Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Manor during CMS and state inspections, most recent first.
Two residents had care plans that did not include interventions for rejection of care despite records and staff interviews showing repeated refusals of showers and other care. The MDS Coordinator was responsible for updating the plans, and the administrator, DON, LPN, CNA, and CMT all acknowledged that rejection of care should have been addressed in the care plans.
Failure to provide and document bathing and personal hygiene care for dependent residents. Three residents who required substantial to total assistance for showers and hygiene had missing shower documentation across multiple scheduled baths, and staff interviews indicated showers could be delayed when aides were pulled to other care. Observations found one resident with long facial hair, one with foul odor and long fingernails, and one with dry flaky skin, foul-smelling skin folds, and caked substance under the breasts and abdominal folds; the resident stated no shower had been received in three weeks.
An LPN left a resident’s Percocet at the bedside without watching the resident take it, and the resident later reported the medication was missing. This happened on more than one occasion, despite the facility policy requiring staff to remain with the resident during medication administration. The resident had intact cognition, almost constant pain, and a care plan noting resistance to care, including medications; the DON and administrator confirmed staff are expected to observe residents take medications and not leave narcotics unattended.
A CMT administered one resident’s Metformin and Metoprolol to another resident who did not have orders for those medications. The resident who received the wrong meds had moderate cognitive impairment, and staff reported the CMT mixed up two residents and did not properly identify the resident before giving the medications. The facility’s medication policy referenced checking the resident’s name and picture, but did not include the five rights of medication administration.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy for residents with unhealed Stage III pressure ulcers. During a high-contact transfer of a cognitively impaired resident with a buttocks wound, a CNA and a CMT wore only gloves, despite an EBP sign on the door and the facility policy requiring gown and gloves for such care, and no PPE was kept near the room. The CNA believed EBP applied only to certain infections and considered the door sign outdated, while the CMT stated they did not know about the wound or see the sign. For two other cognitively intact residents with Stage III pressure ulcers, EBP signs were posted on their doors, but no PPE was available in proximity to their rooms or on door racks. The DON and IP confirmed that EBP and readily accessible PPE are required for residents with wounds or indwelling devices and acknowledged that appropriate PPE use and placement were not occurring.
Staff failed to report two separate resident-to-resident physical altercations to DHSS within the required two-hour timeframe, despite a written abuse policy requiring immediate reporting of all abuse allegations. In the first incident, a cognitively impaired resident with dementia and Alzheimer’s disease struck another resident multiple times after being redirected from an exit door, leading to a physical exchange that staff witnessed, interrupted, and assessed with no injuries, but no timely DHSS report was submitted due to miscommunication and assumptions between an LPN and the administrator. In the second incident, the same resident hit a cognitively intact resident with post-stroke cognitive deficits in the face, prompting the other resident to strike back; staff again intervened, assessed both residents, and notified nursing leadership and physicians, but did not report the allegation to DHSS, and the administrator later stated he/she had decided not to report it because there were no injuries and no suspicion of abuse.
Staff did not consistently perform or document shift-to-shift controlled drug counts with two staff members as required, leading to incomplete records and discrepancies in narcotic counts. A resident receiving opioid pain medication had missing documentation and a discrepancy in pill count, with staff acknowledging that counts were sometimes not performed with two people or not documented due to busy shifts or forgetfulness.
Facility staff failed to store food properly, maintain the mechanical dishwasher, allow dishes to air-dry, maintain the ice machine, and perform hand hygiene, leading to potential contamination and cross-contamination risks.
The facility failed to provide a homelike environment, with multiple observations of damaged and unclean resident areas, including chipped paint and gouged drywall. A persistent urine odor was noted in the 100 hall, attributed to unclean carpets. Staff interviews revealed a lack of communication and follow-through in reporting and addressing maintenance and cleanliness issues.
Facility staff failed to provide written information about the bed hold policy to five residents or their representatives during hospital transfers. Interviews revealed that nurses were not completing the required paperwork, and the issue was not addressed due to the absence of a DON for an extended period.
Facility staff failed to complete the required MDS assessments within the mandated timeframes for seven residents. The MDS Coordinator attributed the delay to working on the floor due to staff shortages, and the administrator confirmed the issue, noting that the Corporate MDS Nurse had been assisting but the facility was still behind schedule.
Facility staff failed to complete Quarterly MDS assessments within the required 92-day timeframe for nine residents. The MDS Coordinator was frequently working the floor due to staff shortages, leading to delays in assessments. The Administrator acknowledged the issue and mentioned that the Corporate MDS Nurse had been assisting, but the facility was still behind on assessments.
