Heritage Pointe of Warren

In the surveyor’s words

From the most serious findings on record at Heritage Pointe of Warren, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 5, 2021

  Based on record review and interview, the facility failed to ensure adequate supervision and interventions to prevent multiple falls for 2 of 3 residents reviewed for falls (Resident B and Resident C). This deficient practice resulted in Resident B sustaining two hip fractures, a large acute right cerebral convexity subdural hematoma, a large acute right hemispheric subdural hematoma with right to left shift of midline structures and a subarachnoid hemorrhage in the right temporoparietal region and Resident C sustaining a fracture to her right hip. The immediate jeopardy began on 1/09/21, when Resident B fell and fractured her hip. […]

• No harm, potential for more than minimal, patternF550Feb 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents with diagnoses of dementia, received locomotion and seating assistance, pre-meal stimulation, toileting assistance, and mask wearing assistance, in a manner to promote dignity for 6 of 6 residents reviewed for assistance to promote dignity. (Residents 4, 34, 37, 47, 57 and 77) Findings include: 1. During a pre-meal and meal observation on 2/24/23 on the 1B Memory Care unit, the following was observed: At 11:01 a.m., an unknown staff member wheeled Resident 47 down the hallway to the dining area. The unknown staff member told the resident she would be eating soon. The resident was placed, in her wheelchair, facing the table as if ready to dine. […]

• No harm, potential for more than minimal, isolatedF690Apr 13, 2026

  Based on observation, interview, and record review, the facility failed to utilize infection prevention and control strategies to prevent contamination of a urinary catheter for 1 of 2 residents reviewed for indwelling catheters. (Resident 70)Findings include:During an observation, on 4/7/26 at 9:53 a.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On 4/8/26 at 10:58 a.m., Resident 70's indwelling catheter drainage bag hung on the resident's bed frame. The bag touched the floor.On 4/8/26 at 11:18 a.m., Resident 70 was laying on her back in her bed. Her indwelling catheter drainage bag hung on the top of the bed's footboard. […]

• No harm, potential for more than minimal, isolatedF761Apr 13, 2026

  Based on observation, interview, and record review, the facility failed to securely store medications during a random observation of 1 of 6 medication carts (2B New End Medication Cart).Finding includes:During a random observation on the 2B hallway, on 4/9/26 beginning at 8:11 a.m., a medication cup with various pills was observed sitting on top of an unlocked medication cart left unattended in the hallway. No nursing staff members were in visual range of the cart. Activity Assistant 11 walked down the hall and stood by the medication cart, indicating she needed to speak with the nurse. At 8:13 a.m., RN 12 opened a resident's door across the hall and approached the medication cart. […]

• No harm, potential for more than minimal, isolatedF880Apr 13, 2026

  A. Based on observation, record review, and interview, the facility failed to ensure food was served and handled under safe and sanitary conditions for 2 of 19 residents observed during meal service. (Residents 3 and 57)B. Based on observation and interview, the facility failed to ensure universal precautions and hand hygiene were implemented during the administration of nasal spray for 1 of 4 residents observed during medication administration. (Resident 19) Findings include:A. During a lunch observation, on 4/6/26 at 12:10 p.m., the following was observed: CNA 4 pulled out a piece of bread with her bare hands from the plastic container. The bread was placed on Resident 3's tray. CNA 4 opened another plastic bag containing bread, removed that piece of bread with her bare hands. […]