Warren Nursing & Rehab

Inspectors wroteBased on observation, closed medical record review, review of the facility water management plan and maintenance logs, review of the Centers for Disease Control and Prevention (CDC) guidance related to legionella, review of infection control tracking, and interviews with staff and representatives from the Local Health Department (LHD), the facility failed to develop, implement and follow a comprehensive and effective infection control/water management plan and remediation program to prevent the risk of legionella growth and spread in the water supply. [...]

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent and/or promote pressure ulcer healing. The facility failed to ensure pressure-relieving equipment was functioning as intended, failed to ensure nutritional interventions were initiated, and failed to ensure treatments were implemented and maintained as ordered to prevent the development and/or worsening of pressure ulcers for Residents #10, #11, #25, #27, #44, and #58. [...]

Inspectors wroteBased on medical record review, review of hospital records, interviews and review of facility policy, the facility failed to provide timely care and services to treat Resident #38's urinary tract infection (UTI). Actual harm occurred on 10/13/25 when Resident #38, who had a history of UTI and had been stating she felt like she had UTI symptoms of frequent urination and burning a couple days prior, was ordered a urine analysis (UA) test by Nurse Practitioner (NP) #842 to assess for UTI and that order was not entered into the physician orders until 10/15/25 by Licensed Practical Nurse (LPN) #341. On 10/16/25 Resident #16 was hospitalized prior to completion of the UA test, and Resident #38 was diagnosed at the hospital with altered mental status, acute UTI, bacteremia (bacteria in the blood) and acute kidney injury and was treated with intravenous (IV) antibiotics for the infection. [...]

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to maintain a sanitary garbage storage area. This had the potential to affect all residents. The facility census was 72.

Inspectors wroteBased on interviews, review of employee personnel files, and review of facility infection surveillance including infection control logs and maps, the facility failed to ensure the Infection Preventionist acquired their Infection Prevention Certificate prior to assuming the role as Infection Preventionist and failed to complete accurate infection control logs and maps. This had the potential to affect all residents in the facility. The facility census was 72.

Inspectors wroteBased on observation, record review, staff interviews and review of facility policy, the facility failed to maintain a safe, functional, sanitary and comfortable environment. This had the potential to affect all 72 residents.

Inspectors wroteBased on personnel record review, interview and document review, the facility failed to ensure complete orientation of 14 newly hired Certified Nursing Assistants. This had the potential to affect all residents residing in the facility. The facility census was 72.

Inspectors wroteBased on observation, interviews, record review, and review of maintenance documents and facility policy, the facility failed to maintain adequate room temperatures in the common area/dining room and resident rooms. This affected six residents (#15, #34, #48, #50, #52 and #69), and had the potential to affect 26 residents (#5, #6, #7, #8, #16, #23, #24, #26, #32, #36, #39, #43, #46, #47, #48, #51, #53, #56, #57, #59, #60, #66, #68, #69, #70 and #93) who used the common area/dining room . The facility census was 72.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure nutritional recommendations were implemented in a timely manner for Residents #11, #21, and #25. Additionally, the facility failed to meet estimated energy needs for Resident #2 who was dependent on enteral (tube) feeding for nutrition. Additionally, the facility failed to evaluate Resident #33 (who was identified to be a high nutritional risk) on a monthly basis. The facility identified 15 current residents who required enteral feeding. This affected five residents (#2, #11, #21, #25, and #33) of 13 residents reviewed for nutrition. The facility census was 72.

Inspectors wroteBased on record reviews, interviews, review of the dialysis agreement and facility policy review, the facility failed to maintain shared communication and collaboration with the dialysis clinic regarding dialysis care and services. This affected six residents (#02, #21, #29, #44, #63, and #67) of eight residents reviewed for dialysis and had the potential to affect six additional residents (#17, #90, #33, #10, #62, #71) identified by the facility as also receiving dialysis. The facility census was 72.