The facility failed to encode and transmit resident assessment data within the required seven days for fourteen residents. The MDS Coordinator was frequently working the floor due to staff shortages, leading to delays in completing and submitting MDS assessments. The administrator acknowledged the issue and noted attempts to call in additional staff and involve a Corporate MDS Nurse to assist.
The facility staff failed to develop and implement comprehensive person-centered care plans for seven residents, leading to inadequate documentation of necessary interventions for ADLs, incontinence care, and other specific needs. Observations and staff interviews confirmed that these aspects should have been care planned but were not documented appropriately.
Facility staff failed to ensure residents who were unable to complete their own ADLs received necessary care to maintain good personal hygiene. Residents were found in soiled conditions, with strong odors of urine and feces, and lacked grooming. Staff did not consistently follow protocols for incontinence care, and the facility lacked adequate policies for shaving, bathing, and incontinence care.
Facility staff failed to lock medication and treatment carts and did not store medications and chemicals safely. Multiple observations showed carts left unlocked and unattended with medications accessible to residents. Staff acknowledged the issue, and interviews with ADON, DON, and the administrator confirmed the carts should be locked to prevent potential harm.
Facility staff failed to maintain a medication error rate below five percent, resulting in a 20.7% error rate. Multiple instances of improper insulin administration were observed, where staff did not prime insulin pens before use, affecting four residents. Staff admitted to not following the correct procedure, acknowledging it could lead to incorrect dosing.
The facility staff failed to count narcotic medications each shift, reconcile a resident's liquid lorazepam, and properly store medications, leading to discrepancies and potential cross-contamination. Observations and interviews revealed incomplete narcotic counts, undated medications, and improper storage practices.
Facility staff failed to maintain proper infection control practices, including hand hygiene and equipment disinfection, for multiple residents. Observations showed lapses in following facility policies, such as not using barriers for medical equipment, improper handwashing, and inadequate disinfection of glucometers. Staff acknowledged these deficiencies, citing shortages of necessary supplies.
Facility staff failed to maintain resident dignity by leaving a resident exposed to the hallway and not covering another resident's urinary catheter bag. Despite known behaviors and requirements, staff did not consistently take actions to ensure privacy, leading to dignity issues.
Facility staff failed to complete baseline care plans within 48 hours of admission for three residents, contrary to the facility's policy. The DON and ADON confirmed the absence of these care plans, and the administrator acknowledged existing issues with MDS and care plan processes.
The facility failed to ensure that two NAs completed the required training program within four months of employment. The administrator, MDS Coordinator, and DON were unaware of the non-compliance, and no tracking system was in place to monitor training dates.
Facility staff failed to notify the family and physician of a resident's fall which resulted in an injury. The resident, who had Parkinson's disease and was at high risk for falls, sustained multiple abrasions and bruises. Interviews revealed that the DON and administrator were unaware if notifications were made, and the physician confirmed they were not informed until the next day.
Care plans not updated for residents who rejected care
Penalty
Summary
The facility failed to update the care plan within 7 days of the comprehensive assessment and failed to have the plan of care prepared, reviewed, and revised by a team of health professionals for two residents. Review of the facility policy showed the Care Planning/Interdisciplinary Team is responsible for developing an individualized comprehensive plan of care for each resident. For one resident, the quarterly MDS dated 04/08/26 showed moderate cognitive impairment and no behaviors or rejection of care, but the care plan dated 03/02/26 did not include direction for staff when the resident rejected care. Progress notes documented refusals of clothing changes, showers, and other care, and during the care plan meeting staff discussed that the resident often refused showers and may decline care. Staff interviews confirmed the resident frequently refused care and that the care plan should have included interventions for rejection of care. For the second resident, the quarterly MDS showed moderate cognitive impairment and no behaviors or rejection of care, but the care plan dated 02/03/26 did not contain direction for staff when the resident rejected care. The resident’s shower sheet documented a refused shower, and staff interviews stated the resident had a history of rejecting care depending on mood. The administrator, DON, LPN, CNA, and CMT all acknowledged that rejection of care should be addressed in the care plan with interventions to guide staff, and the MDS Coordinator stated he/she was responsible for updating the plan of care and had updated one resident’s care plan only after the surveyor asked about the history of rejecting care. The MDS Coordinator said he/she was not told that the second resident rejected care.
