Warren Manor: Van Driver Training Failures - PA
Resident R7 was taken to the hospital for evaluation and found to have no injuries through radiological testing before returning to Warren Manor. But the facility's clinical records showed no evidence of investigating the incident or assessing the resident upon return.
A physician's progress note from July 29, 2025 referenced Resident R7's fall from the wheelchair on the bus. The facility provided no evidence of van driver education about safety procedures before or after the accident.
During an interview on April 1, 2026, the nursing home administrator confirmed there was no evidence of van driver education prior to or after Resident R7's accident. The next day, the administrator confirmed the facility never investigated the accident.
The transportation failures were part of broader safety oversights federal inspectors documented during their April 2026 visit to the Pleasant Drive facility.
Two residents with serious respiratory and mental health conditions were smoking unsupervised despite facility policies requiring staff oversight. Both had diagnoses that should have triggered specific safety interventions.
Resident R4, admitted in August 2024 with COPD, post-traumatic stress disorder, and open sores and infections on both lower legs and feet, had a care plan requiring adherence to smoking policies. The plan specified not having smoking materials that could put others at risk, following designated smoking times, and signing out each time when leaving grounds to smoke.
The resident's most recent smoking assessment indicated they would follow the facility's policy on location and timing. But inspectors found no evidence of specific safety interventions or supervision requirements in the records.
Resident R104, admitted in December 2024 with COPD, respiratory failure, schizophrenia, and anxiety, had similar documentation gaps. Their smoking assessment showed agreement to follow facility policies, but records lacked safety interventions or supervision determinations.
On March 30, 2026, at approximately 9:40 a.m., inspectors observed both residents in wheelchairs entering the door to the designated smoking area. When asked if staff supervised them while smoking, both residents said no.
"Staff do not go out to supervise them when they smoke," they told inspectors.
The nursing home administrator confirmed during an April 1 interview that staff should have been outside supervising residents while they smoke.
The violations highlight gaps in basic safety protocols at Warren Manor. Resident R4's complex medical needs included infected open sores on both legs and feet alongside COPD, conditions that could complicate smoking safety. Resident R104's schizophrenia and anxiety, combined with respiratory failure, presented additional risks requiring professional oversight.
Federal inspectors cited the facility for failing to ensure adequate nursing services and proper management oversight. The violations also referenced Pennsylvania state regulations requiring facilities to maintain responsibility for resident safety and appropriate supervision.
The transportation incident involving Resident R7 revealed systemic problems with staff training and incident response. The van driver's inability to assist the fallen resident alone suggests inadequate preparation for medical transport duties. More concerning, the facility's failure to investigate the accident or assess the resident upon return violated basic safety protocols.
No evidence existed of policy changes or additional training following either the transportation accident or the smoking supervision failures.
The inspection findings affect residents with some of the most vulnerable health profiles in long-term care. COPD patients face increased risks from unsupervised smoking. Residents with schizophrenia may have impaired judgment about safety. Post-traumatic stress disorder can affect decision-making in crisis situations.
Warren Manor's administrator acknowledged the supervision failures but provided no documentation of corrective measures or staff education improvements during the inspection period.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
WARREN MANOR in WARREN, PA was cited for violations during a health inspection on April 2, 2026.
Resident R7 was taken to the hospital for evaluation and found to have no injuries through radiological testing before returning to Warren Manor.
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.