Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Warren Hills Nursing Center during CMS and state inspections, most recent first.
A resident with dementia, pleural effusion, and CHF was started on scheduled ipratropium/albuterol nebulizer treatments for wheezing, but subsequent assessments by the Medical Director and PA repeatedly documented clear lungs, no wheeze, and no respiratory complaints while the medication continued to be administered. Nursing staff, including a support nurse, reported they had not observed ongoing wheezing to justify continued scheduled use, yet the order was never changed to PRN or discontinued. The consultant pharmacist did not recommend adjustment because provider notes indicated continuation of the current regimen, and the PA later stated she intended the bronchodilator to be PRN and was unaware it was still being given routinely. The DON acknowledged the order should have been PRN from the start and that there was no process to systematically review older standing medication orders.
Staff failed to follow hand hygiene and infection control policies during IV therapy and wound care. A nurse prepared medications at a cart, then entered a resident’s room and managed a PICC line and IV antibiotic setup without removing gloves or performing hand hygiene between handling equipment and accessing the line. In separate observations, a wound nurse cleansed two pressure ulcers on one resident and then applied new dressings without changing gloves or performing hand hygiene between wounds or before handling clean dressings, and similarly removed an old dressing from another resident’s pressure ulcer, cleaned the wound, and opened new dressings without an interim glove change or hand hygiene. These actions did not comply with the facility’s IPCP, hand hygiene, and IV therapy policies.
The facility failed to accurately code MDS assessments for three residents. One resident with dementia and multiple pressure ulcers, including a documented stage 4 sacral ulcer, was coded only for a stage 3 ulcer and a DTI, omitting the stage 4 wound. Another resident receiving IV vancomycin via a PICC line for osteomyelitis was coded for IV medication use but not for IV access, despite a care plan addressing PICC-related risks. A third resident with coronary artery disease and cerebral infarction, who was receiving clopidogrel as documented on the MAR, was incorrectly coded as receiving an anticoagulant. The MDS nurse and a support nurse acknowledged these coding errors, and leadership confirmed that the assessments should have been completed accurately.
A resident with severe cognitive impairment and right-sided hemiparesis following a stroke had a care plan and physician order for daily application of a resting hand orthosis, along with ROM exercises and skin checks, to manage contractures. After OT discharge, nursing staff were responsible for splint management, but surveyors repeatedly observed the resident in bed without the splint, which was seen on the bedside table, while the Treatment Administration Record showed it as applied. An RN reported relying on therapy staff to place the splint and documented it as in place without managing its placement or removal, despite facility leadership stating that nursing was responsible for ensuring the splint was applied per the order.
A resident with neuromuscular bladder dysfunction and urinary retention had a physician-ordered indwelling urinary catheter that was observed on multiple occasions without a leg band securement device in place, despite facility staff acknowledging that a leg band was required to prevent dislodgement. During wound care and a later observation, surveyors noted the catheter tubing was unsecured, and the resident reported that staff sometimes forgot to apply the securement device. The IP, a nurse, and a NA each described that nurses were responsible for ensuring the leg band was in place and NAs were expected to notify nurses when it was missing, but this did not occur consistently for this resident.
A resident admitted with pneumonia and cellulitis developed shortness of breath and low O2 saturation, leading an RN to initiate 2 L O2 via nasal cannula and notify the provider, but the oxygen order was never successfully entered into the electronic system. The RN reported difficulty entering the order and did not seek assistance, while the Support Nurse, who stated that the nurse obtaining the order is responsible for entry, did not review the resident’s orders to confirm the oxygen order was present. The DON confirmed the RN’s responsibility to both notify the provider and enter the oxygen order, resulting in the resident receiving ongoing supplemental O2 without a documented physician order.
Surveyors found that two open ophthalmic medications on one medication cart were not dated when opened, contrary to manufacturer instructions and facility practice. An RN observed an open bottle of brimonidine/timolol 0.2/0.5% eye drops and an open bottle of olopatadine 0.2% eye drops on the Hall 100 cart without any open dates, even though both products are to be used or discarded within four weeks of opening. The nurse assigned to the cart stated that medications are supposed to be dated when first opened but she was not present when these were opened and could not explain the omission, and the DON confirmed that nurses are expected to date medications upon opening and verify dates before use.
The facility failed to document advance directive education and opportunities for 13 residents, despite having physician orders for full code or DNR. Interviews revealed that advance directives were supposed to be reviewed during care plan meetings, but documentation was lacking. The Administrator acknowledged the need for proper documentation and reassessment of advance directives.