Failure to Provide and Document Bathing and Personal Hygiene Care
Penalty
Summary
Facility staff failed to ensure dependent residents received the necessary assistance with bathing and personal hygiene. The facility did not provide a shower/bathing policy or a grooming/hygiene policy. Review of records and observations showed three residents who were dependent for showers and personal hygiene did not have consistent documentation that showers were completed or refused, and staff interviews indicated showers could be delayed or not completed when aides were pulled to other care on the floor. One resident was cognitively intact, dependent for showers, toileting, dressing, and personal hygiene, and had a care plan for two showers weekly and facial hair removal. Shower sheets showed only one documented shower in March and one in April, with no documentation of showers or refusals for multiple scheduled dates and none in May. On observation, the resident had long facial hair on the chin, and the resident stated it had been a little while since the last shower and that it sometimes takes two staff to transfer, with not enough staff available. A second resident was cognitively impaired and required substantial to maximal assistance for showering. The care plan directed two showers weekly, but shower sheets documented only one shower in March and two in April, with no documentation for the rest of those months or any in May. The resident was observed with foul odor and long fingernails, and a CNA stated the resident often oozes bowel movement and may require up to five staff for toileting or showering. A third resident also required substantial to maximal assistance for showers; shower sheets for May contained no documentation of a shower or refusal. The resident was observed with dry flaky skin, bright red skin under abdominal folds and breasts covered with a white cakelike substance and foul smell, and stated no shower had been received in three weeks and that the skin folds were red, itchy, and smelled.
Narcotic Medication Left Unattended at Bedside
Penalty
Summary
Facility staff failed to maintain professional standards of care when narcotic pain medication was left unattended at a resident’s bedside and was accessible to the resident’s roommate. The resident had intact cognition, almost constant pain, and a scheduled pain medication order for Percocet 10-325 mg every four hours. The resident’s care plan noted that the resident resisted care, including taking medications, and the facility’s medication administration policy stated staff are to remain in the resident’s room while the resident takes the medication. On two separate occasions, an LPN administered the resident’s morning Percocet dose and left the medication on the bedside table without watching the resident take it. In both instances, the resident later reported the medication was missing after going to the bathroom or falling back asleep. The nurses involved stated they knew medications were not supposed to be left with residents without observing ingestion, but said the resident became upset and agitated when staff tried to watch him/her take medications. The interim DON and administrator confirmed staff are expected to stay and watch residents consume medications and not leave medications at bedside, and the interim DON noted concern because the resident had a roommate.
Medication given to the wrong resident
Penalty
Summary
Staff failed to ensure residents were free from significant medication errors when a CMT administered one resident’s medications to another resident. The facility’s Medication Administration policy stated medications are to be given as ordered by the physician and that staff should introduce themselves, call the resident by name, and check picture identification in the medication book, but the policy did not include documentation directing staff on the five rights of medication administration. The facility census was 91.1. Resident #1’s quarterly MDS showed moderate cognitive impairment. The Medication Error Documentation form showed CMT A gave Resident #3’s medications to Resident #1 and documented that Resident #1 received Metformin and Metoprolol. Resident #1’s POS did not contain physician orders for either medication. LPN C stated CMT A reported administering the wrong medication to the wrong resident. The administrator, DON, and CMT A each stated staff were directed to verify resident identity before medication administration by checking the resident’s picture in the medical record, the name on the door, and asking the resident’s name or another staff member if unsure, and CMT A said he/she mixed up Resident #1 and Resident #3 and did not identify the residents before administering the medications.
Failure to Implement Enhanced Barrier Precautions and Ensure PPE Availability for Residents With Wounds
Penalty
Summary
Facility staff failed to implement their Enhanced Barrier Precautions (EBP) policy for residents with wounds and indwelling devices, resulting in improper use of personal protective equipment (PPE) and lack of readily available PPE. The facility’s March 2024 EBP guidance required gown and gloves for high-contact resident care activities, including transfers and wound care, for residents with wounds or indwelling medical devices, and required PPE to be kept in proximity to the resident’s room with a trash can in the room for disposal. Surveyors found that these requirements were not followed for multiple residents with unhealed Stage III pressure ulcers. For one resident with cognitive impairment, dependence on staff for transfers, and an unhealed Stage III pressure ulcer, surveyors observed a CNA and a CMT enter the room to transfer the resident from bed to a shower chair. Although a sign on the door indicated EBP were required for high-contact care, there was no PPE in proximity to the room. The CNA and CMT donned only gloves, placed a mechanical lift sling under the resident, and transferred the resident without wearing gowns, despite direct contact and the presence of a wound on the upper buttocks. In interviews, the CMT stated EBP are used for residents with catheters, colostomies, or wounds and acknowledged a gown and gloves should have been worn, but said they did not know the resident had a wound and did not see the sign. The CNA stated gowns and gloves are used if staff are told the resident needs them, believed EBP were only needed for certain infections such as C. difficile, shingles, or MRSA, and said the sign on the door was old and did not apply. Surveyors also identified failures to ensure PPE availability for two additional residents with unhealed Stage III pressure ulcers. For one cognitively intact resident who reported having a wound on the bottom, a sign on the door indicated EBP were required for high-contact care, but no PPE was observed in proximity to the room or on a rack inside the room. For another cognitively intact resident who reported wounds on the legs and feet, a similar EBP sign was posted, yet no PPE was available near the door or on a rack inside the room. The DON and the Infection Preventionist confirmed in interviews that EBP should be used for residents with wounds or indwelling devices, that signs should be posted on doors, and that PPE should be available at or on the door, but acknowledged that staff were not using appropriate PPE and that PPE was not in place as required.
