Warren Barr Gold Coast

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure adequate supervision and assistance during toileting hygiene for one resident (R2) out of three residents who required maximum to dependence assistance and contact support during toileting hygiene. This failure resulted in R2 rolling off the edge of the bed and falling to the floor.

Inspectors wroteBased on interview and record review, the facility failed to administer medication as ordered by the physician and failed to notify the physician of missed doses for one resident (R3) out of three residents reviewed for improper nursing care. Findings Include:R3's clinical records show R3 was admitted in the facility on 3/18/26 and discharged to the hospital on 4/18/26. R3's included diagnoses but not limited to Bipolar Disorder, Cerebral Infarction, Gastrostomy Status, Type 2 Diabetes Mellitus, Cognitive Communication Deficit, and Severe Protein-Calorie Malnutrition. R3's Order Summary Report includes the following medication order: Piperacillin Sod Tazobactam Solution Reconstituted 3 0.375 GM. Use 3.375 grams intravenously every 8 hours for infection for 7 days, ordered on 4/13/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was visibly posted for two residents requiring Enhanced Barrier Precaution; and failed to ensure that staff had Personal Protective Equipment (PPE) bin available for staff use. These failures affected two residents (R5 and R10) and has the potential to affect all 35 residents residing on the third-floor unit.

Inspectors wroteBased on interview and record review, the facility failed to provide specialized rehabilitative services per resident's physician order for one (R13) resident out of five residents reviewed for quality of care in a total sample of 16 residents. This failure has the potential to affect a resident from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional and psycho-social well-being.

Inspectors wroteBased on interview and record review the facility failed to complete neurological monitoring following an alleged head injury. This failure affected one resident (R1) in the sample of five residents reviewed for accidents and incidents.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to provide sufficient nursing staff (Registered Nurses/Licensed Practical Nurses) to the third and fourth floors. This failure has the potential to affect 71 residents residing on these floors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer resident's prescribed medications in a timely manner according to the physician orders. This failure affects 29 (R5, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35) residents in a total sample of 35 residents.

Inspectors wroteBased on interviews and records review, the facility failed to provide one (R4) resident of three reviewed with access to medical records in a total sample of six.

Inspectors wroteBased on interview and record review the facility failed to assure that one resident (R2) with intact skin, received the necessary treatment and services to prevent the development pressure wounds. This failure resulted in R2's development and worsening of two pressure ulcers, requiring hospitalization for wound infection and surgical intervention of wound.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve adequate food portions as documented on the menu and meal tickets. This failure has the potential to affect all 213 residents receiving food prepared in the facility's kitchen. Findings Include: On 02/23/25 at 8:45 AM, surveyor entered kitchen and observed the breakfast tray line still in progress. Observed a 4-ounce ladle being used to portion out the grits and oatmeal for all of the diet (regular, ground and pureed) and a number 12-scoop used to portion out pureed toast. On 02/23/25 at 8:50 AM, V14 (Cook) stated she is the one who sets up the tray line with the serving utensils which should be used to portion out the resident's food. V14 stated she looks at the meal tickets to determine the correct portion sizes to be served. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were notified, invited, and engaged to attend meaningful activities that incorporate residents' interests for 2 (R1, R4) out of 3 residents reviewed for residents' rights. Findings Include: On 2/23/25 at 8:55 AM, R1 was observed lying in bed alert and able to verbalize needs. R1 is blind and can't read. R1 can only see contrast and forms. R1 stated R1 would like to go to activities like bingo but staff does not tell R1 of what activities are going on in the facility each day. R1 stated that R1 also likes to go to church and listens to gospels. R1 stated staff used to hand out a sheet about activities, but it's been a while since R1 gotten one. R1 stated R1 does not know what other things are going on in the facility for today. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food storage practices as evidenced by a.) food not properly labeled, b.) food not properly stored, c.) equipment used for food preparation not properly sanitized, and d.) dishwasher temperatures not reaching at least 160 degrees Fahrenheit during the wash/rinse cycle. These deficient practices have the potential to affect all 183 residents receiving food prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (R377) had a functioning call light within reach, and ensure two residents (R14, R24) had access to the call light system in a total sample of 35 residents reviewed.

