Warren Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Warren Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 14, 2023

  Based on observation, interviews, and record review during an abbreviated survey (Case #NY00310764), the facility failed to ensure each resident received adequate supervision to prevent accidents. Specifically, on 2/12/2023, the facility failed to provide Resident #1, who was cognitively impaired, with adequate supervision to prevent an elopement. Subsequently, Resident #1 was able to exit the building through the front door, which was alarmed, and exited the facility for approximately two hours. Did not discover the resident was missing until the resident's Power of Attorney called the facility to alert them that the resident was at their previous house. Review of resident's address on google maps revealed the resident house was approximately 5.2 miles North of the facility. […]

• Actual harm, isolatedF600May 31, 2024

  Based 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 on to the floor and sustained fractures to both of their legs. […]

• Actual harm, isolatedF600Sep 26, 2022

  Based on observation, record review, and interviews during an abbreviated survey (Case #NY 302), the facility did not ensure the resident has the right to be free from physical abuse for 1 (Resident #1) of 3 residents reviewed for abuse. Specifically, the facility did not ensure that Certified Nursing Assistant #1 (CNA) did not enter Resident #1's room after Resident #1 and their resident representative had stated to the Registered Nurse Manager (RNM) during a meeting on 9/2/2022 that they did not want CNA #1 near or providing care to them. On 9/15/2022, CNA #1 entered Resident #1's room, a verbal altercation occurred between CNA #1 and Resident #1, and CNA #1 physically assaulted Resident #1 by pushing their hands forcefully into both of the resident's eyes. […]

• No harm, potential for more than minimal, patternF550Apr 15, 2026

  Based 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.Findings include: The Facility's Policy Titled Resident Rights, revised 5/28/2024, documented Federal and State laws guarantee… […]

• No harm, potential for more than minimal, patternF561Apr 15, 2026

  Based 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. Findings include: Review of the facility policy titled Resident Rights, revised 05/28/2024, documented healthcare personnel shall treat all residents with kindness, respect, and dignity. […]