Inspection Reports for Warrensburg Manor Health Care Center
400 Care Center Dr, Warrensburg, MO 64093, United States, MO, 64093
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
43 residents
Based on a September 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 43
Deficiencies: 6
Date: Sep 19, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with federal and state regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including inaccurate Minimum Data Set (MDS) assessments, incomplete care plans especially related to nutritional status and edema management, inadequate fall investigation and follow-up, improper storage and maintenance of oxygen equipment, failure to maintain required RN staffing and Director of Nursing (DON) coverage, and unsafe storage of cleaning chemicals in a resident's room.
Deficiencies (6)
Failure to ensure accurate MDS assessments and update care plans for residents with swallowing, choking, and weight loss issues.
Failure to develop and implement a complete care plan addressing all resident needs including nutritional status and edema management.
Failure to complete thorough fall investigation, update fall care plan with interventions, and monitor effectiveness for a resident who fell and sustained head injury.
Failure to ensure oxygen equipment was stored properly in plastic bags when not in use, tubing and humidifier bottles were not changed timely, and oxygen tubing was improperly coiled around equipment for three residents.
Failure to maintain RN staffing eight hours per day, seven days per week and to have a full-time Director of Nursing onsite as required.
Failure to ensure safe and secure storage of cleaning chemicals including bleach and laundry soap in a resident's room.
Report Facts
Facility census: 43
Weight loss: 13
RN hours missing: 4
Interim DON hours: 52
Oxygen tubing date: 8
Oxygen tubing date: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse A | LPN | Provided information on MDS assessments and oxygen equipment maintenance |
| Certified Nursing Assistant E | CNA | Interviewed regarding resident feeding, oxygen equipment storage, and fall precautions |
| Director of Nursing | DON | Provided expectations for MDS accuracy, care plan updates, fall investigations, and oxygen equipment maintenance |
| Assistant Director of Nursing | ADON | Discussed fall follow-up procedures and oxygen equipment maintenance |
| Certified Medication Technician B | CMT | Reported on facility DON staffing and resident care |
| Interim Director of Nursing | Interim DON | Discussed staffing coverage and care plan expectations |
| Administrator | Administrator | Discussed staffing challenges and PBJ reporting |
| Housekeeper A | Housekeeper | Reported awareness of cleaning chemicals in resident room |
| Laundry Aid A | Laundry Aid | Interviewed about laundry soap and bleach in resident room |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Aug 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an incident where Resident #2 was found in Resident #1's room with his/her hand under Resident #1's shirt, touching his/her breast, raising concerns of resident-to-resident sexual abuse.
Complaint Details
The investigation was triggered by a complaint regarding Resident #2's inappropriate sexual behavior towards Resident #1. The complaint was substantiated based on observations, interviews, and record reviews confirming the incident and ongoing risk.
Findings
The facility failed to ensure Resident #1 was free from resident-to-resident abuse. Resident #2, who had a history of sexually inappropriate behavior, entered Resident #1's room multiple times despite staff interventions. The bathroom door between the rooms was found unlocked, allowing Resident #2 access. Staff placed Resident #2 on 1:1 observation and moved him/her to a different room. Family members and staff interviews confirmed awareness of Resident #2's behaviors and the facility's attempts to manage the risk.
Deficiencies (1)
Failure to protect Resident #1 from resident-to-resident sexual abuse by Resident #2.
Report Facts
Residents present: 50
Sampled residents: 7
Brief Interview for Mental Status (BIMS) score: 0
Brief Interview for Mental Status (BIMS) score: 3
Date of incident: Jul 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) A | Discovered Resident #2 in Resident #1's room and reported the event | |
| Certified Nursing Assistant (CNA) B | Provided 1:1 observation of Resident #2 and reported inappropriate remarks | |
| Licensed Practical Nurse (LPN) A | Provided statement about the incident and staff interventions | |
| Social Worker | Interviewed regarding Resident #2's admission and behavior | |
| MDS Coordinator A | Discussed referral and admission process for Resident #2 | |
| Administrator | Provided overview of facility response and monitoring of Resident #2 |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Feb 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding the treatment of residents by an agency Licensed Practical Nurse (LPN) who was allegedly inconsiderate, raised his/her voice, and was argumentative with residents.
