Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warrenton Woods Of Journey Llc during CMS and state inspections, most recent first.
PASARR screening was not accurately completed for a resident with bipolar disorder. The resident had diagnoses including intracerebral hemorrhage, cerebral infarction, and bipolar disorder, with a BIMS score of 10 and dependence with ADLs. Interviews with the SSD, business office/HR manager, and DON showed they expected bipolar disorder and other mental health diagnoses to trigger a PASARR level 2, but the resident’s PASARR status was not accurately completed.
A resident with schizoaffective disorder, depression, and anxiety received incorrect doses of sertraline and aripiprazole during a med pass when an RN gave one whole tablet of each instead of the ordered half-tablet doses. The RN confirmed the error and said the package was mislabeled and did not match the order. The DON and pharmacist later noted the wrong doses could have caused adverse effects.
The facility failed to comply with its food safety policy by not discarding expired food items and using expired test strips for sanitizer concentration checks. Expired sweet tea and diced onions were found in the refrigerator, and the Dietary Manager confirmed the oversight. Additionally, expired test strips were used for testing the dishwasher and sink sanitizer concentration, with no valid replacements available.
The facility failed to maintain the kitchen hood extinguishing system, affecting 50 residents. The kitchen hood ventilation fan was non-operational, with the Dietary Manager noting it had been inoperable since November 2024. Despite passing an inspection in January 2025, the exhaust fan was not working. An electrical service inspection revealed no voltage to the motor, and a new motor was ordered. Staff interviews indicated a lack of communication and awareness about the malfunction, with the Administrator and Maintenance Director unaware until February 2025.
A facility failed to maintain resident dignity by not providing a dignity bag for a resident with an indwelling urinary catheter. Despite the facility's policy and staff awareness, the catheter bag was observed uncovered on multiple occasions, visible from the doorway. Interviews with staff confirmed the oversight, and the facility administrator acknowledged the resident should have had a dignity bag.
The facility failed to provide quarterly statements for resident trust fund accounts, affecting two residents. One resident, with little to no cognitive impairment, reported never receiving a statement in three years, while another, with moderate cognitive impairment, was unaware of having an account. Staff interviews confirmed the deficiency, with the Business Office Manager and Regional Human Resource Coordinator unable to provide evidence of statement distribution, despite facility policy requiring it.
The facility failed to maintain two residents' trust fund accounts under the $2,000 limit required for Medicaid eligibility. The policy required spending down accounts exceeding this limit within 10 days, but one resident's account had a balance of $3,743.51, and another's was $2,075.58. The Regional HR Coordinator and Administrator confirmed the issue, and the Business Office was working on obtaining burial policies for affected residents.
The facility failed to maintain a homelike environment, with deficiencies observed in eight resident rooms and the main dining room. Issues included stained ceiling tiles, uncovered ceiling lights, detached ceiling fans, and water leaks. These conditions were confirmed by the Maintenance Director, who noted that work orders were being submitted.
A facility failed to obtain a physician's order for oxygen therapy for a resident with multiple diagnoses, including heart failure and kidney disease. The resident was observed using oxygen without a formal order, and the care plan did not reflect this ongoing use. Additionally, the oxygen equipment was improperly stored, with the nasal cannula tubing found dirty on the floor. The DON acknowledged the oversight in reconciling orders upon the resident's readmission.
A facility failed to follow infection control procedures during glucometer use for a resident, as an LPN did not use barriers on surfaces and did not clean the glucometer as per policy. The ADON confirmed the need for cleaning and barrier use, while the LPN admitted to not receiving proper education on the procedure.
PASARR Screening Not Accurately Completed for Resident With Bipolar Disorder
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for one resident, R52. The resident was admitted with diagnoses including nontraumatic intracerebral hemorrhage, cerebral infarction, and bipolar disorder, unspecified. Review of the MDS showed a BIMS score of 10, dependence with ADLs related to impairment on both sides of the lower extremities, and use of a manual wheelchair. The resident’s care plan did not include a focus related to behaviors or antianxiety medications. During observation, R52 was lying in bed with a brace on the right arm and stated she had been in the facility about two months and had no concerns. Interviews with the SSD, business office/HR manager, and DON showed the facility expected residents with bipolar disorder or other mental health diagnoses to have a PASARR level 2, and that the business office reviewed PASARR information in GAMMIS while the SSD tracked residents on PASARR. The SSD stated that if a resident is schizophrenic, bipolar, or has any mental health issue, they should have a PASARR 2, although it does not always trigger in GAMMIS. The business office/HR manager stated that mental health disorders should trigger a level 2 PASARR and that bipolar disorder should be considered for PASARR 2. The DON also stated that a resident with a bipolar diagnosis should have a PASARR 2 completed.
