Warren Manor

In the surveyor’s words

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

• Actual harm, isolatedF689Apr 2, 2026

  Based on review of information submitted by the facility to the State Agency, policies, clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to ensure essential resident safety measures were followed to prevent a fall which resulted in the actual harm of a right femur (thigh) fracture requiring surgical repair for one resident (Resident R5); and a fall which resulted in the actual harm of a nasal bone fracture for one resident (Resident R2); failed to provide adequate safety interventions to prevent a fall for one resident (Resident R7) and failed to provide supervision to prevent injury for two residents (Residents R4 and R104).Findings include:A facility policy entitled, 'Smoking Policy dated 12/23/25, indicated that… […]

• No harm, potential for more than minimal, widespreadF880Apr 2, 2026

  Based on a review of facility policy, facility and clinical records, observations, and resident and staff interviews, it was determined that the facility failed to adhere to proper infection control practices related to a gastrointestinal outbreak for four of four resident care units observed (A, B, C, and D Units).Findings include: Facility policy Infection Control - Plan Overview dated 12/23/25, revealed the primary of the MANOR's Infection Control Plan is to establish guidelines to follow in preventing, identifying, reporting, investigation, and controlling the spread of contagious, infectious or communicable diseases. […]

• No harm, potential for more than minimal, patternF695Apr 2, 2026

  Based on review of facility policy and clinical records, observations, and staff interview, it was determined that the facility failed to appropriately maintain respiratory care equipment according to physician's orders for four of 22 residents reviewed (Residents R1, R28, R30, and R70).Findings include: A facility policy entitled, Portable Oxygen Concentrators Usage, Care and Maintenance dated 12/23/25, indicated cleaning/maintenance for the particle screens that removes dust fragments must be cleaned with mild soap and water and allow to dry to ensure adequate air flow through the device. The policy further indicated the nasal cannula [NC-a flexible tube to deliver oxygen placed in the nose] should be replaced on a weekly basis along with all oxygen disposables the resident uses. […]

• No harm, potential for more than minimal, patternF684Apr 4, 2025

  Based on review of clinical records, observations, and staff interviews, it was determined that the facility failed to follow physician's orders for four of 26 residents reviewed (Residents R1, R68, CR109, and R3). Findings include: No policy was provided regarding following a physician's order. Resident's R1's clinical record revealed an admitted [DATE], with diagnoses that included neurologic neglect syndrome (a neurological disorder that makes a person lack awareness to stimuli on one side of the body or space), diabetes mellitus (a disease that affects how blood sugar is regulated in the blood), asthma (a chronic condition in which a person's airways become inflamed making it difficult to breathe), and weakness. […]

• No harm, potential for more than minimal, patternF695Apr 4, 2025

  Based on review of clinical records, observations, and staff interview, it was determined that the facility failed to promote cleanliness and help prevent the spread of infection regarding respiratory care equipment for three of three residents and failed to provide oxygen according to physician's orders for one of three residents reviewed for respiratory services (Residents R16, R93 and R95). Findings include: Review of Resident R16's clinical record revealed an admitted [DATE], with diagnoses that included hypertension (high blood pressure), anxiety (a condition that causes a person to be nervous, uneasy, or worried about something or someone), and hypothyroidism (a condition when the thyroid produces low amounts of thyroid hormones). […]