Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Pointe Of Warren during CMS and state inspections, most recent first.
Indwelling Catheter Drainage Bag Contaminated by Improper Placement: A resident with an indwelling catheter, severe cognitive impairment, urinary retention, and obstructive/reflux uropathy had the drainage bag repeatedly hung on the bed frame so it touched the floor, and on one observation the tubing and bag were positioned above bladder level. Staff and facility policy stated the bag must remain below the bladder and off the floor, but this was not maintained.
Unsecured medications were observed sitting on top of an unlocked med cart in a hallway while no nursing staff were in visual range. An RN left the cart unlocked and unattended while assisting a resident who was yelling for help and had urinated in the room. The meds belonged to a resident scheduled for a morning med pass, and staff and facility policy stated meds must be kept locked or under direct observation.
A CNA handled bread with bare hands during meal service for two residents, including touching one resident’s bread while assisting with eating, despite staff and policy stating food should not be handled directly by hand. In a separate event, an LPN administered fluticasone propionate nasal spray to a resident without gloves and did not perform hand hygiene after leaving the room, even though the DON and RN stated gloves and hand hygiene were required.
Failure to Offer Current Pneumococcal Vaccination: The facility failed to provide or offer the current pneumococcal vaccine to two residents reviewed. One resident with DM, CKD, and HF had prior PCV 13 and PPSV 23, but the record lacked evidence of PCV 20 or PCV 21 despite consent for the most current pneumonia vaccine. Another resident with COPD had prior PCV 13, but the record lacked documentation that updated pneumococcal vaccines were offered or that consent/declination was obtained. The IP stated she believed one resident's vaccination was complete and that she had not offered updated pneumococcal vaccines.
Failure to administer and document COVID-19 vaccination: A resident with a history of PE, stroke, and HTN had a record showing consent for the most current COVID-19 vaccine, but there was no documentation that the vaccine was given. The chart also lacked an updated yearly consent or declination, and the IP and DON were unable to locate the updated consent.
The facility did not ensure that two residents received baseline tuberculin skin testing using the required two-step method within the correct time frames. One resident lacked documentation of a second-step TST after admission, while another had a second-step TST that was read too early. Staff interviews and record reviews confirmed these lapses in following established protocols for TB testing.
A facility failed to complete post-dialysis assessments for a resident with end-stage renal disease, despite physician orders and facility policy requiring such assessments. The resident's clinical record lacked documentation of assessments on specific dates, although dialysis was completed. Interviews with staff confirmed the expectation to perform these assessments, but they were not documented in the electronic medical record.
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two medication carts. Observations revealed missing signatures on the Narcotic Sheet Log/Tracking Form for multiple dates, despite staff indicating that counts were completed. The Director of Nursing confirmed that staff were required to complete the narcotic sheet count during shift changes, as per facility policy.
The facility failed to implement proper infection control during wound care for a resident with pressure ulcers, as an LPN did not follow hygiene protocols and mishandled PPE. Additionally, two residents on transmission-based precautions were not managed according to guidelines: one was outside their room without a mask, and a CNA did not wear required PPE when entering another resident's room. These actions were contrary to the facility's infection prevention policies.
A resident with multiple diagnoses and reduced mobility developed a pressure ulcer due to the facility's failure to implement and consistently follow preventive measures. Despite being at risk, the resident's care plan was not adequately adjusted when mobility declined, and staff did not consistently adhere to prescribed interventions.
A facility failed to confirm the placement of a gastrostomy tube before administering medications to a resident with a PEG tube, despite physician orders and facility policy requiring such verification. The lapse was observed during a medication administration and acknowledged by the staff involved.
