Warren Operations RI, LLC DBA Warren Center

In the surveyor’s words

From the most serious findings on record at Warren Operations RI, LLC DBA Warren Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Aug 31, 2023

  Based on record review and staff interview, it has been determined that the facility failed to document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies which must be reviewed and updated as necessary, and at least annually. Additionally, the facility failed to review and update the assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. […]

• No harm, potential for more than minimal, patternF656Sep 19, 2025

  Based on record review and staff interview, it has been determined that the facility failed to implement comprehensive person-centered care plans for 4 of 6 residents reviewed for anticoagulation therapy (a medication that is prescribed to increase the amount of time it takes for blood to clot), Resident ID #s 4, 8, 62, and 64.Findings are as follows:1. Record review revealed Resident ID #4 was readmitted to the facility in May of 2025 with diagnoses including, but not limited to, atrial fibrillation (irregular heart rate) and history of transient ischemic attack (an episode of stroke-like symptoms caused by a brief blockage of blood flow to the brain).Record review revealed a physician's order dated 5/15/2025 for Eliquis 5 milligrams (mg) give one tablet every morning and at… […]

• No harm, potential for more than minimal, patternF658Sep 19, 2025

  Based on record review and staff interview, it has been determined that the facility failed to ensure that services provided meet professional standards of practice relative to physician's orders, for 1 of 1 resident who receives dialysis ( a medical procedure used to remove waste products and excessive fluid from the blood when the kidneys are no longer able to perform this function effectively), Resident ID #7. Findings are as follows:According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, The physician is responsible for directing medical treatment. […]

• No harm, potential for more than minimal, patternF690Sep 19, 2025

  Based on record review and staff interview, it has been determined that the facility failed to provide appropriate treatment and services for 2 of 3 residents reviewed with an indwelling catheter (a flexible tube that collects urine from the bladder and leads to a drainage bag), Resident ID #s 9, and 62.Findings are as follows:According to Brunner & Suddarth's Textbook of Medical-Surgical Nursing Volume 2, 10th Edition, page 1282 states, For patients with indwelling catheters, the nurse assesses the drainage system to ensure that it provides adequate urinary drainage. The color, odor, and volume of urine are also monitored. […]

• No harm, potential for more than minimal, patternF741Sep 19, 2025

  Based on record review and staff interview it has been determined that the facility failed to have sufficient staff who provide direct services to residents with the appropriate competencies and skill sets to provide nursing and related services, including training on caring for residents with mental and psychosocial disorders as well as residents with a history of trauma and/or post-traumatic stress disorder.Findings are as follows:Record review of the following staff members failed to reveal evidence of trauma informed care in-service training:- Nursing Assistant (NA), Staff D- hired on 5/16/2022- NA, Staff E- hired on 11/2/2024- NA, Staff F- hired on 4/18/2024- NA, Staff G- hired on 4/1/2025During a surveyor interview with the Director of Nursing Services on 9/19/2025 at 8:57 AM, she… […]