Warren Center for Rehabilitation and Nursing

Inspectors wroteBased on record review and interviews conducted during the survey, the facility did not ensure each resident was treated with respect, dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life for three (3) (Resident #'s 6,# 10 and #52) of twenty-three (23) residents reviewed. Specifically, (a.) Resident #6 was placed in their room in the active dying phase without staff contact or interventions. (b.) Resident #10 was observed using a bedside commode without privacy curtain closed; and (c.) Resident #52 asked to use the bathroom and was told to soil their brief because staff had no time to toilet them.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure residents were able to exercise the right to self-determination, including making choices regarding daily routines, meals, and living environment, for two (2) (Resident #9, Resident #47, and Resident #71) of three (3) residents reviewed for choices. Specifically, (a.) Resident #9 was not permitted to return to bed upon request and was not provided with meaningful meal choices; and (b.) Resident #47 was expected to have moved from their room without consent despite refusal.

Inspectors wroteBased on record review and interviews during a survey, the facility failed to ensure residents were free from abuse, neglect, misappropriation of resident property for four (4) (Resident #6, #33, # 85 and #87) of five (5) residents reviewed. Specifically, (a.) Resident #6 was abused when touched inappropriately by Resident #33, when Resident #33 had known inappropriate sexual behaviors. (b.) Resident #85 was neglected when rolled out of bed onto the floor during care provided by a single caregiver on 5/04/2025, when Resident #85 was care planned for a two-person caregiver for bed mobility. (c.) On 7/26/2025, Registered Nurse #2 accused Resident # 87 of consuming a crushed narcotic when the nurse left the room. Resident #87 denied taking it and felt humiliated and stated they were not given pain medication as prescribed. The nurse documented the medication was given. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure that resident environments were as free from accidents or hazards as possible for three (3) (Resident #'s 19, 31, 71) of six (6) residents reviewed for accident and hazards. Specifically, (a.) for Resident #19, medications were observed at their bedside; (b.) Resident #31 was at risk for falls and a fall/tripping hazard was observed in their room; (c.) Resident #71 had medications in their room that were not ordered by a physician.

Inspectors wroteBased on observations, interviews, and record review during a survey, the facility failed to ensure licensed nursing staff, including nursing leadership, possessed the competencies and skill sets necessary to provide care and oversight for residents requiring specialized clinical services and safe medication practices. This included failure to ensure staff competency in respiratory/tracheostomy care for two of two (2) residents reviewed for respiratory care (Residents #7 and #87), and for one (1) resident reviewed related to a medication-related incident (Resident #87). The Director of Nursing failed to investigate a serious medication-related incident, failed to ensure physician notification of a narcotic discrepancy in accordance with facility policy, and failed to implement or maintain disciplinary action for unsafe nursing practice. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) of two (2) medication carts (South Unit) and one (1) of one (1) (South Unit) medication room reviewed. Specifically, there were three (3) unopened insulin pens delivered 2 days prior that state keep refrigerated until opened. Two (2) opened insulin kwik pens with no open and or expiration dates. One (1) inhaler with no open and no expiration dates, One (1) inhaler with no expiration date. One (1) box of hard candy in bottom of the medication cart and the medication room narcotic lock box #2, inside lock was left open.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure residents could safely self-administer medication when clinically appropriate for two (2) (Resident #'s 19 and 71) of two (2) residents reviewed for medication administration. Specifically, (a.) Resident #19 had medications in their room, but the resident was not assessed for their ability to self-administer medication, and there was no documentation from the physician or in the resident's care plan that they could self-administer medications; and (b.) Resident #71 had medications in their room that were not ordered by a physician and they reported taking/using the medications.

Inspectors wroteBased on observations, record review, and interviews during the survey, the facility did not ensure a safe, clean, comfortable, and homelike environment for two (2) (Resident #10, #41 and #58) of four (4) residents reviewed. Specifically, Resident #10 had a bedside commode with soiled tissue on the floor next to their bed and commode. There were landing strips at the bedside with copious dried brown material consistent with fecal material. Resident #58 was the roommate to Resident #10 and stated they were subject to soiled materials at the entrance of their room and often had to call for assistance for Resident #10 when they soil the floor.

