Inspection Reports for
Warrenton Manor
65 STATE HIGHWAY AA, WRIGHT CITY, MO, 63383-3301
Back to Facility ProfileDeficiencies (last 9 years)
Deficiencies (over 9 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
167% worse than Missouri average
Missouri average: 5.5 deficiencies/year
Deficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
74% occupied
Based on a January 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate 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
Life Safety
Census: 83
Capacity: 120
Deficiencies: 3
Date: Mar 21, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations.
Findings
The facility failed to ensure proper signage on delayed egress doors, maintain and test the fire alarm system timely, and provide complete documentation for electrical receptacle assessments. Several fire safety and electrical code requirements were not met, posing potential risks to occupants.
Deficiencies (3)
K222 Doors in a required means of egress lacked proper signage indicating delayed egress function, and the facility did not have a policy related to door signs in means of egress.
K345 Facility staff failed to inspect, test, and maintain the fire alarm system as required, and the fire alarm panel in the social services office was not secured.
K914 Facility staff failed to provide complete and verifiable documentation for electrical receptacle assessments in resident care rooms and failed to maintain electrical wiring and replace faulty receptacles with hospital grade ones.
Report Facts
Facility census: 83
Facility capacity: 120
Deficiencies cited: 3
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
Annual Inspection
Census: 84
Capacity: 120
Deficiencies: 13
Date: Apr 18, 2024
Visit Reason
The inspection was the annual survey of Warrenton Manor to assess compliance with federal and state regulations regarding resident rights, safety, care, and facility environment.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident dignity and privacy, inadequate environment maintenance, incomplete resident assessments, medication errors, infection control issues, and food safety violations. The facility submitted a plan of correction to address these issues.
Deficiencies (13)
F 550 Resident Rights: The facility failed to ensure residents' dignity and privacy, including exposing a resident to the hallway and not maintaining privacy curtains.
F 584 Safe Environment: The facility failed to maintain a safe, clean, and comfortable environment, including damaged walls, gouged paint, and strong odors.
F 625 Bed Hold Policy: The facility failed to provide written notification and documentation regarding bed hold policies for residents transferred or on leave.
F 636 Resident Assessment: The facility failed to conduct comprehensive and timely resident assessments as required by federal regulations.
F 655 Baseline Care Plans: The facility failed to develop and implement baseline care plans for residents within 48 hours of admission.
F 656 Comprehensive Care Plans: The facility failed to develop and maintain comprehensive, person-centered care plans for residents.
F 677 Activities of Daily Living: The facility failed to provide adequate assistance with activities of daily living, including grooming, hygiene, and toileting.
F 689 Accident Hazards/Supervision/Devices: The facility failed to ensure a safe environment by leaving medications unlocked and unattended and failing to secure treatment carts.
F 728 Nurse Aide Training: The facility failed to ensure all nursing assistants completed required training and certification within four months of employment.
F 759 Medication Errors: The facility failed to maintain medication error rates below 5%, with multiple errors in insulin administration and narcotic counts.
F 761 Labeling of Drugs and Biologicals: The facility failed to properly label and store medications and biologicals, including narcotics and insulin pens.
F 812 Food Preparation: The facility failed to maintain food safety standards, including proper storage, labeling, and cleanliness of food items and preparation areas.
F 880 Infection Control: The facility failed to establish and maintain an effective infection prevention and control program, including hand hygiene and use of gloves.
Report Facts
Facility census: 84
Total capacity: 120
Medication error rate: 20.7
Number of sampled residents: 22
Inspection Report
Life Safety
Census: 84
Capacity: 120
Deficiencies: 5
Date: Apr 18, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) and related fire safety regulations.
Findings
The facility failed to properly inspect, test, and maintain the fire alarm system, sprinkler system, fire drills, and electrical equipment such as power strips and extension cords. Deficiencies included lack of qualified personnel credentials, gaps around sprinkler heads, incomplete fire drill documentation, and improper use and storage of surge protectors and oxygen cylinders.
Deficiencies (5)
K345 Fire Alarm System - The facility failed to inspect, test, and maintain the fire alarm system annually by qualified personnel and lacked verifiable documentation of technician credentials.