Indwelling Catheter Drainage Bag Contaminated by Improper Placement
Penalty
Summary
The facility failed to use infection prevention and control strategies to prevent contamination of an indwelling urinary catheter for one resident reviewed for catheter care. Resident 70 had diagnoses including chronic kidney disease, urinary retention, and obstructive and reflux uropathy, and the quarterly MDS indicated severe cognitive impairment, dependence on staff for toileting and personal hygiene, and the presence of an indwelling catheter. Current orders required an 18 French 30 milliliter bulb indwelling catheter to be changed every 14 days and as needed, catheter care every shift, the urinary drainage bag to be changed weekly, and catheter tubing to be positioned below bladder level. The care plan also directed staff to position the catheter bag and tubing below the bladder level and to monitor for signs and symptoms of urinary tract infection. During multiple observations, Resident 70's urinary drainage bag was hung on the bed frame and touched the floor, and on one occasion the bag and tubing were positioned above the level of the resident's bladder. Staff interviews confirmed the drainage bag was to remain below the bladder and not touch the floor, and that touching the floor was considered an infection control issue and contamination. The DON, RN, QMA, and Infection Preventionist all stated the bag should be below bladder level and off the floor, and the facility policy likewise required the drainage bag and tubing to be kept off the floor and below bladder level.
Unsecured medications left on unlocked cart
Penalty
Summary
The facility failed to securely store medications during a random observation of 1 of 6 medication carts, the 2B New End Medication Cart. On 4/9/26 at 8:11 a.m., a medication cup containing various pills was observed sitting on top of an unlocked medication cart in the 2B hallway while no nursing staff were in visual range. Activity Assistant 11 stopped by the cart while looking for the nurse, and at 8:13 a.m. RN 12 came out of a resident’s room across the hall and approached the cart. RN 12 stated the cart should not have been left unlocked or with medications sitting on top, and explained that she had left it that way when she went to assist a resident who was yelling for help and had urinated throughout the room. The medications on the cart belonged to Resident 92 and were intended for the morning medication pass. Resident 92’s record showed orders for multiple scheduled medications, including amlodipine, duloxetine, ferrous sulfate, pantoprazole, clopidogrel bisulfate, prednisone, ezetimibe, docusate sodium, furosemide, metformin, gabapentin, and potassium citrate extended release. RN 6 stated medications should not be left on top of the cart or left unlocked out of the nurse’s visual range, and the DON stated medications should not be left unattended and the cart should be locked when out of visual range. The facility policy stated all drugs and biologicals must be stored in locked compartments and, during medication administration, must be under direct observation or locked in the medication storage area/cart.
Unsafe Food Handling and Improper Nasal Spray Administration
Penalty
Summary
The facility failed to ensure food was served and handled under safe and sanitary conditions during lunch service for two residents. During observation, a CNA removed bread from plastic containers and bags with bare hands and placed it on the trays of two residents. The CNA later assisted one resident with eating and again touched the resident’s bread with bare hands before placing it back on the tray after the resident declined a bite. During interview, the CNA stated she had touched the bread with her bare hands and said she should not have done so. The DON also stated staff members should not handle food with their bare hands, and the facility’s dietary policy stated food should be served using clean utensils and not touched directly with hands. The facility also failed to ensure universal precautions and hand hygiene were followed during administration of a nasal spray to one resident. An LPN prepared medications, entered the resident’s room, administered oral medications, then gave fluticasone propionate nasal spray using bare hands and without performing hand hygiene after leaving the room. The LPN stated she did not wear gloves because she did not touch the resident’s nose and did not perform hand hygiene when exiting because she planned to do so when preparing medications for the next resident. An RN stated nasal spray administration should include hand hygiene, gloves, removal of gloves, and hand hygiene again, and the DON stated gloves should be worn during nasal spray administration.
Failure to Offer Current Pneumococcal Vaccination
Penalty
Summary
The facility failed to provide or offer the current pneumococcal immunization to eligible residents according to CDC guidelines for 2 of 5 residents reviewed. Resident 73 had diagnoses including type 2 diabetes mellitus, chronic kidney disease stage 3a, and heart failure. The record showed the resident received PCV 13 on 7/14/17 and PPSV 23 on 11/28/18, and an immunization consent signed on 9/25/25 indicated the resident's representative wanted the resident to receive the most current pneumonia vaccine if eligible and indicated by the physician, specifically PCV 20. However, the clinical record lacked evidence that Resident 73 received PCV 20 or PCV 21. During interview, the Infection Preventionist stated she believed the vaccination was complete because the resident had received PPSV 23 and PCV 13. Resident 57 had a diagnosis of chronic obstructive pulmonary disease and received PCV 13 on 10/31/18. The clinical record lacked evidence that the resident was offered PCV 20 or PCV 21, and there was no consent or declination documented for the updated pneumococcal vaccines. During interview, the Infection Preventionist stated she had not offered any updated pneumococcal vaccines. The DON stated the Infection Preventionist was responsible for ensuring residents receive immunizations according to CDC guidelines. The facility policy stated residents would be assessed for pneumococcal vaccine eligibility, offered the vaccine series when indicated, and vaccinated according to current CDC recommendations.
