Warren Manor

driver was unable to move Resident R7 on his/her own.

The security staff for the facility where he

taken to the hospital emergency department for evaluation and was found to have no injuries via

an investigation of the incident and/or an assessment of Resident R7 upon his return to the facility.

On 7/29/25, a physician's progress note referenced Resident R7's fall from a wheelchair on the bus.There was no evidence of van driver education regarding safety procedures prior to Resident R7's accident and/or after the accident.

During an interview on 4/01/26, at 3:13 p.m. the NHA confirmed there was no evidence of van driver education prior to or after Resident R7's accident.During an interview on 4/02/26, at 7:45 a.m. the NHA confirmed that there was no evidence that the facility investigated Resident R7's accident.

Resident R4's clinical record revealed an admission date of 8/29/24, with diagnoses that included COPD, post-traumatic stress disorder [PTSD (mental health condition that's caused by an extremely stressful or terrifying event - either being part of it or witnessing it, causing flashbacks, nightmares, severe anxiety and uncontrollable thoughts about the event)], and open sores and infections of both lower legs/feet.Resident R4's care plan entitled, I am a smoker dated 8/29/24, included interventions to agree to follow the smoking policies by not having smoking materials on my person, or in a location that puts others at risk, follow smoking times, adhere to recommendations of safe smoking, and that if the facility is non-smoking, to go off the grounds to smoke, tell staff and sign out each time.Resident R4's most recent smoking assessment dated [DATE], indicated that he/she would follow the facility's policy on location and time of smoking.

There was no evidence of specific safety interventions recommended and/or determination of supervision requirements.

Resident R104's clinical record revealed an admission date of 12/23/24, with diagnoses that included COPD, respiratory failure, Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), and anxiety.Resident R104's most recent smoking assessment dated [DATE], indicated that he/she would follow the facility's policy on location and time of smoking There was no evidence of specific safety interventions recommended and/or determination of supervision requirements.Observation on 3/30/26, at approximately 9:40 a.m. revealed Resident R4 and Resident R104 in their wheelchairs entering the door leading out to the designated resident smoking area. At the time of the observation, the surveyor inquired if staff go out and supervise them when they smoke.

Both Residents R4 and R104 shared that staff do not go out to supervise them when they smoke.

During an interview on 4/01/26, at 2:19 p.m. the NHA confirmed staff should have been outside supervising residents while they smoke. 28 Pa.

Code 201.14(a) Responsibility of licensee28 Pa.

Code 211.12(c)(d)(1)(3)(5) Nursing services28 Pa.

Code 201.18(b)(1)(3) Management28 Pa.

Code 201.18(e)(1) Management

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Warren Manor 682 Pleasant Drive Warren, PA 16365

During an

dated/changed/cleaned/maintained as per Resident R28, R30, and R70's physician's orders and

that included sudden respiratory failure, lung cancer, nicotine and alcohol dependency, and Schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking).

Resident R1's clinical record revealed a physician's order dated 2/18/26, to administer oxygen at 2 LPM via NC prn to maintain oxygen levels at or greater than 90% every shift, if unable to maintain oxygen saturation at or greater than 90% on 2 LPM call the physician. A physician's order dated 2/25/26, Oxygen Maintenance: Change O2 tubing and supply bag weekly; wipe down concentrator and clean filter weekly; and change water jug weekly.

Directions indicated one time a day every Sunday.

Resident R1's departmental progress notes indicated he/she was wearing the oxygen mask on multiple occasions.

Observation on 3/31/26, at 8:40 a.m. revealed Resident R1 lying in bed and an oxygen mask (mask placed over the nose and mouth and connected to a supply of oxygen, used when the body is not able to gain enough oxygen by breathing air) laying in the open top drawer of the bedside stand with the tubing attached to the concentrator and concentrator running, the external concentrator filter was covered with a moderate amount of gray fluffy substance.

The tubing connected to the oxygen mask was labeled with white tape and the date was worn and unreadable, and water jug was empty.

During an interview on 3/31/26, at 8:50 a.m.

Licensed Practical Nurse Employee E1 confirmed the position and functioning of the oxygen mask, the moderate amount of gray fluffy substance on the external concentrator filter, the worn illegible tape on the tubing, and the empty water jug. 28 Pa.

Code 211.12(d)(1)(5) Nursing services

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Warren Manor 682 Pleasant Drive Warren, PA 16365

During an interview with Resident R33 on 3/30/26, at

table.

Resident R33 stated, I threw up a couple times and just feel awful. No transmission-based precautions were maintained during the interview/observation.

Interview with Licensed Practical Nurse (LPN) Employee E3 on the C unit on 3/30/26, at approximately 2:45 p.m. revealed that he/she was leaving work due to feeling nauseous. LPN Employee E3 further indicated that the unit had several residents not feeling well with a gastrointestinal illness.

Interview with LPN Employee E1 on the C unit on 3/31/26, at 4:30 p.m. revealed no knowledge or Nurse/Nurse report of any residents on C unit with a gastrointestinal illness.

Interview on 4/01/26, at 1:50 p.m. the Infection Control Registered Nurse (RN) confirmed that the facility was not following proper infection control practices and failed to recognize that further residents who were symptomatic with loose stools, nausea and/or vomiting and failed to implement transmission based precautions to mitigate the gastrointestinal illness from spreading throughout A, B, C and D units.

Interview on 4/01/26, at 2:40 p.m. the Nursing Home Administrator (NHA) confirmed that the facility lacked evidence of surveillance and implementation of infection control measures to prevent the spread of further gastrointestinal illness throughout the facility from A unit to further residents on A, B, C, and D units. 28 Pa.

Code 201.14(a) Responsibility of licensee 28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services

395650 04/02/2026

Warren Manor 682 Pleasant Drive Warren, PA 16365