Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warren Operations Ri, Llc Dba Warren Center during CMS and state inspections, most recent first.
Failure to implement anticoagulation monitoring care plans for four residents. Residents receiving Eliquis or warfarin had care plans addressing bleeding risk and signs of active bleeding, but record review showed no evidence the plans were being carried out. An RN and an LPN were unable to provide evidence that the residents were being monitored for signs and symptoms of abnormal bleeding.
Failure to Administer Ordered Medications: A resident with ESRD and dependence on renal dialysis had multiple physician-ordered medications, including supplements, antidepressants, a stool softener, an iron supplement, protein liquid, and quetiapine, that were not documented as administered on several occasions in the MARs. The DON stated medications should be given as ordered but could not provide evidence that the ordered doses were administered.
Failure to document urinary output for two residents with indwelling Foley catheters. Both residents had diagnoses including obstructive uropathy, urinary retention, and UTI, and both care plans directed staff to monitor catheter output for odor, color, consistency, and amount. The record lacked evidence that output was documented, and the DON could not show how changes in urine output would be identified without measurement; the MD stated output should be documented.
Missing trauma-informed care training for several NAs was identified during record review. Four NAs had no evidence of the required in-service training, and the DON acknowledged that the training had not been completed for those staff members.
A resident with ESRD on dialysis missed multiple ordered doses of Eliquis and Renvela, and staff confirmed the medications were not administered as prescribed. Another resident with HTN received Metoprolol Tartrate despite ordered hold parameters, with MAR review showing numerous doses given when the pulse was below 70; staff, including a CMT, LPN, and DON, acknowledged the medication was administered outside the ordered parameters.
Failure to protect resident privacy and confidentiality occurred when a survey results binder was observed in the main lobby containing a prior recertification survey and a resident/staff roster with identifying information for 12 residents. The Administrator was unable to provide evidence that the facility protected the residents’ identifying information.
Failure to implement strict intake and output monitoring occurred for a resident with AKI and elevated creatinine levels. The resident returned from the hospital with instructions to drink at least 64 ounces of fluids by 3:00 PM each day, receive 1 liter of NS if that amount was not consumed, and return to the ED if urine, eating, or drinking stopped. A physician note also documented the need for strict I&O to monitor kidney function, but the record showed no evidence that it was carried out, and the DON could not provide evidence that it had been implemented.
A resident with pneumonia and dysphagia did not receive their prescribed Ipratropium-Albuterol inhaler on multiple occasions due to a failure in the facility's medication ordering process. The nurse on duty did not verify the physician's order, resulting in the inhaler not being sent to the pharmacy and subsequently not delivered to the facility in time. This led to the resident missing several doses, as confirmed by the DON and a Nurse Practitioner.
The facility failed to comply with physician's orders for several residents, including not removing a Lidocaine patch at bedtime, not applying heel protectors or offloading heels, and not using TED stockings for hypotension. Additionally, weekly weights were not obtained for residents with orders for weight monitoring. These deficiencies were confirmed by staff and acknowledged by the DNS.
The facility did not complete annual performance evaluations for three nurse aides, as required. Personnel files for Staff H, I, and J showed no evidence of evaluations, despite their long-term employment. The issue was identified during a surveyor interview with the DON, who confirmed the evaluations had not been conducted within the past year.
The facility failed to prevent significant medication errors in insulin administration for two residents with type 2 diabetes. One resident received Lispro insulin outside of prescribed blood sugar parameters on multiple occasions, as acknowledged by two RNs. Another resident did not receive insulin Glargine as ordered, with the DON unable to provide evidence of administration. These incidents indicate lapses in following physician orders and medication protocols.
A resident with a history of traumatic brain injury and dysphagia was not provided the required 1 to 1 supervision during meals, as ordered by a physician. Observations showed the resident was left unsupervised with their meal tray, and staff interviews revealed a lack of awareness about the supervision requirement. The unit manager and DON acknowledged the oversight after reviewing the resident's care plan.
The facility failed to maintain accurate medical records for five residents, including not removing a Lidocaine patch, not applying heel protectors, and not obtaining weights as ordered. Staff signed off tasks as completed without performing them, as confirmed by the DNS.
A resident with a history of falls and diagnoses including muscle weakness and cognitive communication deficit experienced multiple falls without timely updates to their care plan. Despite falls occurring on several occasions, the care plan was not revised with new interventions until after the fourth fall, which resulted in hospitalization. The DON could not provide evidence of care plan updates following the initial falls.