Inspectors wroteBased on observation, record review and interview, the facility failed to remove expired wound and tracheostomy care supplies and enteral feeding formula from storage to prevent usage and failed to securely store medications for Residents #30 and #51. This affected two residents (#30 and #51) and had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure sugar-free condiments were available in accordance with the planned consistent carbohydrate, limited concentrated sweets menu. This had the potential to affect 10 residents (Resident #17, #29, #32, #34, #36, #03, #05, #65, #68, #71) the facility identified as having a physician order for consistent carbohydrate, low concentrated sweets diet of 57 residents who received meals from the facility kitchen. The facility identified 15 residents (Resident #90, #18, #21, #22, #25, #27, #02, #10, #41, #42, #11, #58, #01, #62, #67) who did not eat by mouth (NPO). The facility census was 72.

Inspectors wroteBased on observation and interview, the facility did not serve food in a manner consistent with professional standards for food service safety. This had the potential to affect 35 residents (#3, #8, #9,#12, #13, #14, #16, #19, #23, #26, #28, #29, #30, #31, #32, #33, #34, #35, #37, #38, #44, #47, #48, #49, #51, #50, #55, #56, #57, #63, #64, #65, #66, #83, and #84) receiving meals from the second floor kitchenette out of 57 residents who received meals from the facility. The facility identified 15 residents (Resident #90, #18, #21, #22, #25, #27, #02, #10, #41, #42, #11, #58, #01, #62, #67) who did not eat by mouth (NPO). The facility census was 72.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure resident consents or declinations were obtained for influenza and pneumococcal vaccines, and the facility failed to document site of administration, lot number, and expiration dates for administered vaccines. This affected five residents (Resident #5, #20, #25, #29, and #38) of seven residents reviewed for vaccinations. The facility census was 72.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to ensure resident consent or declinations were obtained for COVID-19 vaccinations. This affected five residents (Resident #5, #20, #25, #29, and #38) of seven residents reviewed for vaccinations. The facility census was 72.

Inspectors wroteBased on observation, record review, interview, and review of facility policy, the facility failed to have call lights within reach for Resident #41, #50 and #56. This affected three residents ( #41, #50 and #56) of 72 residents observed for call lights. The facility census was 72.

Inspectors wroteBased on record review, staff interviews and facility policy review the facility failed to ensure resident advanced directives (code status) were accurate. This affected one resident (#6) of 53 residents reviewed for the annual survey. The facility census was 72.

Inspectors wroteBased on record review, interview and policy review the facility failed to ensure they notified the emergency contact of a resident's change in condition. This affected one resident (Resident #38) of one resident reviewed for notification of change. The facility census was 72.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement comprehensive care plans for residents. This affected three residents (#13, #14, and #19) of three residents reviewed for comprehensive care plan implementation. The facility census was 72.

Inspectors wroteBased on observation, record review, interview and policy review the facility failed to ensure residents were assisted with activities of daily living including hair, nail and oral care. This affected three residents (Resident #30, #31 and #51) of 12 residents reviewed for activities of daily living. The census was 72.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Magnetic Resonance Imaging (MRI) study was completed as ordered for Resident #80. This affected one resident (#80) reviewed for MRI follow-up. Also based on observation, record review and interview, the facility failed to ensure wounds received dressing orders and documented care. This affected one resident (Resident #18) of one resident observed for wound care of a surgical wound. The facility failed to ensure dressings were changed as ordered for one resident (Resident #28). The total census was 72.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to have interventions in place to maintain a peripherally inserted central catheter (PICC) line for Resident #31. This affected one resident (#31) of one resident reviewed for intravenous (IV) access and had the potential to affect three additional residents (#1, #2, and #25) identified by the facility with IV access. The facility census was 72.

Inspectors wroteBased on observation, record review, interview, facility policy review and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to provide tracheostomy care according to professional standards for Resident #22 and failed to date and/or change oxygen tubing weekly for Residents #29 and #67. This affected three residents (#22, #29 and #67) of eight residents reviewed for respiratory care. The facility census was 72.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure residents were seen by a physician as required. This affected one resident (#69) of 15 residents reviewed for physician visits. The facility census was 72.

