Inspection Reports for
Warrenton Manor
65 STATE HIGHWAY AA, WRIGHT CITY, MO, 63383-3301
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
9.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
89 residents
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 1
Date: Jan 15, 2026
Visit Reason
The inspection was conducted due to allegations of resident-to-resident physical abuse involving one resident. The facility was investigated for failure to timely report suspected abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe.
Complaint Details
The complaint investigation found that the facility did not report two separate allegations of resident-to-resident physical abuse involving Resident #1 to DHSS within the two-hour required timeframe. The administrator was unaware of the first incident and did not report the second incident, mistakenly believing it was not abuse due to lack of injuries. Intake number 2713416.
Findings
The facility failed to report two separate incidents of resident-to-resident physical abuse within the required two-hour timeframe to DHSS. Both incidents involved Resident #1 and Resident #2, with no injuries reported. The administrator and nursing staff acknowledged the reporting failures and incomplete submission of required reports.
Deficiencies (1)
Failure to timely report suspected resident-to-resident physical abuse to the Department of Health and Senior Services within the two-hour required timeframe.
Report Facts
Residents Affected: 2
Facility Census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Documented the initial incident and failed to submit timely report to DHSS |
| LPN A | Licensed Practical Nurse | Instructed LPN B to start investigation and submit report; did not know administrator failed to submit report |
| Administrator | Was not aware of the incident initially and did not report to DHSS within required timeframe |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 1
Date: Nov 25, 2025
Visit Reason
The inspection was conducted due to a complaint regarding failure of facility staff to complete shiftly controlled drug counts with two staff members per facility policy to prevent misappropriation and ensure correct controlled drug counts.
Complaint Details
The complaint investigation found that narcotic counts were not consistently completed with two staff members as required, leading to missing controlled medications. The missing medications were related to inaccurate signing out rather than misappropriation. Staff received in-service training on 10/25/25, and audits were initiated by the DON starting 11/16/25.
Findings
The facility failed to consistently complete narcotic counts at the beginning and end of each shift with two staff members as required by policy, resulting in missing controlled medications. Staff were in-serviced on the procedure after the incident, and audits were implemented to ensure compliance.
Deficiencies (1)
Failure to complete shiftly controlled drug counts with two staff members per facility policy to prevent misappropriation and assure correct controlled drug counts.
Report Facts
Facility census: 92
Missing controlled medications: 2
Pills counted: 16
Pills counted: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Interviewed regarding narcotic count procedures and missing medications |
| CMT B | Certified Medication Technician | Interviewed regarding narcotic count procedures and missing medications |
| RN C | Registered Nurse | Interviewed regarding narcotic count procedures and staff compliance |
| Administrator | Provided information on narcotic count policies and audits | |
| Director of Nursing | Director of Nursing (DON) | Responsible for auditing narcotic counts and staff compliance |
Inspection Report
Routine
Census: 83
Deficiencies: 13
Date: Mar 21, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility standards, including resident rights, care planning, infection control, medication administration, and safety.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, incomplete care plans, failure to document hospice orders, inadequate skin assessments, improper medication administration, insufficient personal hygiene assistance, lack of adequate activities programming, unsafe transfer and wheelchair practices, unsecured medication carts and hazardous materials, incomplete nurse aide training documentation, failure to post nurse staffing information, improper medication storage, and lapses in infection prevention and control practices.
Deficiencies (13)
Failure to maintain resident dignity by not properly covering urinary catheter bags for two residents.
Failure to develop and implement comprehensive person-centered care plans for five residents.
Failure to document and obtain orders for hospice services and ostomy care for residents receiving hospice or ostomy care.
Failure to document weekly skin assessments for three residents and failure to follow physician orders for medication patches and insulin administration.
Failure to provide adequate assistance with personal hygiene and grooming for eight dependent residents.
Failure to provide an ongoing activities program to support independence and interaction in the memory care unit.
Failure to ensure the activities program was directed by a qualified professional.
Failure to provide safe mechanical transfers and wheelchair propulsion, failure to safely administer medication, and failure to secure medication carts and hazardous materials.
Failure to ensure nurse aides completed training within four months of employment.
Failure to post required nurse staffing information daily.
Failure to store medications properly, including presence of loose and expired medications.
Failure to implement infection prevention and control program including improper oxygen tubing maintenance, lack of enhanced barrier precautions, improper catheter care, and inadequate wound care practices.
Failure to designate a qualified infection preventionist with current certification.