Failure to Administer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to administer a COVID-19 vaccination for one resident after education and consent were documented. Resident 70’s record showed diagnoses of pulmonary embolism without acute cor pulmonale, cerebral infarct, and hypertension. A quarterly MDS assessment dated 2/17/26 indicated her COVID-19 vaccination was not up to date. The record also showed a vaccination consent form dated 8/19/24 in which the resident representative was educated and consented to the administration of the most current COVID-19 vaccine, but the clinical record lacked documentation that the vaccine was actually administered. The clinical record also lacked an updated or yearly COVID-19 vaccination consent or declination. During interview, the IP stated Resident 70 did not receive a COVID-19 vaccination after the initial consent was obtained and she could not locate an updated consent form. The DON stated she was unsure where the updated consent was and that it was possible a previous staff member discarded it. The CDC guidance reviewed by surveyors stated that updated COVID-19 vaccination is recommended for adults in LTC settings and that residents must give consent or agree to receive the vaccine.
Failure to Ensure Proper Two-Step Tuberculin Skin Testing on Admission
Penalty
Summary
The facility failed to ensure that baseline tuberculin skin testing (TST) was conducted using the two-step method within the required time frames for two of three residents reviewed. For one resident, the first-step TST was administered and read at the hospital prior to admission, but there was no documentation of a second-step TST being administered or read after admission. For another resident, the first-step TST was given and read within the appropriate time frame, but the second-step TST was read four hours earlier than the required 48 to 72-hour window. Interviews with nursing staff and the infection preventionist in training confirmed that the facility's process was to administer the first-step TST upon admission and the second-step one to three weeks later, with both steps to be read 48 to 72 hours after administration. However, documentation and timing errors were identified in the records reviewed. The Director of Nursing was unable to locate documentation of a second-step TST for one resident and acknowledged the early reading of the second-step TST for another. Facility policy and state guidance require a two-step TST for new admissions unless there is documentation of a previous positive TB test, with specific timing for administration and reading.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to complete post-dialysis assessments for a resident with end-stage renal disease who required dialysis services. The resident had diagnoses including dependence on renal dialysis, type 2 diabetes mellitus, essential hypertension, hypothyroidism, and muscle weakness. Physician orders specified that a dialysis assessment should be completed every Monday, Wednesday, and Friday, and that a dialysis communication binder with current vitals should accompany the resident to each dialysis appointment. However, the clinical record showed that no dialysis assessments were completed on specific dates in January and February 2025, despite the dialysis binder indicating that dialysis had been completed on those dates. Interviews with facility staff, including an LPN, an RN, and the DON, confirmed that post-dialysis assessments were expected to be completed upon the resident's return from dialysis, but these assessments were not documented in the resident's electronic medical record as required by the facility's policy.
Failure in Narcotic Count and Reconciliation
Penalty
Summary
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two of the three medication carts reviewed. During an observation of the 100A new medication cart, it was found that the Narcotic Sheet Log/Tracking Form lacked shift-to-shift count and reconciliation signatures for controlled medications on multiple dates in January and February 2025. Despite RN 4 indicating that the narcotic shift count was completed every shift, the documentation did not reflect this practice. Similarly, during an observation of the 100A old medication cart, it was noted that the Narcotic Sheet Log/Tracking Form also lacked shift-to-shift count and reconciliation signatures for several dates in February 2025. LPN 5 acknowledged that the narcotic count was supposed to be completed by the oncoming and off-going nurse during shift change, but admitted to not signing the narcotic sheet when taking over the medication cart. The Director of Nursing confirmed that staff were required to complete the narcotic sheet count during shift changes, as per the facility's policy.
