number of health deficiencies.  In the past year, the facility had eleven health deficiencies, which is higher than both the average health deficiencies for both nursing homes in Illinois and across the United States.  The facility’s most significant health deficiencies were improper care and services and risk of falls/accidents.

The nursing home has an obligation to provide a safe and secure facility for its residents and to provide proper care and supervision to maintain the health of its residents.  According to the survey reports, the facility received multiple violations for:

  • Failing to investigate injuries
  • Allowing residents to develop pressure sores
  • Discrepancies in prescribed feeding for a feeding tube
  • Improper resident supervision
  • Expired medication
  • Falling to correct fall hazards
  • Resident elopement
  • faulty alarms for residents with wandering tendencies
  • Dirt and debris in the facility

The numerous deficiencies reported in these surveys calls into question the ability of this facility to properly care for its residents.  The elderly are particularly vulnerable to improper care, which can lead to serious injury and even death.

Pressure sores are a very serious medical condition, especially for residents requiring prolonged bed rest, or with limited mobility and weakness.  Nursing home staff must regularly turn this bedridden group in order to ensure proper blood circulation. Federal regulations require nursing homes to provide residents proper treatment to prevent new pressures sores or heal existing pressure sores.

According to a recent survey at Warren Barr, one resident was admitted to the nursing home with Dementia with Depression and was dependent on staff for all activities of daily living.  The patient developed a Stage 1 pressure sore on the right buttock and had been placed in a chair without a pressure relieving device because the nurse did not notice the pressure sore.

Federal laws also require nursing homes to give each resident care and services to maintain the highest quality of life possible.  In the case of Warren Barr, the facility failed to meet this requirement when one patient had to wait nine days for treatment of a toe infection.  The facility waited until the podiatrist’s next scheduled facility visit, rather than calling the podiatrist’s office for immediate treatment.   The podiatrist stated that the facility should have called his office for an immediate visit to avoid/prevent complications, especially because the patient suffered from diabetes.

Survey results also demonstrate Warren Barr failed to follow its own abuse policy regarding investigation for an injury of unknown origin.  This investigation requirement is in place to prevent nursing home injury and abuse. Staff members failed to investigate an injury (skin tear on the leg) suffered by a resident with Dementia.  When questioned, the certified nurse aid was unable to provide more information about the skin tear.   Yet, no inquiry was made concerning this injury.

The elderly are particularly vulnerable to injuries resulting from falls.  As such, the nursing home must ensure that the nursing home area is free of accident/fall hazards.  During one site visit to Warren Barr, the facility failed to provide adequate supervision to a resident who required extensive assistance and had a doctor’s order for fall precautions.  On this occasion, the resident was left sitting nude on a toilet while a certified nursing assistant was getting the resident dressed.  The staff member accidentally locked the resident in the bathroom without any supervision, and the resident was left alone in the bathroom for three whole minutes while a key was located.  In other residents’ rooms, the inspector noticed old newspapers on top of the heater, expired drops of nasal drops, and a radio cord that created a potential tripping hazard.

Nursing homes are required to minimize the risk of resident elopement.  Warren Barr Pavilion failed to adequately monitor and supervise one resident suffering from Alzheimer’s and Dementia, who had been identified by the facility as an elopement risk because of a prior elopement incident.  As a result, the resident left the facility without being noticed by the staff despite wearing an electronic monitoring device.  The electronic monitoring device failed to activate/alarm when the resident passed through the sensor at the entrance of the building because of system malfunction.  Thankfully, the police were able to locate the resident only three blocks away from the facility.  Nonetheless, elopement is an extremely serious danger that puts the residents in immediate jeopardy.

The nursing home has an obligation to give proper treatment to residents with feeding tubes to prevent problems.  During one site survey, the nursing home failed to ensure that two of seven residents in the sample who were on feeding tubes received the correct type of formula and the correct amount of feeding as prescribed by the physician.   During the period of observation, two patients received significantly less formula than prescribed; each discrepancy was equivalent to over an hour of feeding time missed. This seemingly minor oversight, puts these residents at risk for malnutrition and dehydration.

Nursing homes have an obligation to prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.  On several occasions, the staff at Warren Barr Pavilion served food to patients that was not maintained at proper temperatures (hot foods are maintained at 135 degrees F).  During a residents interview, residents complained that food was often cold upon delivery.  A review of the resident council minutes showed that residents had been complaining about cold food for the past six months.  In addition, several family members had complained about the cold food.

This two-star rated facility has many deficiencies which might be a troubling sign that nursing home residents might not be receiving the proper care and attention they need and deserve.

For laws related to Illinois nursing homes, look here.


0 responses to “Nursing Home Spotlight: Warren Barr Pavilion, Chicago, Illinois”

  1. Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes

    Many nursing home residents require feeding tubes because of illness or weakness. In order to maintain a resident’s strength and health, a feeding tube can be used to either supplement eating by the mouth or completely replace a resident’s…

  2. Sister says:

    Until you have someone in there do you know what really goes on,,,,my family member was in there and i kept a close eye on him. I was going to make sure things didn’t happen to him or i was going to be on the phone with the attorney in a minute. The food was discusting that i wouldnt even feed to my dog. He had one time this red cabbage with just vingear poured over it, i would bring him food when i came up there. Meat if you want to call it meat, that was shredded. He had a sandwich and the meat like i said was shredded and it was about a teaspoon that was on there nothing else no lettuce , no tomato , no condientment. Like i said it wasn’t fited for a human i even went downstairs to ask who was the cook. He had what you call potroast it was a small amount of lunch meat for the roast a few veggies from a can and sauce that was jelled you could put up wallpaper with. He always said that breakfast was the best food of the day can’t mess up to much with that. So you see why i would watch out for him. My brother passed but i still hate that he was in there.