Report Facts
Residents affected: 2
Residents affected: 5
Residents affected: 2
Residents affected: 3
Residents affected: 8
Residents affected: 2
Residents affected: 4
Resident census: 83
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nurse Aid | Named in unsafe mechanical lift transfer observation |
| CNA F | Certified Nurse Aid | Named in unsafe mechanical lift transfer observation |
| CNA G | Certified Nurse Aid | Named in unsafe mechanical lift transfer observation |
| LPN B | Licensed Practical Nurse | Named in medication cart security and insulin administration findings |
| RN Q | Registered Nurse | Named in wound care infection control findings |
| NA N | Nurse Aide | Named in catheter care infection control findings |
| CMT C | Certified Medication Technician | Named in medication administration and catheter care findings |
| Administrator | Named in multiple interviews regarding facility policies and deficiencies | |
| Director of Nursing | Named in multiple interviews regarding facility policies and deficiencies | |
| MDS Nurse | Named in multiple interviews regarding care planning and infection control | |
| Activity Director | Named in activities program findings |
Inspection Report
Routine
Census: 84
Capacity: 120
Deficiencies: 16
Date: Apr 18, 2024
Visit Reason
Routine inspection of Warrenton Manor nursing home to assess compliance with regulatory standards including resident dignity, environment, care planning, medication management, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate environment maintenance, incomplete resident assessments and care plans, medication errors including insulin administration errors, unsafe medication storage, inadequate infection control practices including hand hygiene and glucometer disinfection, and food safety violations including improper food storage and dishwasher maintenance.
Deficiencies (16)
Failure to maintain resident dignity by leaving residents exposed and failing to properly cover urinary drainage bags.
Failure to provide a safe, clean, comfortable and homelike environment with multiple maintenance and cleanliness issues.
Failure to notify residents or representatives in writing of bed hold policy for hospital or therapeutic leave.
Failure to complete required Minimum Data Set (MDS) assessments within required timeframes.
Failure to complete Quarterly MDS assessments at least every 92 days.
Failure to encode and transmit resident assessment data to the State within 7 days of assessment.
Failure to complete baseline care plans within 48 hours of admission for some residents.
Failure to develop and implement comprehensive person-centered care plans addressing all resident needs.
Failure to provide necessary care and assistance for activities of daily living including hygiene and hair care.
Failure to lock medication and treatment carts, unsafe medication storage, and failure to date medications when opened.
Medication errors including failure to prime insulin pens prior to administration resulting in a 20.7% medication error rate.
Failure to count narcotic medications each shift and reconcile narcotic counts resulting in discrepancies.
Failure to store food properly including undated and unsealed bulk food items, damaged cans, and use of non-food grade bags.
Failure to maintain dishwasher at proper temperatures and sanitizer levels, failure to allow dishes to air dry before storage, and failure to maintain kitchen cleanliness.
Failure to maintain ice machine and surrounding areas in a sanitary manner with accumulation of dirt, debris, and improper drainage.
Failure to perform hand hygiene appropriately and failure to disinfect glucometers between resident uses.
Report Facts
Medication error rate: 20.7
Residents affected by dignity deficiency: 2
Residents affected by environment deficiency: 84
Residents affected by bed hold notification deficiency: 5
Residents affected by MDS assessment timeliness deficiency: 7
Residents affected by quarterly MDS deficiency: 9
Residents affected by MDS data encoding deficiency: 14
Residents affected by baseline care plan deficiency: 3
Residents affected by comprehensive care plan deficiency: 7
Residents affected by ADL care deficiency: 5
Nurse aides non-compliant with training: 2
Medication administration opportunities observed: 29
Narcotic count discrepancy: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN V | Licensed Practical Nurse | Named in medication error findings including insulin administration and narcotic count discrepancy. |
| ADON | Assistant Director of Nursing | Named in medication administration and infection control deficiencies. |
| DON | Director of Nursing | Named in narcotic count and medication administration deficiencies. |
| DM | Dietary Manager | Named in food storage, dishwasher, ice machine, and kitchen cleanliness deficiencies. |
| CMT CC | Certified Medication Technician | Named in narcotic count and medication cart security deficiencies. |
| NA P | Nurse Aide | Named in incontinence care and nurse aide training deficiencies. |
| NA DD | Nurse Aide | Named in nurse aide training deficiency. |
| Administrator | Facility Administrator | Named in oversight and responsibility for multiple deficiencies. |
Inspection Report
Routine
Census: 84
Deficiencies: 1
Date: Apr 17, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care and assistance requirements for residents unable to perform activities of daily living, focusing on personal hygiene, incontinence care, and hair care.
Findings
The facility failed to ensure residents who were unable to complete their own activities of daily living received necessary care to maintain good personal hygiene, including being clean, dry, and free from odor, and failed to provide hair care and shaving to several residents. Observations and interviews revealed inadequate incontinence care and inconsistent shower and shaving schedules.
Deficiencies (1)
Failure to provide necessary care and assistance for activities of daily living, including maintaining residents clean, dry, and free from odor, and failure to provide hair care and shaving.
Report Facts
Residents affected: 5
Facility census: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA H | Certified Nurse Aide | Provided incontinent care to Resident #10 and described condition |
| CNA Q | Certified Nurse Aide | Provided incontinence care for Resident #347 and described observations |
| NA P | Nurse Aide | Mentioned in relation to incontinence care and observations for Residents #18 and #347 |
| CNA M | Certified Nurse Aide | Observed passing residents without providing care and described urine odor observations |
| LPN S | Licensed Practical Nurse | Observed providing care to resident's roommate but not to resident with urine odor |
| DON | Director of Nursing | Provided expectations for incontinence care and shower/shaving schedules |
| ADON | Assistant Director of Nursing | Provided guidance on incontinence care frequency and staff responsibilities |
| Administrator | Administrator | Discussed shower schedules, staffing issues, and responsibility for ensuring care completion |
| CNA L | Certified Nurse Aide | Noted difficulty in providing shaving care due to workload |
| CNA K | Certified Nurse Aide | Commented on facial hair preferences and care planning |
| LPN V | Licensed Practical Nurse | Commented on facial hair care responsibilities |
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's family and physician about a fall resulting in injury.