A resident, who was cognitively intact, was not provided with written or verbal notification of a new roommate. The facility's Social Worker admitted to not following the expected process of notifying residents and their responsible parties about roommate changes. The Director of Nursing and the Administrator confirmed the expectation of providing both verbal and written notifications, which was not met in this instance.
A facility failed to refer a resident with a serious mental illness for a Level II PASRR. The resident, diagnosed with delusional disorder, was not referred for further screening despite a significant change in status. The Social Worker and Admissions Director were unaware of the need for a Level II PASRR upon readmission, and the Administrator acknowledged the oversight as a problem.
Expired medication was found in a medication cart during an observation. An opened bottle of Senna-Plus with an expiration date of October 2024 was discovered. A medication aide acknowledged the oversight, stating that the assigned medication aide or nurse should check for expired medications each shift. The DON and Administrator confirmed that the responsibility for checking and removing expired medications lies with the assigned staff.
The facility failed to notify the Ombudsman of hospital transfers for four residents, as required. Record reviews and staff interviews revealed that the Social Worker was unaware of the obligation to send discharge information to the Ombudsman, and the Administrator was not informed of the oversight. This deficiency highlights a communication gap within the facility regarding notification responsibilities.
Failure to Reassess and Discontinue Unnecessary Scheduled Bronchodilator Therapy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary medications by not evaluating the continued need for a bronchodilator prescribed for wheezing. A resident with dementia, pleural effusion, and CHF was started on scheduled ipratropium bromide/albuterol nebulizer treatments every four hours after a nurse reported wheezing to the PA, who also ordered a chest x-ray. The chest x-ray later showed no acute findings, and subsequent clinical assessments by the Medical Director and PA over the following months consistently documented that the resident denied chest pain and shortness of breath, had even and unlabored respirations, and had lungs clear to auscultation without wheeze. Despite this, the MAR showed the bronchodilator continued to be administered as ordered, except when refused, through late February. During observation, the resident was noted in bed without wheeze or shortness of breath, with a nebulizer machine at the foot of the bed. The support nurse responsible for the resident stated she was unsure why the bronchodilator was still being given, as she had not observed wheezing and staff had not reported ongoing symptoms to support its use. The consultant pharmacist reported she reviewed the resident’s medications monthly but did not address the bronchodilator with the provider because the PA’s visit notes indicated continuation of the current treatment plan. The PA later stated the medication should have been ordered PRN for occasional wheeze, that she had not observed wheezing or been informed of it, and that she was unaware the medication continued to be administered on a scheduled basis. The DON acknowledged the order should have been written as PRN initially and that nursing staff should have recognized the absence of symptoms and contacted the provider to change or discontinue the order, and also noted there was no process in place to review older standing orders during clinical meetings.
Failure to Follow Hand Hygiene and Infection Control Practices During IV Therapy and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Infection Prevention and Control Program and Hand Hygiene policy during IV therapy and wound care. Facility policies required staff to perform hand hygiene after contact with non-intact skin, before dressing care or touching wounds, after handling used dressings, after touching equipment near a resident, and to wash hands thoroughly prior to flushing a PICC line. During a continuous observation of medication administration for Resident #28, Nurse #3 donned gloves, prepared medications at the medication cart, and then entered the resident’s room without removing gloves or performing hand hygiene. While still wearing the same gloves used to handle the medication cart and equipment, Nurse #3 hung and primed IV antibiotic tubing, manipulated the IV pump, removed the disinfecting cap from the PICC line, wiped the hub, flushed the PICC line, and connected the IV antibiotic tubing before finally removing gloves and performing hand hygiene after the IV was started. A second component of the deficiency occurred during wound care for Resident #2, who had a stage 4 sacral pressure ulcer with slough and a stage 3 left buttock pressure ulcer. The Wound Treatment Nurse performed initial hand hygiene and donned clean gloves, then cleansed the stage 4 sacral ulcer with wound cleanser and gauze, followed by cleansing the stage 3 left buttock ulcer without changing gloves or performing hand hygiene between the two wounds. The nurse then prepared and applied new wound dressings to both wounds while still wearing the same soiled gloves used for cleansing, and only removed the gloves and performed hand hygiene after all dressings were in place and the treatment was completed. A third observation involved wound care for Resident #22’s left buttock pressure ulcer. The Wound Nurse performed hand hygiene, donned a gown and clean gloves, and removed the old dressing. Without removing gloves or performing hand hygiene after handling the soiled dressing, the nurse proceeded to clean the wound with gauze soaked in wound cleanser and then opened new dressings while still wearing the same gloves. Only after opening the new dressings did the nurse remove gloves and perform hand hygiene, then donned new gloves to place calcium alginate in the wound bed, apply zinc oxide to the wound edges and surrounding area, and cover the wound with a dry dressing. These observed practices did not follow the facility’s infection control and hand hygiene policies requiring glove changes and hand hygiene at key points during wound care and invasive line management.