K353 Sprinkler System - The facility failed to inspect, test, and maintain wet pipe sprinkler systems properly, resulting in gaps between sprinklers and ceilings or walls that could allow smoke and fire to pass.
K712 Fire Drills - The facility failed to conduct and document fire drills quarterly on each shift with varied conditions, and lacked a policy related to fire drills.
K920 Electrical Equipment - The facility failed to maintain electrical wiring and power strips in patient care areas according to code, including improper use of extension cords and surge protectors.
K923 Gas Equipment - The facility failed to properly store oxygen cylinders to prevent accidental damage or combustion hazards and lacked policies for oxygen storage.
Report Facts
Facility census: 84
Total capacity: 120
Number of fire drills reviewed: 12
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
Plan of Correction
Census: 81
Deficiencies: 3
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to investigate deficiencies related to notification of changes in resident condition and failure to notify family and physician of a resident's fall.
Findings
The facility failed to notify the resident's family and physician about a fall that resulted in injury. Documentation and interviews revealed staff did not notify the responsible parties as required by regulations.
Deficiencies (3)
F580 Notification of Changes: The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's family about a fall resulting in injury and potential physician intervention.
A4087 Dr Notification-Change in Condition: Facility staff did not notify the resident's physician in accordance with emergency treatment policies after an accident or significant change in condition.
A4088 Notify Responsible Party-Change in Condition: Facility staff failed to notify the person designated in the resident's record as responsible party after an accident or significant change in condition.
Report Facts
Facility census: 81
Deficiency completion date: Apr 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chanda Knowsten | Administrator | Signed the statement of deficiencies and plan of correction |
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
Plan of Correction
Census: 76
Deficiencies: 2
Date: May 15, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding comprehensive care plans and documentation of bowel movements and skin assessments for residents.
Findings
The facility failed to follow physician orders for three residents related to bowel movement monitoring and weekly skin assessments. Staff did not consistently document bowel movements, skin assessments, or administration of prescribed laxatives as required.
Deficiencies (2)
F 658: The facility failed to meet professional standards by not following physician orders for bowel movement monitoring and weekly skin assessments for three residents. Staff did not document bowel movements or skin assessments consistently and failed to administer prescribed laxatives as ordered.
A4075: Each resident did not receive personal attention and nursing care consistent with their condition and current acceptable nursing practice, as evidenced by the F658 deficiency.
Report Facts
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Amanda Marsten | Administrator | Named as signing the statement of deficiencies and plan of correction |
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 |
Inspection Report
Annual Inspection
Census: 65
Deficiencies: 12
Date: Dec 30, 2022
Visit Reason
The inspection was conducted as an annual survey of Warrenton Manor nursing facility to assess compliance with Medicare and Medicaid regulations.
Findings
The facility was found deficient in multiple areas including Medicaid/Medicare coverage notifications, discharge summaries, ADL care, accident prevention, nurse staffing information posting, drug regimen review, medication storage, infection control, food safety, and psychotropic medication use. Plans of correction were submitted for all deficiencies.
Deficiencies (12)
F582 Medicaid/Medicare Coverage/Liability Notice: The facility failed to ensure that Medicaid-eligible residents were informed in writing about coverage and payment options as required.
F661 Discharge Summary: The facility failed to ensure a discharge summary was completed for a sampled resident upon discharge.
F677 ADL Care Provided for Dependent Residents: Facility staff failed to provide adequate grooming and hygiene assistance to four residents requiring help.
F689 Free of Accident Hazards/Supervision/Devices: Staff failed to provide safe mechanical lift transfers and failed to secure hazardous chemicals away from residents.
F732 Posted Nurse Staffing Information: Facility failed to post required nurse staffing data daily and maintain records for 18 months.
F756 Drug Regimen Review, Report Irregular, Act On: Facility staff failed to communicate pharmacy recommendations and physician responses for four residents' medication reviews.
F758 Free from Unnecessary Psychotropic Meds/PRN Use: Facility failed to limit psychotropic medication orders to 14 days and perform gradual dose reductions as required.
F761 Label/Store Drugs and Biologicals: Facility failed to store and label medications properly and maintain medication storage carts safely.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: Facility failed to maintain proper dishwasher temperatures and sanitizing procedures, risking food safety.