Complaint Details
The complaint investigation found that staff did not notify the resident's family or physician about the fall on 3/5/24. The Director of Nursing and administrator had no documentation of notification. The resident's physician confirmed he was not notified until he visited the facility the next day.
Findings
The facility failed to notify the family and physician of Resident #1's fall on 3/5/24, despite the resident sustaining injuries. Interviews with the Director of Nursing and administrator confirmed lack of notification documentation, and the resident's physician stated he was not informed until the next day.
Deficiencies (1)
Facility staff failed to notify one resident's family and physician of a fall resulting in injury.
Report Facts
Residents census: 81
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding notification failure of resident's fall |
| Administrator | Administrator | Interviewed regarding notification failure of resident's fall |
Inspection Report
Routine
Census: 76
Deficiencies: 1
Date: May 15, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality, specifically focusing on adherence to physician's orders related to monitoring bowel movements and documenting weekly skin assessments for selected residents.
Findings
The facility failed to follow physician's orders for three residents regarding bowel movement monitoring and documentation, and failed to document weekly skin assessments for one resident. Staff inconsistently recorded bowel movements and did not document administration of prescribed laxatives. The facility census was 76.
Deficiencies (1)
Failure to follow physician's orders for monitoring bowel movements and documenting skin assessments for three residents.
Report Facts
Residents affected: 3
Census: 76
Inspection Report
Routine
Census: 65
Deficiencies: 12
Date: Dec 30, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident notices, discharge summaries, care assistance, safe mechanical lift transfers, nurse staffing postings, medication regimen reviews, psychotropic medication management, medication storage, menu preparation, dishwasher operation, waste disposal, and infection control.
Findings
The facility was found deficient in multiple areas including failure to complete Advanced Beneficiary Notices properly, incomplete discharge summaries, inadequate assistance with activities of daily living for some residents, unsafe mechanical lift transfers, failure to post nurse staffing information, lack of physician response to pharmacist medication reviews, improper management of psychotropic medications, unsafe medication storage, failure to follow food preparation recipes, dishwasher temperature and sanitizing issues, improper waste container maintenance, and incomplete tuberculosis screening for new employees.
Deficiencies (12)
Failed to ensure CMS Skilled Nursing Facility Advanced Beneficiary Notice was completed for three residents.
Failed to ensure a discharge summary was completed upon discharge for one sampled resident.
Failed to provide adequate assistance with grooming and hygiene for four residents requiring staff assistance.
Failed to provide safe mechanical lift transfers for three residents and failed to ensure hazardous chemicals and sharps were stored safely.
Failed to post required nurse staffing information daily and maintain records for eighteen months.
Failed to communicate pharmacy recommendations to physicians and obtain physician responses for four residents' medication regimen reviews.
Failed to limit PRN psychotropic medication orders to 14 days and failed to perform gradual dose reductions for psychotropic medications for some residents.
Failed to store and label medications properly in medication storage cart; presence of loose and expired medications.
Failed to follow recipes when preparing meals; added unmeasured ingredients not in recipe.
Failed to maintain correct dishwasher water temperatures and proper sanitizing procedures in three compartment sink.
Failed to properly contain waste and refuse; dumpster lids broken and not replaced.
Failed to ensure two-step tuberculosis screening was completed and documented for five employees.
Report Facts
Facility census: 65
Residents affected: 3
Residents affected: 1
Residents affected: 4
Residents affected: 3
Residents affected: 4
Residents affected: 5
Dishwasher temperature: 92
Dishwasher temperature: 96
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide S | Missing second step TB test documentation | |
| Registered Nurse T | Missing second step TB test documentation | |
| Licensed Practical Nurse U | Missing second step TB test documentation | |
| Housekeeper V | Missing second step TB test documentation | |
| Certified Nurse Assistant P | Missing second step TB test documentation | |
| Social Services Director | Interviewed regarding Advanced Beneficiary Notices and discharge summaries | |
| Administrator | Interviewed regarding multiple deficiencies including staffing postings, medication reviews, and dumpster lids | |
| Licensed Practical Nurse B | Interviewed regarding grooming assistance and medication reviews | |
| Director of Nursing | Interviewed regarding medication reviews, staffing postings, and TB screening | |
| Certified Medication Technician C | Interviewed regarding medication storage and psychotropic medication orders | |
| Dietary Supervisor | Interviewed regarding recipe adherence and dishwasher issues | |
| Maintenance Director | Interviewed regarding dumpster lids and chemical storage |
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