Inspection Reports for Warren Operations Ri LLC DBA Warren Center
642 METACOM AVENUE, WARREN, RI, 02885
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
10.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
200% worse than Rhode Island average
Rhode Island average: 3.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
78% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Census: 49
Capacity: 63
Deficiencies: 12
Sep 19, 2025
Visit Reason
A recertification survey was conducted at Warren Skilled Nursing and Rehabilitation from 9/16/2025 through 9/19/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities. State licensure and emergency preparedness surveys were also conducted.
Findings
Deficiencies were identified related to personal privacy/confidentiality of records, comprehensive care plans, professional standards of quality, quality of care, bowel/bladder incontinence and catheter care, staff sufficiency for behavioral health needs, medication administration errors, life safety code violations, and in-service education. The facility submitted a Plan of Correction to address these issues with ongoing audits and monitoring.
Severity Breakdown
D: 5
E: 5
F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Personal Privacy/Confidentiality of Records - Facility failed to protect identifying information of 12 residents in survey results binder. | D |
| Comprehensive Care Plans - Facility failed to implement comprehensive person-centered care plans for 4 of 6 residents reviewed for anticoagulation therapy. | E |
| Professional Standards of Quality - Facility failed to ensure services met professional standards for 1 resident receiving dialysis. | E |
| Quality of Care - Facility failed to ensure treatment and care in accordance with professional standards for monitoring intake/output for 1 resident. | D |
| Bowel/Bladder Incontinence, Catheter, UTI - Facility failed to provide appropriate treatment and services for residents with indwelling catheters and failed to monitor urinary output. | E |
| Sufficient/Competent Staff - Facility failed to provide sufficient staff with appropriate competencies to meet behavioral health needs related to trauma informed care. | E |
| Residents are Free of Significant Medication Errors - Facility failed to ensure residents were free of significant medication errors related to dialysis medication administration and blood pressure medication parameters. | E |
| Emergency Preparedness - Facility found in compliance with emergency preparedness requirements. | — |
| Life Safety Code - Facility failed to maintain stairways and smokeproof enclosures, and fire door assemblies in accordance with NFPA 101 Life Safety Code. | D |
| Hazardous Areas - Facility failed to maintain hazardous area enclosures in accordance with NFPA 101. | D |
| Rubbish Chutes, Incinerators, and Laundry Chutes - Facility failed to maintain laundry chute fire door assembly and related fire safety requirements. | F |
| In-Service Education - Facility failed to provide mandatory in-service education regarding food services and sanitation for staff. | — |
Report Facts
Census: 49
Total Capacity: 63
Deficiencies cited: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Monica Lopes | Administrator | Signed Plan of Correction and responsible for implementation |
Inspection Report
Annual Inspection
Census: 49
Capacity: 49
Deficiencies: 12
Sep 19, 2025
Visit Reason
A recertification survey was conducted at Warren Skilled Nursing and Rehabilitation from 9/16/2025 through 9/19/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Multiple deficiencies were identified related to personal privacy/confidentiality of records, comprehensive care plans, quality of care, bowel/bladder incontinence management, sufficient competent staff, medication administration errors, in-service education, and life safety code violations including stairways and smokeproof enclosures.
Severity Breakdown
D: 5
E: 5
F: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Facility failed to provide residents with the right to personal privacy and confidentiality of personal and medical records relative to the posting of past survey results. | D |
| Facility failed to implement comprehensive person-centered care plans for 4 of 6 residents reviewed related to anticoagulation therapy. | E |
| Facility failed to ensure professional standards of quality for dialysis resident related to medication administration. | E |
| Facility failed to ensure residents receive treatment and care in accordance with professional standards relative to monitoring intake and output for 1 resident. | D |
| Facility failed to ensure strict intake and output monitoring was implemented as documented in nursing notes. | D |
| Facility failed to provide appropriate treatment and services for residents with indwelling catheters including monitoring urinary output and documentation. | E |
| Facility failed to have sufficient staff with competencies and skills to provide nursing and related services including training on trauma informed care. | E |
| Facility failed to ensure residents are free from significant medication errors for dialysis resident and others related to medication administration and documentation. | E |
| Facility failed to provide mandatory in-service education regarding food services and sanitation for staff. | — |
| Facility failed to maintain stairways and smokeproof enclosures used as exits in accordance with NFPA 101 Life Safety Code. | D |
| Facility failed to maintain hazardous area enclosures in accordance with NFPA 101 Life Safety Code. | D |
| Facility failed to maintain laundry chute in proper condition in accordance with NFPA 101 Life Safety Code. | F |
Report Facts
Census: 49
Total Capacity: 49
Deficiencies cited: 12
Residents with care plan deficiencies: 4
Residents with medication errors: 2
Staff members lacking trauma informed care training: 4
Residents with indwelling catheters reviewed: 3
Inspection Report
Deficiencies: 0
Aug 21, 2025
Visit Reason
A Federal recertification survey, State Licensure survey and complaint investigation survey were conducted at this facility from 08/20/2025 through 08/21/2025.
