Warren Hills Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Apr 8, 2022

  Based on observation and staff interview the facility failed to maintain the kitchen equipment clean and in a sanitary condition to prevent cross contamination by failing to clean 2 of 2 plate warmers. The findings included: During the meal observation on 4/06/22 at 11:35 AM the tray line area was observed. The first 3 cylinder well plate warmer was observed with dark black dried food particles inside each well and the middle well had crumpled up foil in the bottom. The second 3 cylinder well plate/pellet warmer was observed to have dark black dried food particles in each well and the middle well had ketchup packets in the bottom of the well. […]

• No harm, potential for more than minimal, patternF757Feb 26, 2026

  Based on observation, record review, and interviews with staff, the Consultant Pharmacist, and the Physician Assistant, the facility failed to evaluate the continued need for a medication prescribed for wheezing. This deficient practice had the potential to result in residents receiving medications without clinical indication, ongoing monitoring, or justification of continued use for 1 of 6 residents reviewed unnecessary medications (Resident #75).The findings included:Resident #75 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbances, pleural effusion (abnormal accumulation of excess fluid in the space between the lungs and chest wall), and congestive heart failure (CHF). […]

• No harm, potential for more than minimal, patternF880Feb 26, 2026

  Based on observation, record review and staff interviews the facility failed to implement their infection prevention program policies and procedures and follow their Hand Hygiene policy when Nurse #3 failed to perform hand hygiene and change gloves when flushing a peripherally inserted central catheter (PICC) line (a long thin flexible tube inserted through an arm vein near the heart for long term intravenous access) and connecting the intravenous (IV) antibiotic tubing to the PICC line tubing. In addition, the Wound Treatment Nurse failed to change the disposable gloves and perform hand hygiene during wound care observation for Resident #2 and Resident #22. […]

• No harm, potential for more than minimal, patternF578Nov 21, 2024

  Based on record review, resident, and staff interviews, the facility failed to provide written documentation for advance directive information and the opportunity to formulate an advance directive for 13 of 22 residents reviewed for advanced directives. Residents #57, #71, #58, #55, #70, #68, #29, #72, #38, #52, #65, #61, #45. The findings included: a. Resident #57 was admitted to the facility on [DATE]. Resident #57 had severe cognitive impairment. Review of a physician ' s order dated 7/24/24 revealed Resident #57 was a full code. There was no documentation in the medical record for education regarding formulation of an advance directive or documentation that an opportunity to formulate an advance directive was offered to the resident or their responsible party. b. […]

• No harm, potential for more than minimal, patternF812Sep 14, 2023

  Based on observations, record review and staff interviews the facility failed to maintain food service equipment without a build up of debris on 3 of 4 pieces of cookline equipment (top/bottom convection oven, gas range oven) observed for cleanliness, and failed to remove excessive ice buildup and clean 2 of 2 nourishment refrigerators observed for cleanliness. These practices had the potential to affect facility residents. The findings included: During the initial tour of the kitchen on 9/11/23 at 9:52AM observation of the double stacked convection oven revealed a buildup of dark charred food debris on the bottom of both the top and bottom stacked convection ovens. The bottom convection oven door had a buildup of grease on the inside of the doors and lower inside rim of the oven. […]