The facility did not provide written information about the bed-hold payment policy to residents or their representatives before and upon transfer to a hospital. This issue affected five residents, and staff could not provide evidence that these residents were informed about the policy.
Failure to Implement Anticoagulation Monitoring Care Plans
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for 4 of 6 residents reviewed for anticoagulation therapy: Resident IDs 4, 8, 62, and 64. Record review showed that each resident had a care plan addressing risk for injury or complications related to anticoagulation use, with interventions to observe for signs of active bleeding such as bruising, blood in the urine, blood in the stool, nose bleeds, or bleeding gums. However, record review failed to reveal evidence that these care plans were being implemented relative to observing for signs and symptoms of abnormal bleeding. Resident ID #4 was readmitted with diagnoses including atrial fibrillation and a history of transient ischemic attack and had an order for Eliquis 5 mg twice daily. Resident ID #8 was readmitted with chronic atrial fibrillation and had an order for Eliquis 5 mg twice daily. Resident ID #62 was admitted with atrial fibrillation and had warfarin orders that were discontinued and replaced over several days, with a care plan goal that the resident would not exhibit signs and symptoms of bleeding for 90 days. Resident ID #64 was admitted with atrial fibrillation, embolism, and thrombosis of the superficial veins of the lower extremity and had an order for warfarin sodium 7.5 mg at bedtime. During surveyor interviews, an RN and an LPN were unable to provide evidence that Residents #4, 8, 62, and 64 were being monitored for signs and symptoms of abnormal bleeding.
Failure to Administer Ordered Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice related to physician's orders for one resident who received dialysis and had diagnoses including end stage renal disease and dependence on renal dialysis. The resident was admitted in August 2025, and physician's orders included cholecalciferol, citalopram hydrobromide, docusate sodium, ferrous sulfate, protein liquid, quetiapine fumarate, and trazadone. Record review of the August and September 2025 MARs did not show evidence that the morning doses of cholecalciferol, citalopram hydrobromide, docusate sodium, ferrous sulfate, protein liquid, and quetiapine fumarate were administered as ordered on multiple dates. The September 2025 MAR also did not show evidence that trazadone was administered as ordered for the 7:00 AM to 12:00 PM dose on multiple dates. During interview, the DON stated she would expect the medications to be administered as ordered and was unable to provide evidence that the medications were given on the listed dates and times.
Failure to Document Urinary Output for Residents With Indwelling Catheters
Penalty
Summary
Appropriate treatment and services were not provided for two residents with indwelling urinary catheters. One resident was readmitted with diagnoses including obstructive uropathy, urinary retention, acute kidney failure, and UTI, and had a physician order for an indwelling urinary catheter for obstructive uropathy. The resident’s care plan, initiated earlier in the year, directed staff to monitor catheter output for odor, color, consistency, and amount, but the record did not show documentation that urinary output was monitored. A second resident was readmitted with diagnoses including obstructive uropathy, urinary retention, tubule-interstitial nephritis, and UTI, and had an indwelling urinary catheter for bilateral hydroureteronephrosis. This resident’s care plan also directed staff to monitor output for odor, color, consistency, and amount, but the record likewise lacked evidence that urinary output was documented. During interview, the DON was unable to provide evidence that the facility documented urinary output for residents with urinary catheters or explain how changes in output would be identified without such documentation. The Medical Director stated it would be his expectation that output be documented for a resident with an indwelling urinary catheter.
Missing Trauma-Informed Care Training for Nursing Assistants
Penalty
Summary
The facility failed to have sufficient staff members with the competencies and skill sets needed to provide nursing and related services for residents with behavioral health needs, including training on caring for residents with mental and psychosocial disorders and residents with a history of trauma and/or post-traumatic stress disorder. Record review showed no evidence of trauma informed care in-service training for four Nursing Assistants: Staff D, hired 5/16/2022; Staff E, hired 11/2/2024; Staff F, hired 4/18/2024; and Staff G, hired 4/1/2025. During interview, the DON acknowledged that the trauma informed care in-service had not been completed for these staff members.