Inspectors wroteBased on observation, interviews, medical record review, and review of manufacturer instructions and facility policy, the facility failed to timely administer a physician ordered antibiotic for Resident #41 and correctly administer pen injected insulin for Resident #34 utilizing manufacturer instructions. This affected two residents (#34 and #41) out of two residents reviewed for medication administration. The facility identified 19 residents ( #1, #3, #5, #6, #17, #19, #21, #33, #34, #36, #44, #48, #50, #53, #57, #62, #63, #65 and #68) who received pen injected insulin. The facility census was 72.

Inspectors wroteBased on medical record review and interview, the facility failed to obtain physician ordered laboratory testing. This affected three residents (#19, #27 and #57) out of three residents reviewed for laboratory testing. The facility census was 72.

Inspectors wroteBased on observation, record review, staff and family interviews, and facility policy review, the facility failed to provide timely dental services for Resident #6. This affected one resident (#6) of three residents reviewed for dental care. The facility census was 72.

Inspectors wroteBased on observation, record review, interview and review of facility policy, the facility failed to accomodate Resident #27's food preference as requested by the resident. This affected one resident (#27) of two residents reviewed for food choices. The facility census was 72.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to ensure a complete and accurate medical record for Resident #80. This affected one resident (#80) of 53 residents reviewed for the annual survey. The facility census was 72.

Inspectors wroteBased on review of the medical record, interview, and review of the facility policy the facility failed to ensure Resident #80 received an indwelling urinary catheter upon physician recommendation, failed to ensure appropriate care and services related to indwelling urinary catheters were in place when Resident #80 returned to the facility, failed to ensure Resident #80 was free from complications related to the indwelling urinary catheter, and failed to ensure complications were followed-up on timely and appropriately. This affected one resident (Resident #80) of three residents who were reviewed for appropriate care and services related to urinary catheters and urinary tract infections. The facility census was 77.

Inspectors wroteBased on observation, interview, review of the medical record, and review of the facility policy the facility failed to ensure the medication error rate was below five percent (%) when two medication errors occurred during 26 medication administration opportunities, resulting in a medication error rate of 7.69%. This affected one resident (Resident #32) of ten residents who were reviewed for medication administration. The facility census was 77.

Inspectors wroteBased on observation, interview, medical record review, and review of the facility policy the facility failed to ensure enhanced barrier precautions (EBP) were maintained while tracheostomy, ventilator, and feeding tube related care were performed by multiple staff members. This affected one resident (Resident #73) of three residents who had tracheostomies and who were observed during the administration of medications or procedures. The facility census was 77.

Inspectors wroteBased on medical record review, interview, and review of facility policy the facility failed to ensure Resident #27's representative was notified of changes in condition related to an active infection which required a change in treatment and of positive cultures for multi drug-resistant organisms which required care plan updates. This affected one resident (Resident #27) of three residents (Residents #27, #39, and #79) reviewed. The facility census was 81.

Inspectors wroteBased on medical record review, interview, and review of facility policy, the facility failed to implement a person-centered comprehensive care plan that addressed the physical, mental, and psychosocial needs of Resident #27. This affected one resident of five residents (Residents #27, #14, #39, #67, and #79) whose care plans were reviewed for appropriate person-centered interventions.

Inspectors wroteBased on medical record review, interview, and package insert for Venlafaxine Extended Release (ER) the facility failed to ensure drug irregularities noted by the pharmacist were reported to the attending physician and acted upon timely. This affected one resident (Resident #27) of three residents (Residents #27, #39, and #79) who were reviewed for appropriate medications. The facility census was 81.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to assess wounds and obtain appropriate treatment orders upon re-admission from the hospital, failed to ensure wound care supplies were available, and/or failed to complete pressure ulcer treatments as ordered by the physician for Residents #60, #7, and #79. Actual Harm occurred on 04/11/24 when Resident #60, who was severely cogntively impaired, dependent on staff for all activities of daily living, at risk for pressure ulcer development and had a history of pressure ulcers, was found per Wound Physician #675 to have an unstageable (full-thickness pressure ulcer in which the base was obscured by slough and/ or eschar (dead skin) pressure ulcer to the left sacrum. [...]