Infection Control and Precaution Failures
Penalty
Summary
The facility failed to implement proper infection prevention and control strategies during wound care for a resident with pressure ulcers. The resident, who required enhanced barrier precautions due to a gastrostomy tube, was observed during a wound care procedure where the LPN did not follow appropriate infection control protocols. The LPN placed wound care supplies directly on surfaces without a barrier, assisted the resident in the bathroom without maintaining proper hygiene, and failed to perform hand hygiene after glove removal. Additionally, the LPN improperly handled PPE by not removing it before exiting the resident's room and used a contaminated paper towel to dry hands after washing. The facility also failed to ensure transmission-based precautions were followed for two residents placed on such precautions. One resident, who was on yellow zone transmission-based precautions, was observed outside of their room at the nurses' station without a mask, despite the requirement to remain in their room. Staff interviews revealed that the resident was brought out to the nurses' station to reduce fall risk, but this action was contrary to the precautions in place. The resident had respiratory symptoms and was awaiting test results for COVID-19, influenza, and RSV. Another resident on yellow transmission-based precautions was observed with a CNA who did not wear the required N95 mask and face shield/goggles upon entering the resident's room. The resident had tested positive for Influenza A, and the facility's policy required specific PPE to prevent transmission. The CNA acknowledged the failure to don the appropriate PPE, and the Infection Preventionist confirmed the requirements for entering rooms under transmission-based precautions.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for a dependent resident, identified as Resident 28. The resident had multiple diagnoses, including unspecified dementia, intervertebral disc degeneration, type 2 diabetes mellitus, generalized muscle weakness, and reduced mobility. Despite being at risk for pressure ulcers, the resident's care plan and interventions were not adequately adjusted when the resident experienced a decline in mobility. The clinical record lacked new interventions for pressure ulcer prevention prior to the development of the pressure ulcer on the resident's right heel. The resident's care plan included orders for floating heels, applying skin protectant, and using a pressure relief boot. However, observations and interviews revealed that these interventions were not consistently implemented. For instance, during a wound observation, the resident's left foot was not floated, and only one pressure relief boot was in place. Interviews with CNAs indicated that the resident required extensive assistance for repositioning and that some staff members were not adhering to the prescribed interventions, such as floating the resident's heels or using both pressure relief boots. The Director of Nursing (DON) and the Infection Preventionist acknowledged that the resident should have been reassessed for pressure ulcer risk when a decline in mobility was noted. The facility's policy on pressure injury prevention and management emphasized the need for prompt assessment and treatment, as well as modifying interventions as appropriate. However, the facility failed to implement these measures in a timely manner, resulting in the development of a pressure ulcer that progressed from a Stage 2 to an unstageable pressure ulcer with black eschar, and later to a healing Stage 3 pressure injury.
Failure to Confirm G-Tube Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure that the placement of a gastrostomy tube was confirmed prior to medication administration for a resident with a PEG tube. The resident had a history of post-immunization acute disseminated encephalitis, dysphagia, paraplegia, anxiety, and a seizure disorder. A physician's order required checking the G-tube placement before administering medications and maintaining NPO status. During a medication administration observation, an LPN did not check for residual gastric contents to confirm the tube placement before administering medications, which was against the facility's policy and the physician's order. Interviews with the LPN and the Director of Nursing confirmed that the placement of the feeding tube should be verified before administering anything through it. The facility's policy on tube feedings and medication administration also indicated that tube placement should be checked before administering medications. The failure to follow these protocols was observed and acknowledged by the staff involved, highlighting a lapse in adherence to established procedures for ensuring the safety and proper care of residents with feeding tubes.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Markle Health & Rehabilitation | 10.8 mi | ★★★★★ | 1 | 0 |
| Waters Of Huntington Skilled Nursing Facility, The | 13.1 mi | ★★★★★ | 18 | 1 |
| Hickory Creek At Huntington | 13.1 mi | ★★★★★ | 6 | 0 |
| Envive Of Huntington | 13.2 mi | ★★★★★ | 10 | 0 |
| River Terrace Health Care Center | 13.8 mi | ★★★★★ | 30 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.