Failure to Timely Report Resident-to-Resident Physical Abuse Allegations to DHSS
Penalty
Summary
Facility staff failed to timely report two separate allegations of resident-to-resident physical abuse involving one resident to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe, as required by the facility’s Abuse Prevention Policy dated 11/28/2016. The policy states that all alleged violations involving abuse, including resident-to-resident physical altercations such as hitting, slapping, punching, biting, and kicking, must be reported immediately, but no later than two hours after the allegation is made. On 12/18/25, progress notes documented that a resident with moderate cognitive impairment, dementia, Alzheimer’s disease, difficulty speaking and understanding others, and independent ambulation was banging on exit doors, was redirected, then began pacing the hallway where another resident was walking. The cognitively impaired resident grabbed the other resident and hit him/her multiple times, prompting the other resident to hit back. Staff separated the residents, assessed them with no injuries and no pain, placed the aggressor on 15‑minute checks, notified management on call, the physician, and responsible party, and sent the aggressor to the emergency room for evaluation. However, no initial report was submitted to DHSS within two hours. The administrator later stated he/she was not aware of the 12/18/25 incident and acknowledged it should have been reported within two hours, while LPN A and LPN B both stated they knew such incidents must be reported within two hours but each believed the other or management would complete and submit the report. A second incident occurred on 01/07/26 involving the same aggressor resident and another resident assessed as cognitively intact, with diagnoses including cognitive deficits following a nontraumatic intracerebral hemorrhage and independent ambulation. The facility’s investigation documented that the cognitively intact resident came out of his/her room holding the aggressor resident’s arms and asked staff for help, but before staff could intervene, the aggressor resident hit the cognitively intact resident on the left side of the face, and the cognitively intact resident hit the aggressor resident in the mouth. Staff separated and redirected the residents, the nurse assessed both residents, placed them on 15‑minute checks, and notified the DON, ADON, physician, and responsible parties. The investigation report did not contain documentation that the allegation was reported to DHSS within two hours, and review of the DHSS complaint/facility self‑report database showed no record of a report for this incident. The administrator stated he/she investigated the 01/07/26 incident but believed it was the first physical altercation for the aggressor resident, and because there were no injuries, no suspicion of abuse, and interventions were implemented, he/she did not report the incident to DHSS, later acknowledging that, in light of the prior 12/18/25 incident, it should have been reported within two hours.
Failure to Complete and Document Shift Narcotic Counts with Two Staff Members
Penalty
Summary
Facility staff failed to complete shift-to-shift controlled drug counts with two staff members as required by facility policy, resulting in incomplete documentation and discrepancies in controlled medication counts. The facility's policy directs that a physical inventory of narcotics be completed at each shift change by one outgoing and one incoming RN, LPN, or CMT, with both staff members verifying and signing the count. However, review of the Controlled Substance Shift Change Forms revealed that on multiple occasions, only one staff signature was present, and in some instances, there were missing signatures for entire shifts. This failure to follow policy was confirmed through interviews with staff, who acknowledged that narcotic counts were sometimes not performed with two people and that documentation was incomplete or missing due to busy shifts or staff forgetting to sign the forms. A specific incident involved a resident who was moderately cognitively impaired and received opioid pain medication. The controlled substance log for this resident's Tramadol prescription did not contain documentation that staff counted the medication between certain dates. A review showed a discrepancy in the pill count, with two pills unaccounted for over a three-day period. Staff interviews indicated that the missing medication was discovered when a count was eventually performed, and it was reported to a nurse. Staff involved denied taking the medication and stated that they had received education on the correct procedure for counting and documenting narcotics. Further interviews with nursing and administrative staff confirmed that the expectation was for narcotics to be counted at the beginning and end of each shift by two staff members, with documentation on the appropriate forms. However, it was acknowledged that this process was not consistently followed, and audits of the forms were not being performed regularly at the time of the incident. The deficiency was identified through observation, record review, and staff interviews, which collectively demonstrated a pattern of non-compliance with the facility's narcotic count policy.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility staff failed to store food in a manner to prevent potential contamination and outdated use. Observations revealed multiple instances of improperly stored food items, including undated and opened bags of granulated sugar, brown sugar, flour, and other food products stored in non-food-grade containers. Additionally, dented cans were found on the storage rack, and staff were observed using regular trash bags to line bulk food barrels. The Dietary Manager (DM) admitted to not knowing that food products removed from their original packages needed to be stored in food-grade bags or containers and acknowledged that staff were trained on these requirements but failed to follow them consistently. The mechanical dishwasher was not maintained in good repair, resulting in ineffective washing and sanitizing of dishes. Observations showed that the dishwasher's water temperature was consistently below the required minimum of 120 degrees Fahrenheit, and the chlorine sanitizer concentration was excessively high at 200 parts per million (ppm). The DM admitted to knowing about the water temperature issue but continued to use the dishwasher despite it not meeting the required standards. The maintenance director was not informed of the problem in writing, as required by the facility's procedures. The facility staff also failed to allow cleansed dishes to air-dry before stacking them in storage, which could lead to the growth of food-borne pathogens. Observations showed multiple instances of wet dishes being stacked together, and staff were seen using towels to dry dishes instead of allowing them to air-dry. Additionally, the ice machine was not maintained in a sanitary manner, with an accumulation of lime and calcium scale on the exterior and excessive dirt and debris behind and beneath the machine. The DM and maintenance director were unaware of the proper maintenance requirements for the ice machine. Furthermore, staff failed to perform hand hygiene as often as necessary, with multiple instances of staff handling trash and then continuing food preparation or handling clean dishes without washing their hands.