Inspectors wroteBased on record review and interviews during a survey, the facility did not ensure that all alleged violations involving neglect were reported within 24 hours after the allegation was made for one (1) (Resident #85) of five (5) residents reviewed for abuse. Specifically, Resident #85 was neglected when rolled out of bed onto the floor during care provided by a single caregiver on 5/04/2025; Resident #85 was care planned for a two-person caregiver for bed mobility. The incident was not reported to the New York State Department of Health. Findings Include: Cross reference to F-600The Facility's Policy and Procedure Titled Accident-Incidents reviewed 6/01/2024, documented: 12. [...]

Inspectors wroteBased on record review and staff interviews conducted during a survey, the facility failed to ensure that a resident's discharge was appropriate based on the resident's clinical status at the time of discharge (because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility) for one (1) (Resident #83) of three (3) residents reviewed. Specifically, Resident #83 had diagnoses including chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make It difficult to breathe) and was discharged to home despite waiting on results of a lab test: coronavirus disease (COVID)/influenza (flu) swab taken days prior to discharge. The facility did not obtain or review results of diagnostic testing (COVID/Flu) ordered prior to discharge. [...]

Inspectors wroteBased on interview and record review conducted during a survey, the facility failed to ensure that Comprehensive Care Plans were reviewed and/or revised to reflect the resident's current condition for one (1) (Resident #85) of six (6) reviewed for accidents. Specifically, for Resident #85, there was no documented evidence that the Comprehensive Care Plan was reviewed and/or revised after a fall that occurred on 5/04/2026.

Inspectors wroteBased on observation, interview, and record review during a survey, the facility failed to ensure necessary services were provided to maintain good nutrition and activities of daily living for 1 (one) of 4 (four) residents reviewed for activities of daily living care (Resident #41). Specifically, For Resident #41, the facility failed to provide appropriate assistance and cueing during meals as this resident required support when eating.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 6 and 9) of two (2) residents reviewed. Specifically, (a.) Resident #6 was nearing end of life and was not provided with any stimulation or one-to-one interaction or visits; and (b.) Resident #9 stated they felt like a prisoner and were not provided with time outdoors per their preference. Additionally, perfume sampling was included on the activities agenda on 4/14/2026 and could have caused adverse reactions for some residents. Findings Include: [...]

Inspectors wroteBased on observations, interviews, and record review during a survey, the facility failed to ensure respiratory care services were provided in accordance with professional standards for 2 of 2 residents (Resident #87 and #7) with a tracheostomy (surgical opening in the neck necessary for breathing). The facility failed to support a clean environment or the maintenance of the availability of required tracheostomy supplies. The facility failed to ensure the availability of an Ambu bag (rescue breathing device) at the bedside for residents with a tracheostomy. The facility had not ensured staff consistently performed, documented, and demonstrated competent tracheostomy care in accordance with facility policy. This deficient practice had the potential to result in ineffective airway management, increased risk for infection, and compromised respiratory status. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial wellbeing for two (2) (Resident #'s 6 and 9) of two (2) residents reviewed. Specifically, (a.) Resident #6 was nearing end of life and was not provided with any stimulation or one-to-one interaction or visits; and (b.) Resident #9 stated they felt like a prisoner and were not provided with time outdoors per their preference. Additionally, perfume sampling was included on the activity's agenda on 4/14/2026 and could have caused adverse reactions for some residents. Findings Include: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility did not ensure that its medication error rate did not exceed 5 percent for two (2) (Resident #9 and #22) of seven (7) residents observed during medication administration with 25 observations. This resulted in a medication error rate of 24 percent.

Inspectors wroteBased on observation, record review and interviews conducted during a survey, the facility did not ensure residents were free from significant medication errors for one (1) (Resident #9) of seven (7) residents reviewed, for a total of twenty-five (25) observations. Specifically, Resident #22 had a medication dose discrepancy for an anti-seizure medication that was not addressed for twenty-one (21) days after the order was changed.

Inspectors wroteBased on observation, interview, and record review during a survey, the facility failed to ensure food brought into the facility from outside sources was stored, labeled, and maintained in accordance with professional standards of practice to prevent contamination and foodborne illness, for two (2) of two (2) residents reviewed (Resident #2 and Resident # 86). Specifically, Perishable food items (milk, mayonnaise and lettuce) were observed stored in a resident's window were unrefrigerated and not maintained at a safe temperature and were not managed in accordance with facility policy. Findings Include: The facility policy titled Food - From Outside, revised 07/12/20, documented all perishable foods must have been refrigerated, labeled, and discarded within 48 hours, and that foods left without temperature control for more than 2 hours were to have been discarded. [...]