Findings
No deficiencies were identified during the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Sep 26, 2024
Visit Reason
An off-site desk audit was conducted on September 26, 2024, to review all previous deficiencies cited on August 16, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all previous deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Census: 50
Capacity: 63
Deficiencies: 12
Aug 16, 2024
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Warren Skilled Nursing and Rehabilitation from 08/13/2024 through 08/16/2024 to determine compliance with federal and state requirements for Long Term Care Facilities, including licensure and emergency preparedness.
Findings
Deficiencies were cited in multiple areas including bed hold policy before/after transfer, comprehensive care plans, meeting professional standards for services, following physician's orders, nurse aide in-service training, medication administration, resident records accuracy, accident hazards supervision, life safety code compliance, and emergency preparedness. The facility failed to provide required documentation, update care plans timely, and ensure staff compliance with orders and training.
Complaint Details
The survey included a complaint investigation under ACTS Reference Number 96799. Deficiencies were cited as a result of this complaint investigation.
Severity Breakdown
Level 2: 1
Level 3: 11
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to provide written information specifying the facility's bed-hold bed payment policy before and upon transfer to hospital for 5 of 6 residents transferred. | Level 2 |
| Failed to develop and implement a comprehensive person-centered care plan for 1 of 2 residents reviewed relative to falls resulting in injury. | Level 3 |
| Failed to meet professional standards of quality for 1 of 1 resident reviewed with physician's orders for Lidocaine patch, TED stockings, heel protectors, and weight loss interventions. | Level 3 |
| Failed to ensure adequate supervision to prevent accidents for 1 of 4 residents reviewed. | Level 3 |
| Failed to complete annual performance reviews for 3 of 3 nurse aides reviewed. | Level 3 |
| Failed to ensure residents are free of significant medication errors for 2 of 2 residents reviewed for insulin administration. | Level 3 |
| Failed to maintain medical records that are accurate, complete, and systematically organized for 5 of 13 residents reviewed. | Level 3 |
| Failed to ensure each resident receives adequate supervision to prevent accidents relative to 1 to 1 supervision while eating for 1 of 4 residents reviewed. | Level 3 |
| Failed to maintain means of egress free of all obstructions in accordance with NFPA 101 Life Safety Code, impacting 16 residents in one smoke zone. | Level 3 |
| Failed to maintain stairways and smokeproof enclosures free of items obstructing egress. | Level 3 |
| Failed to provide evidence that fire drills were conducted at varied times on all shifts as required. | Level 3 |
| Failed to ensure emergency power supply system (EPSS) generator was maintained and tested in accordance with NFPA standards. | Level 3 |
Report Facts
Residents transferred to hospital without bed hold policy notice: 5
Residents reviewed for comprehensive care plan: 2
Residents reviewed for professional standards: 6
Residents reviewed for accident supervision: 4
Nurse aides reviewed for annual performance review: 3
Residents reviewed for medication errors: 2
Residents reviewed for medical records accuracy: 13
Residents impacted by means of egress deficiency: 16
Residents impacted by fire drills deficiency: 50
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 17, 2024
Visit Reason
A complaint investigation survey was conducted at the facility on 01/17/2024 to determine compliance with Federal and State Laws and Regulations.
Findings
No deficiencies were identified during the complaint investigation survey.
Complaint Details
Complaint investigation survey, ACTS reference numbers 93906, was conducted to determine compliance. No deficiencies were identified.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 4, 2023
Visit Reason
A revisit survey was conducted on October 4, 2023, for all previous deficiencies cited on August 29, 2023, related to the Re-certification/Licensure Life Safety Code survey.
Findings
All deficiencies have been corrected and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Annual Inspection
Deficiencies: 9
Aug 31, 2023
Visit Reason
A Recertification Survey and Complaint Investigation Survey were conducted at Warren Skilled Nursing and Rehabilitation on 8/28/2023 to determine compliance with Federal and State Laws and Regulations. Additionally, an annual Federal Life Safety Code survey was conducted by the State Survey Agency.
Findings
Deficiencies were cited related to tube feeding management, medication errors, facility assessment, resident records, life safety code violations including means of egress, cooking facilities, sprinkler system installation, fire drills, and maintenance of smoke and fire doors. The facility failed to meet several regulatory requirements, including medication error rates above 5%, incomplete facility assessments, and fire safety code compliance issues.