Significant Medication Errors and Failure to Follow Hold Parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for a dialysis resident and a resident receiving blood pressure medication with hold parameters. Resident ID #7, admitted with end stage renal disease and dependence on renal dialysis, had physician orders for Eliquis 2.5 mg twice daily and Renvela 0.8 grams three times daily. Review of the MAR for August and September 2025 showed no evidence that Eliquis was administered on four morning doses, and no evidence that the morning dose of Renvela was administered on multiple dates. Staff A acknowledged the medications were not given as ordered, and both the NP and DNS stated the resident should have received the medications as ordered. Resident ID #38, admitted with hypertension, had an order for Metoprolol Tartrate 25 mg every morning and at bedtime with instructions to hold the medication if systolic BP was less than 100 or pulse was less than 70. Review of the MAR showed multiple doses were signed off as given even though the resident’s pulse was below 70 for 11 morning doses and 23 bedtime doses between August and September 2025. A CMT acknowledged the medication was signed off as administered when the pulse was less than 70, an LPN acknowledged it was given outside of parameters, and the DNS acknowledged it should have been held due to the low pulse readings.
Failure to Protect Confidential Resident Information in Survey Binder
Penalty
Summary
The facility failed to protect residents’ right to personal privacy and confidentiality of personal and medical records when past survey results were posted in a survey results binder in the main lobby. During observation, the binder was seen in the lobby area, and record review showed it contained copies of a previous recertification survey dated 8/16/2024, including a resident/staff roster with identifying information for 12 residents. During interview, the Administrator was unable to provide evidence that the facility protected the identifying information of the 12 residents listed in the binder.
Failure to Implement Strict Intake and Output Monitoring for Resident With AKI
Penalty
Summary
Failure to provide treatment and care according to orders, resident preferences, and goals occurred when strict intake and output monitoring was not implemented for a resident with acute kidney injury. The resident was admitted in June 2025 with diagnoses including cerebral infarction and AKI, with a creatinine level of 4.98 mg/dL. After being rehospitalized with continued AKI and a creatinine level of 5.93 mg/dL, the resident returned to the facility with recommendations to drink at least 64 ounces of liquids by 3:00 PM each day and to receive 1 liter of normal saline if that amount was not consumed by that time. The resident was also instructed to return to the emergency department if he or she stopped making urine, eating, or drinking. A physician progress note documented that the resident had been hospitalized due to an elevated creatinine of approximately 6 mg/dL and that strict intake and output monitoring was needed to monitor kidney function. However, the record did not show evidence that strict intake and output monitoring was implemented. During interview, the physician stated that nurses were expected to follow through with the strict intake and output monitoring documented in the note, and the DON, in the presence of the Administrator, was unable to provide evidence that such monitoring had been implemented for the resident.
Failure to Administer Prescribed Inhaler Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the resident not receiving their prescribed inhaler medication on multiple occasions. The resident, who was admitted with diagnoses including pneumonia and dysphagia, had a physician's order for Ipratropium-Albuterol solution to be administered four times daily. However, the Medication Administration Record showed that the inhaler was not administered on several specified dates and times. The Director of Nursing Services acknowledged that the failure occurred because the nurse on duty did not verify the order when it was entered, resulting in the order not being sent to the pharmacy for delivery. Consequently, the inhaler was not delivered to the facility until two days later, leading to the resident missing multiple doses. A Nurse Practitioner also confirmed that she was unaware of the missed doses until after the fact and expected the order to have been sent to the pharmacy and administered as prescribed.
Non-Compliance with Physician's Orders in Resident Care
Penalty
Summary
The facility failed to meet professional standards of quality for several residents due to non-compliance with physician's orders. For Resident ID #8, a Lidocaine patch was not removed at bedtime as ordered, which was confirmed by Certified Medication Technicians during interviews. Resident ID #22 did not have heel protectors applied or heels offloaded while in bed, as observed on multiple occasions, and acknowledged by the Director of Nursing Services (DNS). Similarly, Resident ID #26 was not wearing TED stockings as ordered for hypotension, which was confirmed by staff during interviews. Additionally, the facility failed to obtain and document weekly weights for residents with physician's orders for weight monitoring. Resident ID #29's weight was not recorded for the week of 8/5/2024, and Resident ID #34's weights were not documented for the weeks of 7/29/2024 and 8/5/2024. These omissions were acknowledged by the DNS during interviews. The deficiencies highlight a pattern of non-compliance with physician's orders, impacting the care and monitoring of residents with specific medical needs.
Failure to Conduct Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to conduct annual performance evaluations for nurse aides, as required, for three staff members. A review of personnel files revealed no evidence of completed evaluations for Staff H, I, and J. Staff H was hired in November 2007, Staff I in May 2023, and Staff J in September 2015. During an interview with the Director of Nursing Services, it was confirmed that performance evaluations had not been completed within the last 12 months for these employees, and this issue was only identified when brought to the attention of the Director by a surveyor on August 15, 2024.