  3. You’ve got an excellent point about not truly understanding how facilities operate until you see them first-hand. Thank you for sharing your observations of the conditions at Warren Barr. Hopefully, others will take your observations into consideration when selecting a Chicago nursing home for their loved ones. Jonathan

  4. Robert G. Karlic Sr. says:

    I’m a 70 year old senior citizen. I had hip replacement surgery at Weiss Memorial Hospital about 3 years ago. At that time the surgery and follow rehab was amazing. This time August of 2011 the follow up was pathetic. After the surgery I had some complications. Weiss Hospital had NO follow up program there any longer. Not knowing anything about it I was sent to Warren Barr after this hip replacement. I was sent to Warren Barr by ambulance from I.C.U at Weiss Memorial Hospital in Chicago. About maybe 2 miles at a cost of $899.00. Talk about outrageous medical costs !!! The rehab care there was just okay. Not great just okay, about 1 hour in the morning and 1 hour in the after noon. Most of the nurses aid’s and nurses were really very sub standard except for a few. Who were excellent. The food there wasn’t fit for farm pigs. One day for dinner I received a hot dog with a stale bun and a scoop of mashed potatoes. With what was called a cup of soup. Pea’s / carrots / water and what tasted like a beef billion cube. It was so salty it wasn’t eatable. They served this soup for 3 days. What ever I selected on the menu’s I was given usually was not served. When I called their kitchen on 2 occasions over a 2 week period I was told the items I had chosen on the menu were never available. When I asked them one morning about my coffee I was told they couldn’t be bothered , that was up to the nurse. Bottom line is over all the surroundings were pleasant. Most of the aids hardly spoke English. And the food was the worse I’ve ever had in my life. And God knows I’m not a fussy eater. Normally I’m not a complainer…But just felt this needed to be said. I was only there about 10 days and still in a lot of morning pain. The hospitalization Blue Cross/ Blue Shield of Illinois refused to pay for any more.But by then I wanted out of there. Our medical system has turned to CRAP !!! Lets all thank the Republicans…Just my thoughts about this….

  5. Kelly says:

    My mother was a patient at Warren Barr this past May. It is a disgusting and dangerous place. The staff treats the residents and their family like we are prison inmates. It was a horrible experience.

  6. Mark Murphey says:

    Thank you for sharing your concerns. We are so sorry to hear that your experiences at Warren Barr did not meet your expectations.
    We think you will be pleased to note that significant changes have taken place at Warren Barr since the visits noted here. Most noticeably, Warren Barr is under completely new management.
    In addition there is a new administrative team on-site at Warren Barr, including an experienced and well-credentialed Director of Nursing and Administrator.
    Our new team is working diligently to address some of the issues addressed on this blog, and we look forward to returning the center to its prior standing as a leading provider of post-acute
    rehabilitative and long-term care in the Chicago market.
    We think you will also be pleased to note that we’ve made several strides in the right direction. Warren barr recently earned The Joint Commissions’s Gold Seal of Approval (TM) for accreditation. With Joint Commission accreditation, we are making a significant investment in quality on a day- to- day basis form the top down. We’ve also added a new transitional cardiac care program, made changes to our dining menu and invested significantly in staff training.
    We would sincerely appreciate the opportunity to speak with you directly. We truly believe that a “complaint is a gift” and an opportunity for us to learn more about how we can do better. We’d value your input. Please don’t hesitate to call me/our administrator Mark Murphey at 312-705-5100 if you would like to share additiional concerns. Thank you.

  7. Mark-
    Thank you for courteous response. I’m happy that such positive changes are taking place at your facility. You and your company should be commended for both recognizing these issues and taking corrective measures— particularly in a public forum.
    Best regards,

  8. Daughter of patient in Jan-Feb 2012 says:

    As of 2012 Feb the service is STILL horrible.
    Seriously, all that was written back a couple years ago even though they say it’s changed. It has NOT.
    I called Transitional Care Management, to let them know, that had I done more research (if you read the most negative reviews; that is an accumulation of what has happened.) we would have never put Mom in there for the rehab. Their name is connected with a malfunctioning facility. Please, pass on the word. I will not suggest this place to anyone. And will speak up if anyone asks.
    Perhaps they have changed in some way since this posting (which I highly doubt.) Contact the supervisor for that place first.

  9. Bjwilliams1998 says:

    I was at Warren Barr visiting my aunt.  She told me that she had to go to the bathroom and asked me to press her call button, which I did.  No response.  I could hear the beep from the nurses station because her room is nearby.  Finally, I walked out to the nurses station and there was a nurse standing there looking at something in a binder.  When I said, “Excust me”, she turned and was surprised to see me.  I told her that my aunt needed to use the bathroom.  The nurse for her room happened to be walking past on the opposite side of the hall and she told her that my aunt had to use the bathroom.  This is unacceptable that nurses ignore call lights!  What if it my aunt had been in her room alone?  How long would it have taken them to assist her? The food there is horrible!  I was there when my aunt was served dinner.  On her plate was a dry, leathery chicken breast on a hamburger bun, a hash brown patty and three cucumbers in a paper cup with some kind of white sauce.  Her menu said that she was supposed to have vegetables but food service did not bring any.  I went into the hall and asked the nurse about the vegetables and if she could have some mayonnaise for the chicken breast.  The food service person was still there.  He said that he noticed that there were no vegetables and that the kitchen did not have any! He gave me a packet of mayonnaise.  I put it on my aunts sandwich and she still could not eat it!   A family member is there every day and we  bring her something to eat because the food there is awful!  If you have a loved one in a nursing home, someone from the family should visit them each day.  Then the staff will know that they have an advocate and that they have to treat your loved one with dignity and respect! 

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