Failure to Maintain a Homelike Environment and Address Maintenance Issues
Penalty
Summary
The facility staff failed to provide a comfortable and homelike environment, as evidenced by multiple observations of damaged and unclean resident areas. Specific observations included chipped paint, gouged drywall, and missing paint in several occupied rooms, as well as the activity room in the Memory Care Unit. Interviews with staff revealed that maintenance issues were supposed to be reported in a maintenance log book at the nurse's station, but there was no verification process to ensure the Maintenance Director was checking the log daily. The Maintenance Director reported not receiving any recent concerns regarding drywall or paint issues in residents' rooms. Additionally, there was a persistent odor of urine throughout the 100 hall, which was noted over several days and times. Staff interviews indicated that the odor was likely coming from the carpet, which was not being cleaned regularly due to a lack of a cleaning schedule and insufficient staffing. The floor technician and housekeeping supervisor confirmed that there was no schedule for carpet cleaning, and the floor technician stated that it was challenging to keep up with cleaning all the carpets in the facility. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the urine odor and attributed it to the carpet, which they believed held the smell. The facility did not have policies for environment, maintenance repairs, and cleaning, contributing to the deficiencies observed. Staff interviews highlighted a lack of communication and follow-through in reporting and addressing maintenance and cleanliness issues. The administrator admitted that no one was checking to ensure the Maintenance Director was reviewing the maintenance log, but stated that this would start. The persistent urine odor and damaged resident areas indicated a failure to maintain a safe, clean, and comfortable environment for residents.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
Facility staff failed to provide written information to the resident and/or the resident's representative of the bed hold policy for five residents out of a sample of 22. The facility's policy required notification of the bed hold guidelines on admission, at the time of transfer to the hospital, and at the time of non-covered therapeutic leave. However, the medical records for Residents #18, #19, #23, #340, and #355 did not contain documentation that staff notified the residents or their representatives of the bed hold policy during their transfers to the hospital and subsequent returns to the facility. The facility census was 84 at the time of the survey. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator revealed that the nurses were not completing the bed hold paperwork as required. The DON mentioned that the facility had not had a DON for a couple of years, which may have contributed to the oversight. The ADON and the Administrator confirmed that the nurses were supposed to fill out the bed hold forms, especially during emergencies or when the Social Services Director (SSD) was not available. The Administrator admitted to being unaware of the issue until it was brought to attention during the survey.
Failure to Complete MDS Assessments on Time
Penalty
Summary
Facility staff failed to complete the required Minimum Data Set (MDS) assessments within the mandated timeframes for seven residents. The facility did not have a policy for MDS assessments, and the assessments for the residents were found to be in progress and not submitted on time. The MDS Coordinator acknowledged the delay and attributed it to spending a significant amount of time working on the floor due to staff call-ins and medical leaves. The administrator was aware of the issue and mentioned that the Corporate MDS Nurse had been assisting, but they were still unable to keep up with the required assessments. The residents affected included those with annual MDS assessments and one with an admission MDS assessment. The MDS Coordinator and the administrator both confirmed that the assessments were behind schedule, and the facility was struggling to manage the workload due to staffing shortages. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were new, and the MDS Coordinator had been filling in for those positions before they started, further contributing to the delay in completing the assessments.
