Warren Manor: Dirty Oxygen Equipment Violations - PA
Resident R1 arrived at Warren Manor on February 18 with sudden respiratory failure, lung cancer, and substance dependencies. The patient also had schizophrenia, a severe mental disorder affecting thoughts and behavior.
The doctor ordered oxygen at 2 liters per minute as needed to keep oxygen levels above 90 percent. If staff couldn't maintain that level, they were supposed to call the physician immediately.
A second order on February 25 was more specific: Change oxygen tubing and supply bag weekly. Wipe down the concentrator and clean the filter weekly. Change the water jug weekly. All on Sundays.
Nobody followed those orders.
When an inspector arrived on March 31 at 8:40 a.m., Resident R1 was lying in bed. The oxygen mask sat in an open bedside drawer, still connected to a running concentrator. The external filter was covered with what the inspector described as "a moderate amount of gray fluffy substance."
The tubing had white tape with a date that was "worn and unreadable." The water jug was empty.
Licensed Practical Nurse Employee E1, interviewed ten minutes later, confirmed everything the inspector had observed. The gray substance on the filter. The illegible date on the tubing. The empty water jug.
The violations extended beyond Resident R1. During a March 30 interview, Registered Nurse Employee E2 confirmed that respiratory equipment for three other residents — R28, R30, and R70 — also wasn't being maintained according to doctor's orders and facility policy.
Resident R1's medical records showed the patient had worn the oxygen mask on multiple occasions, according to departmental progress notes. On March 16, an inspector had already documented problems with oxygen tubing hanging over a water jug for other residents.
The facility's own policy required the same maintenance schedule the doctor had ordered. Change tubing weekly. Clean filters weekly. Replace water weekly. The policy matched the physician's instructions exactly.
But staff weren't following either set of rules.
For a patient with sudden respiratory failure and lung cancer, properly functioning oxygen equipment can mean the difference between adequate breathing and dangerous oxygen desaturation. The doctor's order was clear: if oxygen levels dropped below 90 percent on the prescribed 2 liters per minute, call immediately.
With a clogged filter reducing the concentrator's efficiency and an empty water jug eliminating humidification, the equipment couldn't deliver oxygen as prescribed. The worn, illegible date on the tubing meant staff had no way to track when it was last changed.
Employee E2's confirmation that multiple residents faced the same equipment maintenance failures suggested a systematic breakdown in respiratory care protocols. The March 16 documentation of oxygen tubing draped over water containers indicated ongoing problems with basic equipment handling.
The gray substance coating the external filter represented weeks or months of accumulated debris that should have been cleaned away every Sunday. Instead, it remained until an inspector discovered it during the March 31 survey.
Resident R1's combination of conditions — lung cancer, respiratory failure, and severe mental illness — made proper oxygen delivery particularly critical. Schizophrenia can affect a patient's ability to communicate breathing difficulties clearly, making consistent equipment monitoring essential.
The facility received a citation for failing to provide adequate nursing services under Pennsylvania regulation 28 Pa. Code 211.12. Inspectors classified the violation as causing minimal harm or potential for actual harm to some residents.
But for Resident R1, lying in bed while a concentrator with a clogged filter ran uselessly nearby, the distinction between minimal and actual harm may have depended entirely on timing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Warren Manor from 2026-04-02 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
WARREN MANOR in WARREN, PA was cited for violations during a health inspection on April 2, 2026.
Resident R1 arrived at Warren Manor on February 18 with sudden respiratory failure, lung cancer, and substance dependencies.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at WARREN MANOR?
- Resident R1 arrived at Warren Manor on February 18 with sudden respiratory failure, lung cancer, and substance dependencies.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in WARREN, PA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from WARREN MANOR or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 395650.
- Has this facility had violations before?
- To check WARREN MANOR's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.