Incorrect psychotropic medication doses given to a resident
Penalty
Summary
Resident R35, who was admitted with diagnoses including encounter for orthopedic aftercare following surgical amputation, altered mental status, schizoaffective disorder, bipolar type, depression, and anxiety disorder, was found to have received incorrect medication doses during a medication pass. The quarterly MDS dated 12/30/2025 indicated a BIMS score of 15, showing the resident was cognitively intact. Physician orders dated 01/9/2026 directed Abilify 5 mg, 0.5 tablet by mouth daily for schizoaffective disorder and sertraline HCl 50 mg, 0.5 tablet by mouth daily for depression. During observation of the medication pass on 03/31/2026 at 9:40 AM, RN CC administered one whole tablet of sertraline 50 mg and one whole tablet of aripiprazole 5 mg to R35 instead of the ordered half-tablet doses. In interview, RN CC confirmed the resident received the wrong dose and stated the medication package was mislabeled and did not match the prescribing order. The DON later stated the pharmacy had been notified and that the resident could have experienced effects such as levels being off, stupor, confusion, tardive dyskinesia, or a reverse effect causing agitation. The pharmacist stated the wrong doses could have caused overdose, nausea, tremors, anxiety, and restlessness.
Deficiency in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to its policy on food safety, specifically regarding the proper labeling, storage, and disposal of food items. During an inspection, it was observed that two one-gallon pitchers of sweet tea and two five-pound bags of diced onions were stored in the refrigerator past their expiration dates. The Dietary Manager, responsible for labeling and dating, confirmed the oversight and discarded the expired items. Additionally, the facility was found to be using expired test strips for checking the concentration of sanitizer in the dishwasher and sink, with no valid replacements available at the time of the inspection.
Kitchen Hood Ventilation System Malfunction
Penalty
Summary
The facility failed to ensure that essential kitchen equipment was in working order, specifically the kitchen hood extinguishing system. This deficiency was identified through observations, staff interviews, and record reviews. The kitchen hood ventilation fan was found to be non-operational during an initial kitchen tour and subsequent follow-up visits. The Dietary Manager indicated that the fan had not been operable since November 2024. Despite a facility-provided document indicating that the kitchen hood passed inspection on January 30, 2025, it was noted that the exhaust fan was not operable. An electrical service inspection on February 22, 2025, revealed no voltage to the kitchen hood motor, and a recommendation was made to order a new motor. A follow-up service visit on February 24, 2025, documented that the motor was operating but lacked a belt, which was then replaced. Interviews with facility staff revealed a lack of communication and awareness regarding the malfunction. The Life Safety Code (LSC) DD confirmed that the kitchen staff and leadership were informed that cooking under the hood was prohibited until repairs were made. The Administrator was unaware of the malfunction until February 22, 2025, and confirmed that alternative meals would be served to residents. Dietary staff were uncertain about when the hood system stopped working, with one staff member speculating it occurred after bad weather in January. The Maintenance Director was also not informed of the issue until February 22, 2025. This deficiency had the potential to affect 50 residents receiving an oral diet from the kitchen.
Failure to Provide Dignity Bag for Resident with Catheter
Penalty
Summary
The facility failed to maintain resident dignity by not providing a dignity bag for a resident with an indwelling urinary catheter. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of maintaining privacy, yet observations revealed that the resident's catheter bag was uncovered and visible from the doorway on multiple occasions. The resident, who had moderate cognitive impairment and was at risk for urinary tract infections and skin breakdown, was observed with an uncovered catheter bag containing amber-colored urine. Interviews with facility staff, including a CNA and an LPN, confirmed that the catheter bag should have been covered with a dignity bag. The CNA acknowledged that CNAs are responsible for catheter care at the beginning and end of each shift, as well as when needed. The facility administrator also confirmed that the resident should have had a dignity bag. Despite the facility's policy and staff awareness, the dignity bag was not provided until after the deficiency was identified by surveyors.