Inspectors wroteBased on interview and record review conducted during the survey, the facility did not ensure the facility-wide assessment was updated to determine what resources were necessary to ensure residents were able to maintain or attain their highest practicable physical, functional, mental, and psychosocial well-being and meet current professional standards of practice. Specifically, the Facility assessment dated [DATE], documented under Special Treatment and Conditions, the number/average or range of residents were zero (0). The facility actually had one (1) active (#7) and one (1) discharged (#87) tracheostomy resident at the time of review.

Inspectors wroteBased on observation, interview, and record review conducted during a survey, the facility failed to maintain records in accordance with accepted professional standards and practices, as accurately documented and completed for two (2) (Resident #'s 65 and 84) of 23 residents reviewed. Specifically, (a.) for Resident #65, there was no documentation in the electronic medical record that a verbal order was received from the Medical Provider to schedule the resident's pain medication and no documentation that the nurses administered the resident's pain medication after the order was changed on 4/14/2026; and (b.) for Resident #84 there was missing documentation in the Certified Nurse Aide tasks record that care was provided to the resident. Additionally, the narcotic book shift count for the south unit was signed in advance.

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility did not ensure an infection prevention and control program was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (2) of two (2) residents reviewed for infection control practices (Resident #2 and Resident #7). Specifically, the facility did not ensure proper storage of perishable food items to prevent bacterial growth and potential foodborne illness and did not ensure staff adhered to infection control practices including hand hygiene, use of personal protective equipment, and appropriate handling of contaminated equipment.

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #s NY00337932 and NY00340604), the facility did not ensure a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 3 (Resident #s 1, 2, and 3) of 3 residents reviewed. Specifically, the facility did not ensure it revised the residents' care plan to include A) Resident #1's five (5) falls that occurred from 1/09/2024 to 4/25/2024, B) Resident #2's incident of alleged sexual abuse that occurred on 4/18/2024, and C) Resident #3's fall that occurred on 4/7/2024. This is evidenced by: The Policy and Procedure titled, Care Plans - Comprehensive, last revised 10/2019, documented assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition change. Resident #1: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00331618), the facility failed to ensure residents were free from neglect. Specifically, Certified Nurse Aide #1 did not follow Resident #3's care plan which included that the resident required physical assistance from two nursing staff to safely complete bed mobility. On 1/15/2024, Certified Nurse Aide #1 attempted to roll the resident while they were in bed without assistance from another nursing staff member. Subsequently, the resident fell onto the floor and sustained fractures to both of their legs. This resulted in actual harm that was not immediate jeopardy for Resident #3. This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey conducted from [DATE] through [DATE], the facility did not ensure drugs and biologicals used in the facility were stored, and labeled in accordance with currently accepted professional principles, on 2 of 4 medication carts. Specifically, the facility did not ensure medications (floor stock bottle of Colace) on 1 of the 2 medication carts on the North/East (NE) Unit, and medications (opened insulin pens and an unrefrigerated bottle of insulin) on the South/West (SW) Unit were stored in accordance with facility policy and accepted professional standards. This was evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 10/31/2023 through 11/06/2023, the facility did not ensure food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in the main kitchen. Specifically, two (2) of 3 food temperature thermometers were not calibrated to 32 degrees Fahrenheit (F) when tested in a standard ice-bath method; the thermometers registered 37F and 37F; the slicer, microwave oven, kitchen door, dining room, wall around the keypad from the dining room, and mop room floor were soiled with food particles, and/or dirt: and the facility did not have the correct test kit to check the concentration of sanitizing solution used to manually sanitize food contact surfaces. This was evidenced as follows: [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure comprehensive person-centered care plans were developed, and implemented for 2 (Resident #'s 5, and #47) of 2 residents reviewed for Comprehensive Care Plans (CCP). Specifically, for Resident #5, the facility did not ensure oxygen (O2) was being provided at 2 liters via nasal cannula (2LNC) as ordered by the physician between 10/31/2023 through 11/02/2023; and for Resident #47, a pillow was not placed under their left side while in bed to discourage them from leaning on 10/31/2023, 11/02/2023, and 11/03/2023. This was evidenced by: [...]

