Warren Barr Lieberman

In the surveyor’s words

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

• Actual harm, isolatedF686Feb 24, 2023

  Based on observation, interview and record review the facility failed to provide an ongoing assessment, monitoring and reporting on skin/wound of resident who are at risk for skin impairment . This failure resulted to ( R1) worsening of current skin impairment (MASD- Moisture associated skin disorder) and developed new wound that the facility is not aware of; and to (R7) for developing necrotic tissues on right lower leg that facility is not aware of. The facility also failed to follow manufacturer recommendation regarding using of low air loss mattress avoiding multilayer linens over the mattress. The facility failed to implement care plan to enhance wound healing and prevent development of new skin impairment. […]

• Actual harm, isolatedF684May 17, 2022

  Based on interview and record review the facility failed to identify or have a treatment plan in place for a facility acquired venous stasis wound to right heel for 1 of 3 residents (R2) reviewed for skin assessments. This failure resulted in R2 being at the local hospital for a chronic treatment where the right heel ulcer was noted to be foul smelling with purulent drainage, and a black [CONDITION(S)] around it, R2 was diagnosed and treated with intravenous antibiotic for [CONDITION(S)] of the right heel at the local hospital. Based on interview and record review the facility failed to inform attending physician of resident's change in condition and failed to provide radiology services in a timely manner. This affected 1 resident (R13) of 3 residents reviewed for professional standards. […]

• Actual harm, isolatedF689May 17, 2022

  Based on interview and record review the facility failed to prevent an avoidable accident while allowing a resident identified to be a fall risk due to impaired mobility, to assist push another resident in a wheelchair on the nursing unit. This affected 1 of 3 residents reviewed for avoidable accidents. This failure resulted in R10 pushing R3 around the nursing unit where R3 fell from the wheelchair and went to the local hospital where R3 was diagnosed with comminuted sub capital fracture of the right femoral, and a minimally displacement of the left nasal bone inferiorly anteriorly, had a hemiarthroplasty to repair the right hip. […]

• Actual harm, isolatedF689Feb 18, 2022

  Based on interview and record review the facility failed to monitor and provide supervision for a resident known to be at risk for falls. This affected 1 of 4 (R5) residents reviewed for fall. This failure resulted in R5 falling and hitting his head requiring treatment at the local hospital for forehead laceration and a subdural hematoma. Findings include: On 2-18-22 at 9:37 AM, V2 (DON) said R5 is alert and oriented x 1. Unable to make needs known due to advanced dementia and Alzheimer's. R5 has poor safety awareness. R5 is a high fall risk due to unsteady gait, history of fall at facility, and history of dementia without behaviors. R5 requires close supervision due to history of falls, unsteady on feet, and requires redirection. R5 had an observed fall by CNA. […]

• No harm, potential for more than minimal, widespreadF880Dec 17, 2023

  Based on observation, interview, and record review, the facility failed to ensure infection control procedures were followed and implemented to prevent the spread and transmission of COVID-19 within the facility during a COVID outbreak. Facility staff failed to conduct proper hand hygiene, gowning and doffing, and proper wearing of PPE (Personal Protective Equipment) to contain the spread of infectious disease. This failure has the potential to affect all 231 residents currently residing in the facility. Findings include: At time of entrance, facility provided census indicating 231 residents currently in the facility. […]