Failure to Provide Resident Trust Fund Account Statements
Penalty
Summary
The facility failed to provide quarterly statements for resident trust fund accounts as required by their policy. Two residents, one with little to no cognitive impairment and another with moderate cognitive impairment, were identified as not having received these statements. The first resident, who had been at the facility for three years, reported never receiving a statement and expressed a desire to know the balance of his account. The second resident was unaware of having a trust fund account until informed by the surveyor, and his financial responsible party confirmed not receiving any statements. Interviews with facility staff, including the Business Office Manager and the Regional Human Resource Coordinator, confirmed the deficiency. The Business Office Manager acknowledged the responsibility for managing the trust fund accounts and confirmed the absence of statements in the resident's room. The Regional Human Resource Coordinator verified the facility's policy requiring quarterly statements to be provided to residents and maintained in the business office. However, she was unable to provide evidence that the statements had been distributed to the residents or their responsible parties, indicating a lapse in adherence to the facility's policy.
Trust Fund Accounts Exceed Medicaid Eligibility Limit
Penalty
Summary
The facility failed to ensure that two residents' trust fund accounts remained under the $2,000 limit necessary to maintain eligibility for Medicaid services. The facility's policy, dated 1/9/2022, required that accounts exceeding $2,000 be spent down within 10 days. However, a review of Resident 38's fund statement from 10/1/2024 to 12/31/2024 showed a beginning balance of $2,801.28 and an ending balance of $3,743.51, both exceeding the limit. Additionally, a trial balance document revealed that Resident 8's balance on 2/22/2025 was $2,075.58, also above the threshold. Interviews with the Regional Human Resource Coordinator and the Administrator confirmed that the accounts of these residents exceeded the Medicaid eligibility limit. The Business Office Manager was in the process of obtaining a burial policy for residents with balances over $2,000, and the Business Office Department was identifying affected residents to establish a burial fund.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for residents, as evidenced by several deficiencies observed in eight of 54 resident rooms and the main dining room. Observations revealed large brown stains on eight ceiling tiles in the dining room, a ceiling light without a cover, and floor tiles with dark stains in shared bathrooms. Additionally, a ceiling fan was found detached from the ceiling in one resident room, and a wall plate covering for a television cable outlet and a ceiling exhaust fan were detached in another room. These conditions were confirmed by the Maintenance Director, who stated that work orders were being submitted through the electronic maintenance reporting system. Further observations over several days revealed brown stains and discolorations on the floors of shared restrooms in multiple rooms, as well as a water leak around the toilet in a shared bathroom. These deficiencies indicate a failure to provide a safe, clean, and comfortable environment for residents, as outlined in the facility's policy titled Safe and Homelike Environment. The policy emphasizes the importance of creating and maintaining a homelike environment that minimizes the institutional character of the setting, which was not upheld in this instance.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards and regulatory requirements for a resident who was receiving oxygen therapy. The resident, who was admitted with multiple diagnoses including chronic systolic heart failure and chronic kidney disease, was observed using oxygen at 2 liters per minute via nasal cannula on multiple occasions. However, there was no physician's order for the oxygen therapy, and the resident's care plan did not reflect the ongoing use of oxygen. Additionally, the facility did not ensure proper storage and handling of the oxygen equipment. During an observation, the nasal cannula tubing was found on the floor, dirty, and not stored in a plastic bag. The Director of Nursing acknowledged that the facility failed to obtain a physician's order for the oxygen therapy after the resident's discharge from the hospital, which was against the standard protocol of reconciling orders upon readmission.
Infection Control Lapse in Glucometer Use
Penalty
Summary
The facility failed to adhere to its infection control process during the use of a glucometer for a resident with a physician order for blood glucose monitoring. The facility's policy required that the glucometer be cleaned and disinfected according to the manufacturer's instructions and the facility's disinfection policy. However, during an observation, an LPN was seen performing a glucometer test on a resident without using a barrier on surfaces where the supplies and glucometer were placed. The LPN placed the supplies directly on the overbed table and the bed without a barrier, and later placed the glucometer on the medication cart without a barrier as well. The Assistant Director of Nursing confirmed that the glucometer should be cleaned with a germicidal disposable wipe after each use and that a barrier must be used when placing the glucometer and supplies on any surface. The LPN involved admitted to not having received education on cleaning the glucometer from the facility. This lack of adherence to infection control practices had the potential to place residents at risk of infection due to cross-contamination.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warrenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thomson Health And Rehabilitation | 9.9 mi | ★★★★★ | 8 | 0 |
| Gibson Health Opco Llc | 12.7 mi | ★★★★★ | 4 | 0 |
| Sparta Health And Rehabilitation | 15.2 mi | ★★★★★ | 8 | 0 |
| Woods At Sparta Of Journey Llc, The | 19.2 mi | ★★★★★ | 10 | 0 |
| Pruitthealth - Washington | 22.2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.