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, ensure timely and accurate assessments were completed, ensure treatments were completed as ordered and/or to ensure staff were knowledgeable of care planned interventions for Resident #76 and Resident #82. [...]

Inspectors wroteBased on observation and interview, the facility failed to store tortillas, cheese, salami, and turkey in a manner to prevent food borne illness and contamination. This had the potential to affect all 69 residents residing in the facility who were receiving food from the kitchen. There were 15 residents (#7, #33, #44, #55, #67, #69, #70, #71, #72, #76, #77, #79, #81, #83, and #238) who were identified by the facility as receiving nothing by mouth. The facility census was 86.

Inspectors wroteBased on record review, resident representative interviews, and staff interviews, the facility failed to ensure residents and/or their responsible parties were included in and offered the opportunity to participate in quarterly care plan meetings. This affected five residents (#13, #18, #25, #42, and #56) of five residents reviewed for care planning. The facility census was 86.

Inspectors wroteBased on record review and interview the facility failed to obtain written authorizations to manage resident funds. This affected three residents (#18, #34, and #291) of eight residents reviewed for facility fund management. The facility census was 86.

Inspectors wroteBased on record review, observation, interview, and review of the facility policy the facility failed to ensure a clean environment with walls in good repair for Resident #12. The facility did not ensure an environment free of broken window blinds for Residents #48 and #71. The facility did not ensure a room with comfortable temperatures for Residents #54 and #64. This affected five residents (#12, #48, #71, #54 and #64) of 34 residents observed for environment who resided on the Dogwood and Crab Apple units. The facility census was 86.

Inspectors wroteBased on record review and interview the facility failed to ensure resident care plans were updated to reflect the physician's orders. This affected two residents (#42 and #66) of six residents reviewed for care plans. The facility census was 86.

Inspectors wroteBased on record review, interview, and review of the facility policy the facility did not ensure they had an effective antibiotic stewardship program that monitored antibiotic use including reducing the risk of adverse effects of the development of antibiotic resistant organisms from unnecessary or inappropriate antibiotic use. This affected 28 residents (#10, #16, #29, #30, #31, #38, #40, #44, #47, #51, #53, #55, #59, #63, #68, #73, #75, #77, #80, #83, #189, #190, #191, #238, #287, #288, #290 and #337) out of 34 residents identified as ordered antibiotics during the months of February 2024 and March 2024. The facility census was 86.

Inspectors wroteBased on interview, observation, record review, and review of the facility policy the facility did not ensure Resident #80 was treated in a dignified, respectful manner after he requested a blanket from staff because he was cold, and the blanket was not provided. This affected one resident (#80) out of two residents reviewed for dignity. The facility census was 86.

Inspectors wroteBased on record review and staff interview the facility failed to notify two residents (#8 and #34) when their personal funds account balance was within two hundred dollars of the state allowed limit. This affected two residents (#8 and #34) of eight residents reviewed for personal funds. The facility census was 86.

Inspectors wroteBased on interview, observation, and record review the facility did not ensure staff were knowledgeable regarding how to locate baseline care plans and/ or had [NAME]'s (communication tool that identifies care and services residents require) in place to ensure staff were aware what care and services residents were to receive on admission. This affected two residents (#76 and #82) out of two residents reviewed for baseline care plan. The facility census was 86.