F814 Dispose Garbage and Refuse Properly: Facility failed to properly contain waste and refuse, allowing dumpster lids to remain broken and uncovered.
F880 Infection Prevention & Control: Facility failed to implement adequate infection control policies, including TB screening and employee immunizations.
F803 Menus Meet Resident Nds/Prep in Adv/Followed: Facility failed to ensure menus met nutritional needs and followed recipes for food preparation.
Report Facts
Facility census: 65
Deficiencies cited: 12
Plan of correction completion date: Feb 9, 2023
Inspection Report
Life Safety
Census: 65
Capacity: 120
Deficiencies: 5
Date: Dec 30, 2022
Visit Reason
The inspection was a Life Safety Code survey conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to meet several Life Safety Code requirements related to fire alarm system maintenance, sprinkler system testing, fire drills, emergency power system testing, and oxygen storage safety. Deficiencies were noted in securing fire alarm control panels, maintaining sprinkler systems free of obstructions, conducting fire drills quarterly on all shifts, and maintaining generator and electrical system inspections.
Deficiencies (5)
K345 Fire Alarm System - Testing and Maintenance: The facility failed to inspect, test, and maintain the fire alarm system monthly and secure the control panel against unauthorized access.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinklers free of obstructions and provide complete documentation for quarterly inspections and testing.
K712 Fire Drills: Facility staff failed to conduct fire drills quarterly on all shifts and did not conduct a simulated resident evacuation drill annually.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: Facility staff failed to conduct weekly generator inspections, fuel quality tests, and annual main feeder circuit breaker inspections.
K923 Gas Equipment - Cylinder and Container Storage: Facility staff failed to secure oxygen cylinders properly and store combustibles away from oxygen storage rooms.
Report Facts
Facility census: 65
Facility capacity: 120
Date survey completed: Dec 30, 2022
Plan of correction completion date: Feb 9, 2023
Inspection Report
Routine
Deficiencies: 0
Date: Feb 9, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 and CMS and CDC recommended practices for COVID-19 preparedness and infection control.
Inspection Report
Plan of Correction
Census: 85
Deficiencies: 2
Date: Mar 11, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, specifically regarding wound care and adherence to physician orders for residents.
Findings
The facility failed to follow physician orders when staff removed a wound dressing against the physician's order for one resident. The deficiency involved improper wound care and failure to maintain proper dressing protocols.
Deficiencies (2)
F658 Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i). The facility failed to follow physician orders when staff removed a wound dressing against the physician order for one resident. The facility census was 85.
A4074 19 CSR 30-85.042(67) Nursing Care per Res Condition. Each resident shall receive personal attention and nursing care in accordance with his/her condition and consistent with current acceptable nursing practice. This regulation is not met as evidenced by Class II.
Report Facts
Facility census: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen L. Cowan | Initiative Executive Director | Signed the deficiency statement and plan of correction |
Inspection Report
Plan of Correction
Census: 86
Deficiencies: 10
Date: Oct 31, 2019
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, infection control, nurse staffing information posting, food safety, and other regulatory requirements at Warrenton Manor.
Findings
The facility failed to maintain professional standards of care for residents, including documentation and application of splints, catheter care, oxygen orders, and use of adaptive equipment. The facility also failed to post required nurse staffing information, maintain proper food temperatures, and ensure adequate handwashing and sanitation practices.
Deficiencies (10)
F658 Services Provided Meet Professional Standards: Facility staff failed to document application of splints, catheter care, oxygen orders, and use of a lidded two-handle coffee cup for residents as ordered.
F732 Nurse Staffing Information: Facility failed to post required nurse staffing data including total number of staff and actual hours worked per shift. Facility census was 86.
F804 Nutritive Value/Appearance, Palatability/Preferred Temperature: Facility staff failed to maintain internal temperatures of hot food at least 120°F upon service. Observations showed multiple hot foods served below required temperatures. Facility census was 86.
F812 Food Procurement, Store/Prepare/Serve-Sanitary: Facility staff failed to wash hands as often as necessary and failed to properly wash and sanitize kitchenware, increasing risk of cross-contamination. Facility census was 86.