Inaccurate MDS Coding for Wounds, IV Access, and Medications
Penalty
Summary
The facility failed to ensure accurate completion of MDS assessments for three residents by not correctly coding existing conditions and treatments documented in their records. One resident with dementia and behaviors had a wound provider note identifying a stage 4 pressure ulcer to the sacrum, a stage 3 pressure ulcer to the left buttock, and an unstageable deep tissue injury to the right heel. However, the quarterly MDS assessment coded only one stage 3 pressure ulcer and one unstageable deep tissue injury, omitting the documented stage 4 pressure ulcer. The MDS nurse confirmed that the stage 4 pressure ulcer was present at the time of the assessment and acknowledged she had overlooked it despite having the wound provider documentation available. Another resident admitted with osteomyelitis of the right ankle and foot had a physician order for IV vancomycin via a PICC line and a care plan addressing IV medication via PICC with associated risks. The admission MDS assessment coded IV medication use but did not code IV access, and the MDS nurse later acknowledged that the PICC line should have been coded as IV access and that it was inadvertently overlooked. A third resident with coronary artery disease and a history of cerebral infarction had a standing order and ongoing administration of clopidogrel, an antiplatelet medication, as documented in the MAR. The quarterly MDS assessment for this resident was coded as receiving an anticoagulant, and the nurse being trained on MDS completion confirmed this was an error in coding. In each case, the Administrator stated that the responsible MDS staff should have completed the assessments accurately based on the available information.
Failure to Apply Prescribed Hand Splint for Contracture Management
Penalty
Summary
The deficiency involves the facility’s failure to apply a prescribed resting hand orthosis to a resident’s right hand for contracture management as ordered. The resident was admitted with a history of stroke with right-sided hemiparesis/hemiplegia and had severe cognitive impairment, with documented functional limitations in range of motion on one side of both upper and lower extremities. The care plan, initiated and later reviewed, included interventions such as performing ROM exercises with morning and evening care, applying the resting hand orthosis daily, and completing hand hygiene and skin checks. An OT discharge summary documented that the resident had reached maximum potential, that an order for the orthosis was in place, and that both family and nursing staff had been educated on splinting. A physician’s order directed that the right upper extremity splint be applied daily on day shift with hand hygiene and skin checks to prevent contracture and skin breakdown. On multiple observations over two consecutive days, the resident was seen in bed without the splint in place, while the splint was observed lying on the table in the room. Despite this, the TAR showed that the splint was documented as in place on those days by a nurse. In interview, the nurse stated that therapy staff had been placing the splint and then notifying her, and she would document it as applied, and she believed the splint was to remain in place for 8 hours, but she did not manage its placement or removal. The Rehabilitation Manager clarified that once the resident was discharged from therapy, nursing was responsible for managing the splint per the physician’s order, and that the recommended wear time was up to 4 hours during the day shift. The DON and Administrator both stated that the nurse on duty for those days was responsible for ensuring the splint was applied as ordered.
Failure to Maintain Securement Device for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to secure an indwelling urinary catheter with a leg band securement device for a resident with neuromuscular bladder dysfunction and urinary retention. The resident was admitted with these diagnoses and had a physician’s order for an indwelling urinary catheter. A quarterly MDS documented that the resident was cognitively intact and had an indwelling catheter. During a wound care observation, surveyors noted that the resident did not have a leg band in place to secure the catheter tubing, although there was no tension on the tubing at that time. In an interview immediately afterward, the resident reported that staff sometimes forgot to place the securement device and was unable to recall how long it had been missing, though he denied discomfort or tension on the tubing. On a subsequent observation the next day, the resident was again seen in bed with the catheter tubing not secured, and there was still no tension on the tubing. The Infection Preventionist confirmed that the resident was supposed to have a leg band to prevent the catheter from becoming dislodged and stated that the nurse on the hall was responsible for ensuring the leg band was in place, with nurse aides expected to notify the nurse if it was missing. Nurse #4 stated that nurses were responsible for checking for the leg band and reported not being aware that it was absent. NA #1 acknowledged being informed by the Infection Preventionist that the leg band was missing and stated the resident usually had one, but she had not yet reached him on her care rounds to notify the nurse. NA #1 also stated the resident received his bath on night shift, and attempts to contact the night-shift NA who cared for the resident during the relevant period were unsuccessful. The DON stated that either the nurse or the nurse aide should have ensured the catheter tubing had a securement device in place.
