Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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 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 | — | 0 | 0 |
| Crestwood Nursing & Rehabilitation Center Inc | 1.5 mi | — | 3 | 0 |
| The Dawn Hill Home For Rehab And Healthcare | 1.8 mi | — | 5 | 0 |
| Silver Creek Rehab And Healthcare Center | 2.4 mi | — | 11 | 0 |
| Country Gardens Health And Rehabilitation Center | 3.5 mi | — | 3 | 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 August 2026) and official state health department websites.