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by deficiencies in F658.
A4085 Infection Control/Communicable Disease: Facility failed to ensure timely two-step Tuberculin (TB) testing for staff and residents. Documentation was incomplete or missing for several employees. Facility census was 86.
A7002 Wash Hands/Arms & Clean Fingernails: Employees failed to thoroughly wash hands and exposed arms with soap and warm water before work and after activities, and failed to keep fingernails clean and trimmed.
A7036 Food Temperature Compliance: Hot food served to residents was below required temperatures of 120°F or above 45°F for cold foods, violating food safety regulations.
A7064 Kitchenware/Surfaces/Pitchers-Clean/Sanitize: Facility failed to properly wash, rinse, and sanitize food-contact surfaces and equipment, increasing risk of contamination.
F812 Handwashing and Sanitation: Facility failed to ensure staff washed hands properly and sanitized kitchenware, increasing risk of cross-contamination.
Report Facts
Facility census: 86
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Named in relation to splint application and documentation deficiencies |
| Director of Nursing | DON | Named in relation to expectations for staff documentation and oxygen orders |
| Certified Nursing Assistant D | CNA | Interviewed regarding resident care and oxygen administration |
| Certified Nursing Assistant I | CNA | Interviewed regarding resident care and oxygen administration |
| Dietary Manager | DM | Interviewed regarding dietary orders and food temperature monitoring |
| Cook E | Cook | Observed for food handling and sanitation practices |
| Dietary Aide F | DA | Observed for handwashing and food service practices |
| Dietary Aide G | DA | Observed for handwashing and food service practices |
Inspection Report
Life Safety
Census: 86
Capacity: 120
Deficiencies: 12
Date: Oct 31, 2019
Visit Reason
Life Safety Code inspection conducted to evaluate compliance with fire safety regulations including sprinkler system maintenance, corridor doors, smoke barriers, fire drills, and gas equipment storage.
Findings
The facility failed to maintain the sprinkler system, ensure corridor doors were smoke resistant and properly latched, maintain smoke barrier walls, conduct fire drills as required, and properly store oxygen cylinders. These deficiencies have the potential to affect all facility occupants.
Deficiencies (12)
K353 Sprinkler System - Facility staff failed to maintain sprinklers free of foreign materials and provide complete documentation of inspection and testing. This failure could lead to system failure in an emergency.
K363 Corridor Doors - Facility staff failed to ensure doors leading to corridors were solid, resisted smoke passage, and had positive latching, exposing gaps and damage on multiple doors.
K372 Smoke Barrier - Facility staff failed to maintain two of five smoke barrier walls free of openings to provide required fire resistance rating, risking containment of smoke between fire zones.
K712 Fire Drills - Facility staff failed to conduct fire drills on all shifts quarterly and maintain documentation for all drills, risking delayed emergency response.
K923 Gas Equipment - Facility staff failed to store oxygen cylinders in an enclosed area with proper ventilation and secure helium tanks, and failed to remove combustible materials near oxygen cylinders.
A1065 Drinking Fountains - Facility failed to provide accessible drinking fountains in the lobby, recreation area, and nursing units, affecting all residents.
A1088 Door No Louvre/Transom - Doors between rooms and corridors lacked required louvers or transoms, failing fire resistance requirements.
A2003 No Fire Hazard - Facility failed to ensure no fire hazards were present in building construction as required.
A2010 Oxygen Storage - Facility failed to properly store oxygen cylinders with racks or fasteners and maintain safety caps, risking physical injury and structural damage.
A2034 Sprinkler System-Test/Maintain - Facility failed to inspect, maintain, and test sprinkler systems as required by regulation.
A2054 Smoke Section Walls/Doors - Facility failed to maintain fire-rated walls and doors with self-closing and automatic closing features as required.
A2061 Fire Drill Requirements, Evacuation - Facility failed to conduct required fire drills quarterly on each shift and maintain documentation.
Report Facts
Facility census: 86
Facility capacity: 120
Deficiency completion dates: 12
Inspection Report
Annual Inspection
Census: 78
Capacity: 120
Deficiencies: 10
Date: Jan 18, 2019
Visit Reason
Annual inspection of Warrenton Manor to assess compliance with emergency preparedness, life safety code, fire safety, and other regulatory requirements.