Complaint Details
Complaint investigation was part of the recertification survey conducted on 8/28/2023. Deficiencies related to tube feeding management and medication errors were cited based on complaint findings.
Severity Breakdown
SS=E: 2
SS=F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to ensure residents who require feeding tubes receive appropriate treatment and services to prevent complications. | — |
| Medication error rate exceeded 5%, with 3 errors in 27 opportunities (11.1%). | — |
| Failure to conduct and document a comprehensive facility assessment as required. | — |
| Failure to maintain resident records accurately and confidentially, including opioid administration documentation. | — |
| Means of egress obstructed by tables and chairs; missing door handle and obstacles outside exit door. | SS=E |
| Kitchen hood suppression system not maintained according to NFPA standards. | — |
| Sprinkler system components did not meet installation requirements per NFPA standards. | SS=E |
| Fire drills not conducted at varied times on all shifts as required. | SS=F |
| Maintenance, inspection, and testing of fire doors not properly documented or conducted. | SS=F |
Report Facts
Medication error rate: 11.1
Residents potentially affected by means of egress deficiency: 32
Residents potentially affected by kitchen hood suppression deficiency: 44
Residents potentially affected by sprinkler system deficiency: 44
Residents potentially affected by fire drills deficiency: 44
Residents potentially affected by fire door maintenance deficiency: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Interviewed regarding feeding tube supplement holding |
| Staff B | Licensed Practical Nurse (LPN) | Present during interview about feeding tube supplement |
| Staff C | Certified Medication Technician (CMT) | Observed during medication administration errors |
| Staff D | Unit Manager | Acknowledged medication administration and MAR documentation errors |
| Administrator | Acknowledged facility assessment incompleteness | |
| Maintenance Director | Acknowledged and responsible for fire safety deficiencies and corrective actions |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 23, 2022
Visit Reason
An off-site desk audit was conducted on August 23, 2022 for all previous deficiencies cited on July 20, 2022.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected. The facility is in compliance with all regulations surveyed.
Inspection Report
Renewal
Deficiencies: 3
Jul 20, 2022
Visit Reason
A Recertification Survey, vaccination compliance, and complaint investigation survey ACTS Reference Numbers 85536 and 85958 were conducted at Warren Skilled Nursing and Rehabilitation from 07/18/2022 through 07/20/2022 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. A State licensure and emergency preparedness surveys were also conducted.
Findings
Deficiencies were cited related to failure to implement a comprehensive person-centered care plan for one resident regarding skin integrity, failure to ensure proper hydration status maintenance for one resident, and failure to establish smoking policies in accordance with applicable laws. No Life Safety Code deficiencies were identified during the annual fire safety survey.
Complaint Details
Complaint investigation was part of the survey as indicated by reference numbers 85536 and 85958. Specific substantiation status is not stated.
Deficiencies (3)
| Description |
|---|
| Failure to implement a comprehensive person-centered care plan for one resident related to skin integrity and weekly skin assessments. |
| Failure to ensure proper hydration status maintenance for one resident with fluid restrictions, including lack of evidence of sufficient fluid intake documentation. |
| Failure to establish smoking policies in accordance with Federal, State, and local laws regarding smoking areas and smoking safety. |
Report Facts
Survey reference numbers: 2
Dates of survey: 3
Plan of correction completion dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Susan LaNina | Administrator | Signed the plan of correction documents. |
Inspection Report
Life Safety
Deficiencies: 0
Jun 29, 2021
Visit Reason
The inspection was conducted to verify compliance with the Life Safety Code, 2012 Edition of NFPA 101, following a previous plan of correction.
Findings
Based on an acceptable Plan of Correction and supporting documentation, compliance with the Life Safety Code has been achieved. An off-site desk audit confirmed that all previous deficiencies cited on May 28, 2021, have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Life Safety
Deficiencies: 3
May 27, 2021
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency to assess compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition, focusing on physical environment and life safety code requirements.
Findings
Deficiencies were identified related to means of egress, storage of combustible materials, kitchen hood fire suppression system maintenance, and emergency electrical systems including generator maintenance and testing. Corrective actions and systemic changes were planned and monitoring established.
Deficiencies (3)
| Description |
|---|
| Means of egress hallways were not maintained free of obstructions, specifically recliners stored in exit corridors. |
| Kitchen hood fire suppression system was not maintained in accordance with NFPA standards. |
| Emergency electrical systems lacked proper documentation and maintenance records, including generator testing and battery maintenance. |
Report Facts
Survey date: May 27, 2021
Corrective action completion dates: Jun 5, 2021
Corrective action completion dates: Jun 8, 2021
Monitoring period: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Richard N. Mancini | Center Executive Director | Signed the Life Safety Code survey report |
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