Warren Barr North Shore

In the surveyor’s words

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

• Actual harm, isolatedF698Jun 3, 2026

  Based on observation, interviews and record review, the facility failed to ensure dialysis treatments were provided for a resident dependent on dialysis. This failure resulted in R107 having a change of condition and was hospitalized for bradycardia and hyperkalemia due to missed dialysis treatments requiring emergent hemodialysis. This applies to 1 of 10 residents (R107) reviewed for dialysis in the sample of 33. The findings include: R107's face sheet shows diagnoses including chronic kidney disease, end stage renal disease, dependence on renal dialysis, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarct affecting right dominant side and hypertension. […]

• Actual harm, isolatedF689Nov 26, 2024

  Based on interview and record review the facility failed to ensure a resident was repositioned safely. This failure resulted in R1 sustaining a intertrochanteric (thigh/femur/hip bone) fracture that required an open reduction surgery. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 12. The findings include: On November 23, 2024 at 1:08 PM, R1 stated, V11 Certified Nursing Assistant (CNA) came to her room to change her multiple times. She refused to have V11 change her because she felt like she was rough with her. She refused to be changed two times. The third time, V11 CNA told her she was going to get changed and threw her legs over the rail and she heard a pop. After that she had pain in her left leg. She stated, she (V11) would not listen to nothing. […]

• Actual harm, isolatedF684Aug 1, 2024

  Based on interview and record review the facility failed to provide ongoing assessments for a resident who had an injury of unknown origin on 7/3/24. R1 remained at the facility until he was sent to the emergency roiagnom on [DATE] for abnormal behavior. This failure resulted in R1 having a mildly impacted and angulated left femoral neck fracture and deep venous thrombosis for 1 of 3 residents reviewed for a change in condition in the sample of 6. The findings include: The Nursing Daily Evaluation dated 7/3/24 for R1 showed R1 was wincing when being changed. The nurse practitioner was notified. An order for an x-ray to both hips was received and completed. […]

• Actual harm, isolatedF689Mar 25, 2024

  Based on observation, interview, and record the facility failed to supervise a resident who was at risk for falls due to history of falls and failed to put specific fall intervention in place to prevent further falls, this failure resulted in R3 sustaining a nasal fracture and left forehead lacerations requiring stitches for 1 of 3 residents reviewed for falls in the sample of 6. The findings include: R3's face sheet show R3 is 76 y/o with diagnoses that include chronic venous hypertension, kidney failure and heart disease. R3's fall risk assessment dated [DATE] shows R3 is HIGH risk for falls. A Facility Reported Incident dated 3/22/24 (initial) show, At 1 pm, NOD (Nurse on duty) responded to a call for help from the room. […]

• Actual harm, isolatedF689Jan 24, 2024

  Based on observation, interview and record review the facility failed to ensure a mechanical lift (Hoyer) was used to safely transfer a resident to bed for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being sent to the hospital with a laceration to her right posterior thigh that required 9 stitches after being transferred with a sit to stand lift. The findings include: R1's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of end stage renal disease, lack of coordination, hypotension, dependence on renal dialysis, anemia, abnormalities of gait, abnormal posture and bradycardia. […]