Inspectors wroteBased on interview, observation, record review, and review of the facility policy the facility failed to ensure residents who were dependent on staff for assistance with activities of daily living (ADL) including hygiene, fingernail care, and oral care were provided with adequate care. This affected three residents (#51, #71, and #82) out of six residents reviewed for ADL care. This had the potential to affect 67 residents (#1, #3, #4, #6, #7, #8, #9, #11, #12, #14, #15, #19, #21, #22, #23, #25, #26, #27, #28, #29, #30, #32, #33, #34, #35, #36, #37, #39, #40, #42, #44, #45, #46, #47, #48, #49, #51, #50, #53, #54, #55, #57, #59, #60, #63, #64, #65, #66, #67, #70, #71, #72, #73, #74, #77, #79, #80, #81, #82, #83, #187, #237, #238, #287, #288, #289, and #290) who required assistance with ADL. The facility census was 86.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure Resident #53's concern regarding hearing and/or request for hearing aids were timely met. This affected one resident (#53) out of one resident reviewed for hearing and had the potential to affect six residents (#6, #15, #30, #51, #53, and #69) identified as hard of hearing. The facility census was 86.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to change nasal cannula oxygen tubing in a timely manner. This affected two residents (#6 and #289) of 34 residents utilizing oxygen. The facility census was 86.

Inspectors wroteBased on interview, observation, record review, and review of self-reported incident (SRI) the facility did not ensure Resident #6's behavior plan of care was followed by staff. This affected one resident (#6) out of one resident reviewed for behavioral health services. The facility census was 86.

Inspectors wroteBased on interview and record review the facility did not ensure Resident #13's lab work was obtained as ordered by the physician. This affected one resident (#13) out of five residents reviewed for unnecessary medications including lab work. The facility census was 86.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had received and/or the facility had documented evidence that residents were offered the pneumococcal and influenza vaccines. This affected three residents (#39, #61, #80) of the five residents reviewed for immunizations. The facility census was 86.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #16 donned a safety apron during smoking per his intervention on his care plan and that the designated smoking area was maintained in a clean, safe, and sanitary manner. This affected one resident (Resident #16) out of two residents (Resident #16 and #33) reviewed for smoking and had the potential to affect six residents (Resident #8, #12, #16, #50, #316 and #367) who smoke in the designated smoking area off the 600 unit.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store, label, and dispose of resident medications. This affected one resident (Resident #14) of three residents on the 700 unit who received latanoprost ophthalmic solution (eye drops), one resident (Resident #2) of two residents on the 700 unit who received Lantus (long acting insulin), one resident (Resident #10) of one resident on the 700 unit who received Novolog (short acting insulin), one resident (Resident #57) of one resident on the 700 unit who received trifluridine ophthalmic solution (eye drops), and one resident (Resident #30) of four residents on the 600 unit who received Novolin (short acting insulin).

Inspectors wroteBased on record review and interview, the facility failed to notify Resident #165's physician timely of a change in the resident's abdominal incision. This affected one (Resident #165) of two residents reviewed for general skin conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #37 and #46's comprehensive assessments were completed accurately. This affected two (Residents #37 and #46) of twenty-five residents whose records were reviewed for accurate comprehensive assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #33's care plan was revised as needed. This affected one resident (Resident #33) out of 25 residents whose comprehensive care plans were reviewed. The facility census was 67.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #16 received restorative nursing range of motion and restorative ambulation program per his plan of care. This affected one resident (Resident #16) out of one resident reviewed for restorative nursing programs. The facility identified eight residents (Resident #2, #14, #16, #21, #30, #42, #49, #56) who had a restorative nursing program.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician orders were obtained timely for Resident #165's wound care to the laproscopic wound on her right upper quadrant. This affected one (Resident #165) of two residents reviewed for general skin conditions.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a multi-use glucometer was appropriately disinfected and sanitized between resident use to prevent cross contamination. This affected one resident (Resident #13) of nine residents (Resident #11, #13, #14, #18, #25, #37, #40, #46, #167) who received blood glucose testing (BGT) on the 500 unit.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #30 and Resident #64 had or that facility had documented evidence that they were offered the pneumococcal vaccine. This affected two residents (Resident #30 and #64) out of five residents (Resident #8, #20, #28, #30, #64) reviewed for immunizations. The facility census was 67.