Failure to Complete Quarterly MDS Assessments on Time
Penalty
Summary
Facility staff failed to ensure that Quarterly Minimum Data Set (MDS) assessments were completed no less frequently than once every 92 days for nine residents out of a sample of 22. The MDS assessments for these residents were found to be in progress and not submitted within the required time frame, with all sections showing incomplete information. The facility did not have a policy for MDS assessments, and the review of the Resident Assessment Instrument (RAI) manual confirmed the required assessment time frames were not met for the residents in question. Interviews with the MDS Coordinator and the Administrator revealed that the MDS Coordinator had been frequently working the floor due to staff call-ins and medical leaves, which hindered the completion of MDS assessments. The Administrator acknowledged the issue and mentioned that the Corporate MDS Nurse had been assisting, but the facility was still unable to keep up with the required assessments. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were both new, and the MDS Coordinator had to fill in for their positions before they started, further contributing to the delay in completing the assessments.
Failure to Timely Encode and Transmit Resident Assessment Data
Penalty
Summary
The facility failed to encode and transmit resident assessment data within the required seven days after completing the assessments for fourteen residents out of a sample of twenty-two. The Minimum Data Set (MDS) assessments for these residents were found to be in process and not submitted within the required time frame. The MDS Coordinator acknowledged the delay, attributing it to spending a significant amount of time working on the floor due to staff call-ins and medical leaves. The administrator confirmed the issue, noting that the MDS Coordinator had been frequently covering shifts on the floor for the past three to four months, which contributed to the backlog in completing MDS assessments. The report detailed specific instances where the MDS assessments for various residents, including annual, quarterly, admission, and discharge assessments, were not submitted on time. The MDS Coordinator and the administrator both recognized the problem, with the administrator mentioning attempts to call in additional staff and the involvement of a Corporate MDS Nurse to assist. Despite these efforts, the facility remained behind in completing and submitting the required assessments, impacting the timely encoding and transmission of resident data to the state.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility staff failed to develop and implement a comprehensive person-centered care plan for seven residents out of 22 sampled residents. The care plans lacked documentation of necessary interventions for Activities of Daily Living (ADLs), incontinence care, and other specific needs. For instance, Resident #3's care plan did not include interventions for ADLs despite requiring moderate assistance for various tasks. Similarly, Resident #18's care plan did not address the assistance required for ADLs and incontinence care, leading to the resident being found in a urine-soaked bed multiple times. Staff interviews confirmed that these aspects should have been care planned but were not documented appropriately. Resident #22, who had severe cognitive impairment and was at risk for choking and aspiration, did not have care plan directions to ensure the resident's bed was at a 45-degree angle during and after meals. Observations showed the resident being fed in a chair angled at 15 degrees, contrary to the required 45 degrees. Staff interviews revealed that the resident's choking and aspiration risks should have been included in the care plan but were omitted. Similarly, Resident #33's care plan lacked directions for multiple care areas, including communication, ADLs, urinary incontinence, behavioral symptoms, nutritional status, dental care, pressure ulcers, and psychotropic drug use. Observations and interviews indicated that these omissions led to inadequate care, such as the resident having unshaved facial hair and food stains on clothing. Other residents, such as Resident #241 and Resident #340, also had incomplete care plans that did not address their specific needs, including ADL assistance, facial hair preferences, and psychotropic medication use. Resident #376's care plan did not include directions for facial hair preferences, resulting in the resident having long facial hair and greasy, uncombed hair. Staff interviews consistently highlighted that these care areas should have been documented in the care plans but were not. The MDS Coordinator acknowledged the deficiencies and noted that the DON had been educating staff on updating care plans, but the care plans remained incomplete at the time of the survey.
Failure to Provide Adequate ADL Assistance and Personal Hygiene Care
Penalty
Summary
Facility staff failed to ensure residents who were unable to complete their own activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. Specifically, staff did not ensure that residents remained clean, dry, and free from odor. For instance, Resident #10, who had severe cognitive impairment and was always incontinent of bowel and bladder, was observed multiple times over several hours covered in feces without being changed by staff. Similarly, Resident #18, who was occasionally incontinent of bowel and bladder, was found in a bed saturated with urine, and staff failed to provide timely incontinence care despite the strong odor of urine being noticeable in the hallway outside the resident's room. Resident #347, who had moderate cognitive impairment and was frequently incontinent of bladder, was also found in bed with a strong urine odor. Staff walked by the resident's room multiple times without checking for the source of the odor. When incontinence care was finally provided, it was revealed that the resident was wet. Additionally, Resident #376 and Resident #383 were observed with greasy, uncombed hair and long facial hairs, indicating a lack of grooming and personal hygiene care. Both residents expressed dissatisfaction with their appearance and the lack of assistance provided by the staff. Interviews with staff, including CNAs, the ADON, the DON, and the administrator, revealed that incontinence care should be provided every two hours and as needed. However, staff admitted to not following these protocols consistently. The DON and administrator acknowledged that some residents were not receiving regular showers or shaves due to a lack of a shower schedule and staffing issues. The facility's policies did not adequately address the frequency or preferences for shaving and bathing, and there was no policy for incontinence care, contributing to the deficiencies observed.