Complaint Details
The complaint involved Agency LPN A being inconsiderate, raising his/her voice, and being argumentative with residents, including Resident #1 who has severe cognitive impairment and Resident #18 with bipolar disorder. Multiple staff and residents witnessed the behavior. Agency LPN A was asked to leave the facility and placed on leave pending investigation.
Findings
The facility failed to ensure two sampled residents were treated with dignity and respect. Agency LPN A was reported to have raised his/her voice and been argumentative with residents, including incidents involving Resident #1 and Resident #18. The facility investigated, obtained witness statements, and removed Agency LPN A from the facility.
Deficiencies (1)
Failure to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Report Facts
Residents affected: 2
Facility census: 53
Sampled residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency LPN A | Licensed Practical Nurse | Named in findings related to disrespectful and argumentative behavior toward residents. |
| Certified Nurses Aide B | Certified Nurses Aide | Provided witness statement regarding Agency LPN A's behavior. |
| Certified Medication Technician B | Certified Medication Technician | Witnessed and reported interactions between Agency LPN A and Resident #1. |
| Housekeeping Supervisor | Reported Resident #1's upset state and Agency LPN A's behavior to the Administrator. | |
| Administrator | Facility Administrator | Conducted investigation and removed Agency LPN A from the facility. |
| Director of Nursing | Director of Nursing | Provided interview regarding expectations for documentation and staff orientation. |
| Agency Human Resources | Human Resources | Verified information and placed Agency LPN A on leave pending investigation. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 9
Date: Feb 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding resident dignity and respect, infection control practices, care plan comprehensiveness, medication storage, hospice services, vaccination offerings, and facility maintenance issues.
Complaint Details
The complaint investigation was triggered by allegations of resident mistreatment, infection control breaches during an outbreak, inadequate care planning, medication storage issues, hospice service coordination failures, vaccination offering deficiencies, and facility maintenance problems.
Findings
The facility failed to ensure residents were treated with dignity and respect by staff, maintain infection control practices during an outbreak, develop comprehensive care plans reflecting current resident status including hospice care, monitor and reconcile medications in the Cubex system, offer vaccinations to all residents, and maintain facility equipment such as windows and vending machine areas.
Deficiencies (9)
Failed to ensure two sampled residents were treated with dignity and respect by an agency LPN who raised his/her voice and was argumentative.
Failed to maintain Resident #31's wheelchair clean and free of hair clumps; failed to prevent storage of contaminated trash in shower rooms; failed to maintain shower room and ceiling fans in good repair.
Failed to develop comprehensive, individualized care plans reflecting current health status for six sampled residents, including lack of hospice care plans and fall prevention interventions.
Failed to ensure safe medication storage system and monitoring of Cubex medication dispensing system.
Failed to maintain kitchen and dry good storage areas free of dust and grime, maintain faucet to prevent leaking, and maintain floors and refrigerator gasket in good repair.
Failed to ensure physician's orders for hospice services were transcribed onto the physician's order sheet including service provider, services provided, and frequency for four sampled residents.
Failed to implement infection prevention and control program including outbreak management, transmission based precautions, hand hygiene, PPE use, signage, visitor notification, and monitoring during a gastrointestinal illness outbreak affecting multiple residents.
Failed to ensure windows in rooms of two sampled residents operated properly for resident convenience and failed to maintain area under vending machine free of dust and grime.
Failed to offer influenza and pneumococcal vaccinations to one sampled resident and one supplemental resident, and failed to document vaccination status.