Inspectors wroteBased on interview and record review the facility failed to complete a resident's assessment and transmit data to the CMS (Centers for Medicaid and Medicare) system within 14 days after resident discharged from the facility for one (R151) resident reviewed in a sample of 35 residents.

Inspectors wroteBased on interviews and record review, the facility failed to refer one resident (R143) of seven residents reviewed with serious mental disorders for a Preadmission Screening and Resident Review (PASARR) level 11 assessment in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure ulcer preventative measures were accurately applied for three residents (R3, R26 and R49) in a sample of 35 residents reviewed for pressure ulcer.

Inspectors wroteBased on observations, interviews and records review, the facility failed to keep record of receipt and disposition of one controlled drug in sufficient detail to enable an accurate reconciliation in a medication cart that serves 23 residents on the 8th floor and failed to keep an account of all controlled drugs is maintained and accurate for three (R61, R117, R429) in a sample of 35 reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for two (R89, R427) of six residents reviewed for medication administration resulting in a 6.67% error rate in a sample of 35 reviewed.

Inspectors wroteBased on interviews and review of records the facility failed to provide planning of care related to oral/dental care for 1 (R1) of 3 residents reviewed for improper nursing care.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement fall precaution interventions for two (R2, R4) residents identified as a fall risk out of three residents reviewed for fall precautions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that a dependent resident's call device was answered promptly for 1 of 9 residents (R3) reviewed for care.

Inspectors wroteBased on interview and record review, the facility failed to administer medication per physician parameters prior to hemodialysis which affected one resident (R2) in the total sample of 10 residents reviewed for improper nursing care.

Inspectors wroteBased on interviews and record review, the facility failed to immediately transfer a resident (R2) on blood thinning medication to a local hospital for emergent services after a fall with head injury. This failure affected one resident (R2) of three reviewed for falls and as a result, there was a delay of 39 minutes in R2 receiving treatment for an acute subdural hematoma and subsequently died nine days later.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and homelike environment for the residents. This failure applies to all 188 residents in the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that fall care plan and interventions were updated and in place for one resident (R4) who has history of falls and is recognized as a high fall risk patient. This failure has the potential to affect 6 other individuals classified as 'High Fall Risk' patients.

Inspectors wroteBased on interviews and record review, the facility failed to immediately transfer a resident (R2) to a local hospital for emergent services after a fall with head injury. This failure affected one resident (R2) of three reviewed for falls and as a result, there was a delay of 39 minutes in R2 receiving treatment for an acute subdural hematoma.

Inspectors wroteBased on observation, interview, and record review, a facility staff failed to wear the proper personal protective equipment while providing direct care for one resident (R4) on isolation. This failure has the potential to affect all 188 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate use of personal protective equipment (PPE) was worn by staff caring for three residents(R6, R7, R8) with potential and known infectious disease. This failure has the potential to affect 77 residents residing on the fifth and seventh floor in facility.

Inspectors wroteBased on observation, interview and record review the facility failed to keep 4 residents (R30, R94, R97, R274) rooms clean. This failure has the potential all the residents residing on the 7th floor. Findings including: R30 has a diagnosis of but not limited to Radiculopathy, Major Depressive Disorder, Chronic Embolism and Thrombosis of Deep Veins of Left Lower Extremity and Heart Failure. R30 has a Brief Interview of Mental Status score of 15. R94 has a diagnosis of Multiple Sclerosis, Spinal Stenosis, Hyperlipidemia, Anxiety Disorder, Hypertension and Venous Insufficiency. R94 has a Brief Interview of Mental Status score of 15. R97 has a diagnosis of Folate Deficiency Anemia, Vitamin D Deficiency, Seizures, Acute Embolism and Thrombosis of Deep Vein of Right Lower Extremity, Unsteadiness on Feet, and Retention of Urine. R97 has a Brief Interview of Mental Status score of 11. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store food 6 inches off the floor in effort to prevent foodborne illness and failed to ensure the dish washer machine sanitized the dishes at the proper temperature. These failures have the potential to affect all 182 residents receiving oral nourishments in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly log refrigerator temperatures for resident's personal refrigerators, ensure safe temperatures for resident's personal refrigerators, remove food items from the resident's personal refrigerators by the expiration date for six residents (R6, R29, R23, R58, R43 and R62) and check for a working thermometer in a resident's personal refrigerator(R6). These failures have the potential to affect all 56 residents in the sample.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that a call light was accessible for one visually impaired resident (R43), from a sample of 60 residents reviewed for call devices.