Failure to Secure Medication and Treatment Carts
Penalty
Summary
Facility staff failed to lock medication and treatment carts and did not store medications and chemicals in a safe manner. The facility's policy required all medications to be stored in locked cabinets, rooms, or mobile carts, and for these carts to be under visual control or locked when unattended. However, multiple observations showed that treatment and medication carts were left unlocked and unattended in hallways with residents nearby. These carts contained various medications, including antifungal medication, insulin pens, and wound cleansers, which were accessible to residents and posed a potential safety hazard. On several occasions, staff members, including an LPN and a CMT, acknowledged that they should not have left the carts unlocked or unattended. For instance, an LPN left a box of insulin pens on top of an unlocked cart while administering insulin to a resident. Similarly, a CMT left a card of Lisinopril on top of an unlocked and unattended medication cart. These actions were observed multiple times over several days, indicating a pattern of non-compliance with the facility's medication storage policy. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the facility administrator confirmed that medication and treatment carts should be kept locked and that medications should not be left on top of the carts when unattended. They acknowledged that leaving carts unlocked and unattended could allow residents, staff, or visitors to access the medications, potentially causing harm. Despite these acknowledgments, the observations showed a consistent failure to adhere to the facility's policies, resulting in a significant safety concern for the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
Facility staff failed to maintain a medication error rate less than five percent, resulting in a 20.7% error rate out of 29 opportunities observed. Six errors were identified, affecting four residents. The errors primarily involved the improper administration of insulin via insulin pens, where staff did not prime the pens before each use as required by the manufacturer's recommendations. This failure was observed in multiple instances involving different staff members, including an LPN and the Assistant Director of Nursing (ADON). The staff members involved admitted to not following the correct procedure, which they acknowledged could lead to incorrect dosing and thus constituted medication errors. Resident #23, who was cognitively intact, had orders for Lispro and Lantus insulin, but the LPN did not prime the insulin pen before administration. Similarly, Resident #15, also cognitively intact, had orders for Novolog and Levimer insulin, but both the LPN and ADON failed to prime the pen before administration. Resident #18, another cognitively intact resident, had orders for Lantus and Lispro insulin, and the ADON again did not prime the pen. Interviews with the LPN, ADON, DON, and the administrator confirmed that insulin pens should be primed with two units before each use to ensure accurate dosing and that failure to do so is considered a medication error.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility staff failed to count narcotic medications each shift for three medication carts and did not reconcile a resident's liquid lorazepam, leading to discrepancies in narcotic counts. The facility's policy required a physical inventory of narcotics at each shift change, but logs from March and April 2024 showed incomplete shift counts for the Memory Care Unit and the 100 and 200 halls. Observations confirmed that staff did not complete narcotic counts at shift changes, and interviews revealed that staff often skipped this step due to being busy or unaware of the procedure. One resident's lorazepam count showed a significant discrepancy, which was not immediately reported or investigated by the staff on duty. The facility also failed to store medications properly, as observed in the 100 hall treatment cart and the southwest medication room refrigerator. Multiple treatments were not separated by resident, and several medications were opened without being dated. Observations showed loose pills and trash in medication carts, and interviews with staff confirmed that it was their responsibility to date medications when opened and keep the carts clean. However, this was not consistently done, leading to potential cross-contamination and medication errors. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and other staff members highlighted a lack of adherence to the facility's policies regarding narcotic counts and medication storage. The ADON and DON acknowledged that narcotic counts should be completed at each shift change and that medications should be dated and stored properly. Despite these policies, the staff did not consistently follow these procedures, resulting in multiple deficiencies in medication management and storage.
Infection Control Deficiencies in Hand Hygiene and Equipment Disinfection
Penalty
Summary
Facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Staff did not perform hand hygiene properly for four residents and failed to disinfect a multi-use glucometer between two residents. The facility's policies on blood glucose monitoring, handwashing, and glove use were not followed, leading to potential contamination and infection risks. Specifically, staff did not use barriers when placing medical equipment on bedside tables, did not wash hands correctly, and did not disinfect the glucometer as required. Observations showed that an LPN did not clean the glucometer before use, placed it on a resident's bedside table without a barrier, and performed a finger stick. The LPN also failed to wear gloves while administering insulin and did not wash hands properly. The LPN admitted to these lapses, citing a shortage of Sani-wipes and unavailability of gloves in resident rooms. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed these observations and acknowledged the lapses in following proper infection control procedures. Further observations revealed that the ADON also failed to follow proper hand hygiene and glove use protocols while administering insulin to residents. The ADON did not wash hands after removing gloves and did not use gloves while administering insulin. The ADON and the DON both stated that staff should wash hands before and after resident care, use barriers for medical equipment, and disinfect glucometers with Sani-wipes. The facility's administrator also confirmed these expectations and acknowledged the deficiencies in infection control practices.