Findings
The facility failed to complete required emergency preparedness exercises and had multiple deficiencies related to life safety code including delayed egress door locking, emergency lighting, sprinkler system maintenance, fire drills, and gas equipment training. The facility census was 78 with a capacity of 120.
Deficiencies (10)
E039 Emergency Preparedness Testing. The facility failed to complete one of two required annual emergency preparedness exercises, delaying emergency response.
K222 Egress Doors. Two of five designated exit doors with delayed-egress magnetic locks did not comply with Life Safety Code requirements, potentially delaying evacuation.
K291 Emergency Lighting. Facility staff failed to conduct required annual functional testing of emergency lighting, risking evacuation delays.
K353 Sprinkler System Maintenance. Facility staff failed to maintain verifiable documentation for three of four quarterly sprinkler system inspections.
K363 Corridor Doors. Facility staff failed to ensure corridor doors were solid, latched, and resisted smoke passage, risking fire containment.
K521 HVAC. Facility staff failed to provide functioning exhaust ventilation units in four resident room toilet rooms, risking air quality and infection control.
K712 Fire Drills. Facility staff failed to conduct required quarterly fire drills on each shift, risking delayed emergency response.
K761 Maintenance, Inspection & Testing - Doors. Facility failed to inspect and test fire door assemblies annually as required by NFPA standards.
K918 Electrical Systems. Facility staff failed to provide complete and verifiable documentation for emergency generator inspections and testing.
K926 Gas Equipment. Facility staff failed to provide continuing education on medical gas safety and handling to personnel, risking improper use.
Report Facts
Facility census: 78
Total capacity: 120
Deficiencies cited: 10
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 7
Date: Jan 18, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with state and federal regulations for Warrenton Manor nursing facility.
Findings
The facility was found to have multiple deficiencies including unsafe and uncomfortable environment conditions, incomplete resident assessments, inadequate hearing and vision care, improper drug regimen reviews, and insufficient infection control measures. The facility census was 78 during the survey.
Deficiencies (7)
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide a safe and comfortable environment, with damaged walls, doors, and missing paint observed in multiple resident rooms. The maintenance log lacked documentation of needed repairs.
F636 Comprehensive Assessments & Timing. The facility did not conduct comprehensive assessments of residents' functional capacity, missing limits in range of motion and contracture documentation for sampled residents.
F685 Treatment/Devices to Maintain Hearing/Vision. The facility failed to assist one resident in gaining access to hearing services and did not document interventions related to hearing loss.
F688 Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide restorative therapy and appropriate treatment to prevent decline in range of motion and mobility for residents with contractures.
F756 Drug Regimen Review, Report Irregular, Act On. The facility failed to communicate pharmacy recommendations to physicians for four residents and did not ensure monthly drug regimen reviews were properly documented.
F758 Free from Unnec Psychotropic Meds/PRN Use. The facility failed to ensure psychotropic drugs were used only when necessary and did not properly document or limit PRN orders for psychotropic medications.
F880 Infection Prevention & Control. The facility failed to establish and maintain an infection prevention and control program that met accepted national standards, including water management to prevent Legionella.
Report Facts
Facility census: 78
Sampled residents: 18
Residents with hearing issues sampled: 16
Residents with contractures sampled: 18
Residents with medication review issues: 4
Inspection Report
Plan of Correction
Census: 77
Deficiencies: 2
Date: May 4, 2018
Visit Reason
The inspection was conducted to evaluate compliance with professional standards related to comprehensive care plans, specifically focusing on the timely replacement of indwelling urinary catheters for residents.
Findings
The facility failed to replace two residents' indwelling urinary catheters in a timely manner according to physician orders, resulting in documentation deficiencies and potential risk of urinary tract infections.
Deficiencies (2)
F 658: Services provided did not meet professional standards as staff failed to replace two residents' indwelling urinary catheters timely per physician orders, and documentation of catheter changes was incomplete.
A 4074: Nursing care per resident condition was not met as evidenced by the deficiency cited in F 658.
Report Facts
Facility census: 77
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