Warren Barr Gold Coast

In the surveyor’s words

From the most serious findings on record at Warren Barr Gold Coast, in the surveyor’s own words.

• Actual harm, isolatedF686Mar 20, 2025

  Based 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. Findings include: R2's medical diagnoses include but are not limited to intraspinal abscess and granuloma, neuromuscular dysfunction of bladder, unsteadiness on feet, secondary malignant neoplasm of colon, neoplasm of unspecified behavior of endocrine glands and other parts of nervous system, essential hypertension. […]

• Actual harm, isolatedF684Dec 14, 2023

  Based 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. Findings include: According to Electronic Medical Record, R2 is [AGE] year old with diagnosis including but not limited to: Unsteadiness on feet, Lack of coordination, Venous Insufficiency, Chronic Venous Hypertension, Heart Failure and Unspecified Right Bundle- Branch Block. […]

• Actual harm, isolatedF689Oct 20, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF803Feb 24, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Dec 6, 2024

  Based 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. Findings include: On [DATE], at 10:15 AM, during initial kitchen tour with V21 (Dietary Manager), the following food items were found in the walk-in cooler: 1. […]