Failure to Maintain Resident Dignity
Penalty
Summary
Facility staff failed to maintain resident dignity by leaving one resident exposed to the hallway and failing to properly cover a urinary drainage bag for another resident. Resident #12, who had moderate cognitive impairment and required maximal assistance for daily activities, was observed in bed with only a brief on, visible from the hallway. Despite the resident's known behavior of undressing himself/herself, staff did not consistently pull the privacy curtain or close the door, leading to the resident being exposed to passersby. Interviews with staff revealed that while some were aware of the issue, they did not take consistent action to maintain the resident's privacy and dignity. Resident #355, who also had moderate cognitive impairment and was dependent on staff for all activities of daily living, was observed in the dining room with an uncovered urinary catheter bag. The bag, which was supposed to be placed in a privacy bag before the resident left the room, was visible to other residents. Staff interviews indicated that they were aware of the requirement to cover the catheter bag but failed to do so on multiple occasions. The Assistant Director of Nursing and the Director of Nursing both acknowledged that the uncovered catheter bag was a privacy issue. The facility's policies did not include a specific policy for maintaining resident dignity. The Director of Nursing and the administrator both stated that they expected staff to take measures to ensure residents' privacy, such as closing doors and using privacy curtains. However, the lack of consistent action and oversight led to the residents being exposed in ways that compromised their dignity.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to complete a baseline care plan within 48 hours of admission for three residents out of 22 sampled residents. The facility's policy requires a temporary care plan to be implemented within 24 hours of admission to meet the resident's immediate needs. However, the medical records for the three residents did not contain a baseline care plan, indicating non-compliance with the facility's policy. The Director of Nursing (DON) confirmed the absence of baseline care plans in the system, and the Assistant Director of Nursing (ADON) acknowledged that staff are not completing the baseline care plans as required. The administrator stated that the nurses start the baseline care plans and the Minimum Data Set (MDS) Coordinator finishes them within 24 to 48 hours. Despite this process, the baseline care plans were not completed for the three residents. The ADON mentioned spending more time on the floor as a floor nurse than performing ADON duties, which may have contributed to the oversight. The administrator also noted that there were existing MDS and care plan issues before their tenure at the facility, and staff education was planned to address these issues.
Failure to Ensure Nurse Aide Training Compliance
Penalty
Summary
The facility failed to ensure that two Nurse Aides (NAs), NA DD and NA P, completed the required nurse aide training program within four months of employment. NA DD was hired on 05/18/23, and NA P was hired on 08/28/23, but neither had documentation in their personnel files showing completion of the training program. The facility's payroll records from April 2024 confirmed that both NAs were working at the facility. Interviews with the administrator, MDS Coordinator, and Director of Nursing (DON) revealed that none of them were aware of the non-compliance. The MDS Coordinator, who recently took over scheduling and monitoring the NAs' online classes, admitted to not having a tracking system in place to monitor the training compliance dates. The DON, who started about a month ago, also had not reviewed the NA compliance dates.
Failure to Notify Family and Physician of Resident's Fall
Penalty
Summary
Facility staff failed to notify the family and physician of a resident's fall which resulted in an injury. The resident, who had diagnoses of Parkinson's disease, pain, and insomnia, was assessed to be at high risk for falls. On the date of the incident, the resident was found on their right side with a large abrasion and bruise on the right side of their face and two small abrasions between the knuckles on their right hand. The resident complained of pain from the injuries. However, there was no documentation indicating that the staff notified the resident's physician or family about the fall. Interviews with the Director of Nursing (DON) and the facility administrator revealed that they were unaware if the family and physician had been notified. The resident's physician confirmed that they were not informed about the fall until they visited the facility the next day. The facility's policy required immediate notification of the resident, their physician, and family in the event of an accident resulting in injury, but this protocol was not followed in this instance.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 73 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wright City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Jonesburg | 9.5 mi | ★★★★★ | 19 | 0 |
| Troy Manor | 13.9 mi | ★★★★★ | 0 | 0 |
| Lincoln County Nursing & Rehab | 14.3 mi | — | 3 | 0 |
| New Haven Care Center | 16.4 mi | ★★★★★ | 0 | 0 |
| Grandview Healthcare Center | 18.6 mi | ★★★★★ | 17 | 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.