Inspectors wroteBased on observation, record review and interview during the recertification and abbreviated survey (Case #NY00261136) the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs for 7 (Resident #'s 2, 10, 40, 44, 71, 220, and 272) of 22 residents reviewed for Comprehensive Care Plans (CCPs). Specifically, for Resident #2, the facility did not ensure a care plan was developed to address the resident's dental care; for Resident #10, did not ensure the CCP for wound care and pain management was implemented, and ensure the CCP for ADL care had resident specific interventions; [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #'s 10, 19, and #44) of 5 residents reviewed for ADLs. Specifically, for Resident #10, the facility did not ensure the resident was provided assistance necessary to maintain good personal hygiene daily or was consistently transferred out of bed per resient prefernce; for Resident #19 did not ensure the resident, who was unable to carry out ADLs, received weekly showers to maintain good personal hygiene; and for Resident #44, did not ensure the resident, who was unable to carry out ADLs, received peri care daily with morning and evening care. This is evidenced by: [...]

Inspectors wroteBased on record review and interview during a recertification survey and abbreviated survey (NY00281118) on 8/16/2021, the facility did not ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #s 4 and 47) residents of 22 residents reviewed for Quality of Care. Specifically, for Resident #4, the facility did not ensure that physician orders for a urinalysis and a urine culture and sensitivity were obtained from 7/24/21 through 7/30/2021 when the resident was transferred to the hospital for a change in condition and diagnosed with a urinary tract infection. For Resident #47 the facility did not ensure that physician orders for the application of [NAME] wraps and protective heel boots to the resident's right lower extremities was implemented. This was evidenced by: [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not maintain equipment in a clean and sanitary manner in accordance with professional standards for food service safety. Food preparation and serving areas are to be kept in good repair and equipment is to be kept clean. Specially, food and non-food contract surfaces were not kept clean and/or in good repair. This is evidenced as follows. The main kitchen and kitchenettes were inspected on 09/08/2021 at 9:15 AM. In the main kitchen the meat slicer, can opener, stove top, oven, food preparation table, electrical outlets under the food preparation tables, and walls behind the grill line and the ice machine were soiled with grease or food particles, and the gasket on the door of the ice machine was ripped. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification and abbreviated surveys (NY00261136, NY00281118), the facility did not ensure a quality assurance and performance improvement (QAPI) program that put forth good faith attempts to identify and correct quality deficiencies. [...]

Inspectors wroteBased on observations, record reviews and interviews during a recertification survey, the facility did not ensure 1 (Resident #63) of 4 residents reviewed were treated with dignity and respect in an environment that maintained or enhanced their quality of life. Specifically, for Resident #63, the facility did not ensure the resident was treated with dignity and respect when staff talked on personal cell phones and used inappropriate language while providing personal care and while in hallways on the unit. This is evidenced by: The Policy and Procedure (P&P) titled Quality of Life-Dignity dated 9/2019, documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice for 1 (Resident #10) of 4 residents reviewed for pressure ulcers. Specifically, for Resident #10, the facility did not ensure wound care was provided per physican orders and per professional standards of practice. This is evidenced by: Resident #10: Resident #10 admitted to the facility with diagnoses of osteomyelitis of sacral area, pressure ulcer of the sacral region, and pressure ulcer of the right hip. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure the resident's environment remained as free of accident hazards as was possible for 1 (Resident #2) of 5 residents reviewed for accidents. Specifically, for Resident #2, the facility did not ensure the resident's fall risk was reassessed and the root causes of the fall were determined after the resident, who had previously fallen multiple times, fell and sustained a skin tear to the right cheek requiring steri-strips (thin adhesive bandages) at 2:18 AM on 9/5/2021. This is evidenced by: Resident #2: Resident #2 was admitted to the facility with the diagnoses of anxiety disorder, psychotic disorder, and vascular dementia. [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure the medication regimen for one (Resident #272) of six residents reviewed for unnecessary medication, were free from unnecessary medication. Specifically, for Resident # 272, the facility did not ensure the resident's medical record included a clinical indication to support the use of an opioid pain medication (Oxycodone) was adequately documented and included documentation to support an increase in the frequency of Oxycodone (pain medication) from three times a day to four times a day. This is evidenced by: Resident #272: This resident was admitted to the facility with diagnoses of dementia without behavioral disturbance, anxiety, restlessness and agitation and aphasia. [...]

Inspectors wroteBased on interviews and record reviews during a recertification survey, the facility did not ensure each resident's drug regimen was free from unnecessary psychotropic drugs for one (Resident #272) of six residents reviewed for unnecessary medications. Specifically, for Resident #272, the facility did not ensure that non-pharmacologic interventions, documentation of behaviors, and effect of medication for an anti-anxiety medication were consistently documented in the medical record. Additionally, the facility did not ensure the resident's increase in lethargy and refusal to eat was documented in the medical record and reported to the MD after the resident received an increase in a psychotropic medication. [...]