Inspectors wroteBased on observation, interview and record review the facility failed to provide incontinence care to one resident (R30) out of a sample of 60 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have low air loss mattress at the correct weight setting for a resident with pressure ulcer who is at high risk for further pressure ulcers. This failure affected one resident (R25) of two residents, reviewed for pressure ulcer prevention interventions, in a total sample of 60 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen tubing per the facility policy. This failure affected one resident (R118) reviewed for oxygen equipment, in a total sample of 56 residents.

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall by not implementing appropriate fall interventions for a dependent confused resident (R4) with a language barrier and history of falling. The facility also failed to follow fall prevention intervention to prevent a fall incident, to ensure that the appropriate side rails were used, and to ensure that the use of side rails was evaluated first before utilizing to a resident (R5) who was confused and at high risk for falls. These failures affected 2 (R4, R5) out of 3 residents reviewed for accidents and incidents. R4 had an unwitnessed fall incident. R4 was observed by facility staff on the floor by R4's bed and sustained a fracture of left hip transverse proximal femoral basicervical fracture with medial impaction. R5 had an unwitnessed fall incident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medications for two (R9, R10) residents reviewed for medications administration. This failure has the potential to affect R9 and R10's health.

Inspectors wroteBased on interview and record reviews, the facility failed to complete quarterly restorative assessments that detail the progress or lack of progress in the restorative services for 5 of 5 residents(R8, R19, R21, R26, R37) reviewed for limited range of motion and/or restorative services in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to properly discard a multi-dose insulin 28 days after opening for 1 resident (R65); to properly date opened multi-dose inhalers for 2 residents (R65, R101); and to properly date opened multi-dose insulin vials for 4 residents (R9, R79, R145, R150) from three of six medication carts inspected for medication storage and labeling.

Inspectors wroteBased on observation, interview and record review, facility failed to follow their call light policy to ensure call lights are placed within reach for 1 resident (R124) reviewed for call lights in a final sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 staff members are present during a resident transfer with a mechanical lift for 1 of 8 residents (R83) reviewed for safe transfers. Findings Include: R83's Face Sheet documents resident is a [AGE] year old with diagnoses including but not limited to: EXTENDED SPECTRUM BETA LACTAMASE (ESBL) RESISTANCE, UNSPECIFIED ABNORMALITIES OF GAIT AND MOBILITY, UNSPECIFIED LACK OF COORDINATION, MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED, OTHER LACK OF COORDINATION, PARAPLEGIA, UNSPECIFIED, PERSONAL HISTORY OF OTHER VENOUS THROMBOSIS AND EMBOLISM, MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION, SECONDARY MALIGNANT NEOPLASM OF BONE. Minimum Data Set Section G (MDS) (dated 12/05/2022) scored R2 as (4) total dependence and a (3) requiring 2-to-3-person physical assistance for transfers. [...]

Inspectors wroteBased on interview and record review, facility failed to follow their policy and procedure to ensure the use of indwelling catheter was assessed at least quarterly to determine if use is still justified for a resident with history of Urinary Tract Infection. This failure has the potential to affect 1 of 2 residents (R96) reviewed for Indwelling Catheter Care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one resident received physician ordered oral nutritional supplements. This failure affected 1 of 4 residents (R103) reviewed for nutritional supplements.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician order for administering the correct ordered amounts of enteral tube feeding and enteral water flushing for 1 of 2 residents (R93) reviewed for enteral tube feeding management.

Inspectors wroteBased on record review and interview, the facility failed to develop a person-centered dementia care plan for 1 of 1 resident (R26) reviewed for dementia care in a sample of 35.