Warren Nursing & Rehab

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880Dec 31, 2025

  Based 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. […]

• Actual harm, isolatedF686Dec 31, 2025

  Based 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. […]

• Actual harm, isolatedF690Dec 31, 2025

  Based 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. […]

• Actual harm, isolatedF686May 1, 2024

  Based 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. […]

• Actual harm, isolatedF686Apr 11, 2024

  Based 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. Actual Harm occurred on 02/22/24 when Resident #82 who required substantial to maximum staff assistance with bed mobility and was totally dependent on staff with transfers and toileting was found per Wound Physician #703 progress note to have an unstageable (full-thickness pressure ulcer in which the base was obscured by slough and/ or eschar (dead skin)… […]