Medication Administration Errors in Insulin Management
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. For one resident with type 2 diabetes mellitus, there were multiple instances in July and August 2024 where Lispro insulin was administered despite blood sugar levels being below the physician-ordered threshold of 150. This occurred on several dates, with blood sugar readings ranging from 101 to 145. During interviews, two registered nurses acknowledged administering insulin outside of the prescribed parameters, indicating a lack of adherence to the physician's orders. Another resident, also with type 2 diabetes mellitus, experienced a failure in the administration of insulin Glargine. A Nurse Practitioner's note indicated that the insulin was to be held on one day and started the following morning. However, the August 2024 Medication Administration Record did not show evidence of the Glargine being administered as ordered on the specified date. The Director of Nursing Services was unable to provide evidence of compliance with the order, highlighting a lapse in medication administration protocol.
Failure to Provide 1 to 1 Supervision During Meals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required 1 to 1 supervision while eating. The resident, admitted in August 2024, had a history of traumatic brain injury and was diagnosed with dysphagia, necessitating a puree texture diet with 1 to 1 supervision during meals. Despite a physician's order for such supervision, surveyor observations on two separate occasions revealed that the resident was left unsupervised with their meal tray, contrary to the prescribed care plan. Interviews with staff members, including nursing assistants and the unit manager, indicated a lack of awareness regarding the resident's need for 1 to 1 supervision during meals. The unit manager initially believed the resident could feed themselves independently but later acknowledged the requirement for supervision after reviewing the medical record. The speech therapist confirmed that the supervision was necessary for the resident's safety due to dysphagia. The Director of Nursing Services was unable to provide evidence that the supervision order was being followed, highlighting a significant oversight in the resident's care plan implementation.
Inaccurate Medical Record-Keeping and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for five residents. For Resident ID #8, a Lidocaine patch was not removed at bedtime as per the physician's order, despite being signed off as completed in the Medication Administration Record (MAR). Staff B acknowledged the oversight, and Staff C admitted to signing off the task without completing it. Resident ID #22 did not have heel protectors applied or heels offloaded as ordered, despite these tasks being signed off as completed in the Treatment Administration Record (TAR). The Director of Nursing Services (DNS) confirmed the tasks were not completed and expressed that orders should only be signed off if completed. Similarly, Resident ID #26 was not provided with [NAME] stockings as ordered, although the TAR indicated they were applied. Staff D and E acknowledged the oversight, and the DNS reiterated the expectation for accurate documentation. For Resident ID #29 and Resident ID #34, weights were not obtained as ordered, yet the MARs indicated they were. The DNS confirmed the weights were not recorded and emphasized the importance of accurate documentation. These deficiencies highlight a pattern of inaccurate record-keeping and failure to follow physician orders, impacting the care provided to the residents.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a history of falls. The resident, admitted in July 2024, had diagnoses including muscle weakness, cognitive communication deficit, and a history of falling. The care plan dated 7/22/2024 identified the resident as at risk for falls due to impaired mobility, with interventions such as providing choices and maintaining a clutter-free environment. However, the resident experienced multiple falls on 8/1, 8/6, and 8/8, with the last fall resulting in hospitalization and bruising around the eyes and forehead. The care plan was not updated with new interventions after each fall until after the fourth fall on 8/8/2024. During an interview, the Director of Nursing Services could not provide evidence that the care plan had been updated to address the falling risk after the initial falls on 8/1 and 8/6.
Failure to Provide Bed-Hold Policy Information
Penalty
Summary
The facility failed to provide written information to residents or their representatives regarding the bed-hold payment policy before and upon transfer to a hospital. This deficiency was identified for five out of six residents who were transferred to the hospital. Specifically, residents with IDs 15, 21, 24, 51, and 205 were transferred on various dates, and there was no evidence that they were offered the opportunity to request a bed hold as required by the facility's policy. During an interview, Staff A from the business office was unable to provide documentation that these residents were informed about the bed-hold policy upon their transfer to the hospital.
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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) |
|---|---|---|---|---|
| Grace Barker Nursing Center | 1 mi | ★★★★★ | 4 | 0 |
| Crestwood Nursing & Rehabilitation Center Inc | 1.5 mi | ★★★★★ | 3 | 0 |
| The Dawn Hill Home For Rehab And Healthcare | 1.8 mi | ★★★★★ | 9 | 0 |
| Silver Creek Rehab And Healthcare Center | 2.4 mi | ★★★★★ | 11 | 0 |
| Country Gardens Health And Rehabilitation | 3.5 mi | ★★★★★ | 3 | 0 |
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