Report Facts
Facility census: 53
Residents affected by dignity deficiency: 2
Residents affected by wheelchair and environment deficiency: 40
Sampled residents with care plan deficiencies: 6
Residents affected by medication storage deficiency: 53
Residents affected by infection control deficiency: 28
Residents affected by hospice order deficiency: 4
Residents affected by vaccination deficiency: 2
Residents affected by window and vending machine deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency Licensed Practical Nurse A | Agency LPN | Named in findings related to resident mistreatment and verbal altercations with residents #1 and #18 |
| Certified Nurses Aide B | CNA | Witness statement regarding Agency LPN A's behavior |
| Certified Medication Technician B | CMT | Witness to Agency LPN A's behavior and resident interactions |
| Housekeeping Supervisor | Provided observations and statements regarding environmental cleanliness and resident concerns | |
| Administrator | Involved in investigation and removal of Agency LPN A; provided statements on facility policies and outbreak management | |
| Director of Nursing | DON | Provided statements on care plan responsibilities, infection control, and medication storage |
| Agency Human Resources | HR | Verified investigation and leave status of Agency LPN A |
| Certified Medication Technician D | CMT | Provided statements on resident behaviors and infection control |
| Licensed Practical Nurse B | LPN | Provided statements on care plans and Cubex system |
| MDS Coordinator | Responsible for care plan monitoring and updating | |
| Infection Control Preventionist | Provided statements on outbreak management and infection control policies | |
| Certified Nursing Assistant D | CNA | Provided statements on infection control practices and resident care |
| Certified Nursing Assistant A | CNA | Observed providing care without proper hand hygiene and PPE |
| Certified Medication Technician C | CMT | Provided statements on infection control and visitor precautions |
| Certified Nursing Assistant E | CNA | Observed providing care without proper hand hygiene and PPE |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Mar 31, 2021
Visit Reason
The inspection was conducted to investigate complaints related to resident falls, injury prevention, respiratory care, pharmaceutical services, and infection control practices at Warrensburg Manor Care Center.
Complaint Details
The investigation was complaint-driven focusing on falls, respiratory care, pharmaceutical services, and infection control.
Findings
The facility was found deficient in conducting comprehensive fall investigations including root cause analysis and documentation of interventions for fall prevention. Improper cleaning and storage of a resident's CPAP mask was observed. The facility failed to ensure shift change narcotic counts were consistently completed and signed. Infection control practices were inadequate, including improper glove use and hand hygiene during resident care.
Deficiencies (4)
Failed to ensure comprehensive fall investigation process including root cause analysis and documentation of interventions for fall prevention for sampled residents.
Failed to ensure proper cleaning and storage of a resident's CPAP mask when not in use.
Failed to ensure shift change narcotic counts were completed and signed by both oncoming and off-going nursing staff.
Failed to ensure proper infection control practices including hand hygiene and glove use during resident care.
Report Facts
Facility census: 47
Controlled drug count opportunities: 85
Un-signed narcotic count opportunities: 24
Narcotic count opportunities not signed by both staff: 10
Narcotic count opportunities missing package count: 15
CPAP mask storage frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided information on fall review process, CPAP mask storage expectations, narcotic count procedures, and infection control expectations. |
| LPN B | Licensed Practical Nurse | Described fall assessment and documentation procedures. |
| Certified Medication Technician B | Certified Medication Technician | Described notification and documentation procedures for resident falls and CPAP mask storage. |
| CNA A | Certified Nursing Assistant | Described fall notification procedures and CPAP mask storage. |
| CNA B | Certified Nursing Assistant | Described fall notification procedures and hand hygiene expectations. |
| CNA C | Certified Nursing Assistant | Observed providing care with improper glove use and hand hygiene. |
| CNA D | Certified Nursing Assistant | Described proper hand hygiene and glove use during resident care. |
| CNA E | Certified Nursing Assistant | Described proper hand hygiene and glove use during resident care. |
| LPN A | Licensed Practical Nurse | Described expectations for hand hygiene and glove use during resident care. |
| Registered Nurse | Registered Nurse (RN) | Described expectations for hand hygiene and glove use during resident care. |
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