Failure to Obtain and Enter Physician Order for Supplemental Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to obtain and enter a physician order for supplemental oxygen for a resident who required respiratory support. The resident was admitted with cellulitis of the right lower leg and pneumonia and was cognitively intact, with the admission MDS indicating no use of supplemental oxygen. On one occasion, the resident complained of shortness of breath and was found to have oxygen saturation levels in the 80s on room air. Nurse #3 applied 2 L of oxygen via nasal cannula, which improved the saturation to 94–96%, and documented that the provider was notified via electronic communication. However, a review of the physician orders showed no order for supplemental oxygen for this resident. Nurse #3 reported that she did obtain an oxygen order from the provider but had difficulty entering it into the system and did not realize it had not been successfully entered. She stated that she usually could “fumble” through entering orders and that Support Nurses normally entered physician orders, so she did not frequently perform this task. She did not notify a Support Nurse or seek assistance when she encountered difficulty entering the oxygen order. The Support Nurse assigned to the resident stated that the nurse who obtained an order was responsible for entering it and acknowledged she did not think to review the resident’s orders to ensure the oxygen order was present. The DON confirmed that Nurse #3 was responsible for notifying the provider and entering any orders for supplemental oxygen and stated that Nurse #3 should have reached out to her or another nurse for help when having difficulty entering the order. At the time of observation, the resident continued to receive 2 L of oxygen via nasal cannula without a corresponding physician order in the record.
Undated Open Ophthalmic Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in medication labeling and storage on the Hall 100 medication cart, where two ophthalmic medications were found open without documented open dates. During an observation with a nurse, one plastic squeeze bottle of brimonidine/timolol 0.2/0.5% eye drops, used to treat eye conditions such as glaucoma, and one plastic squeeze bottle of olopatadine 0.2% eye drops, an antihistamine for allergic conjunctivitis, were noted to be open with no open date recorded, despite manufacturer instructions that each be used or discarded within four weeks of opening. The nurse present stated that medications were supposed to be dated when initially opened but she had not been present when these bottles were opened and could not explain why they were not dated. The DON confirmed that facility practice required nurses to date medications when opened and to check any open medication for an open date before administering it, but this had not occurred for the two eye drop bottles on the Hall 100 cart.
Failure to Document Advance Directive Education and Opportunities
Penalty
Summary
The facility failed to provide written documentation for advance directive information and the opportunity to formulate an advance directive for 13 out of 22 residents reviewed. This deficiency was identified through record reviews and interviews with residents and staff. The residents involved had varying levels of cognitive impairment, with some being cognitively intact and others having severe or moderate cognitive impairment. Despite holding physician orders for either full code or Do Not Resuscitate (DNR), there was no documentation in their medical records indicating that education regarding the formulation of an advance directive was provided or that an opportunity to formulate one was offered to the residents or their responsible parties. Interviews with the facility's Social Worker and Administrator revealed that advance directives were supposed to be reviewed during care plan meetings and documented in the Care Plan assessment or Social Services assessment upon admission and readmission. The Social Worker mentioned that an advance directive form was filled out to show that the topic was discussed with residents or their families during care planning, and this form was uploaded into the electronic medical record. However, the form lacked documentation of education regarding the formulation of an advance directive or evidence that an opportunity to formulate one was offered. The Administrator acknowledged that the education and discussion of advance directives should have been documented for each resident in the facility. He also stated that residents were expected to be reassessed for advance directives upon readmission and during care plan meetings. The absence of proper documentation and education regarding advance directives for the residents reviewed highlights a significant deficiency in the facility's compliance with residents' rights to make informed decisions about their care.
Failure to Notify Resident of Roommate Change
Penalty
Summary
The facility failed to provide written notification of a roommate change for a resident who was cognitively intact. The resident, who was admitted to the facility on an unspecified date, reported that approximately 2 to 3 weeks prior to the interview, she received a new roommate without any prior written or verbal notification. The resident discovered the new roommate upon returning from an appointment, indicating a lack of communication from the facility regarding the change. The facility's Social Worker (SW) admitted that her usual process involved verbally notifying residents and their responsible parties about roommate changes, but not in writing. However, in this instance, the SW did not notify the resident or their responsible party either verbally or in writing. The Director of Nursing and the facility Administrator confirmed that it was expected for residents and their responsible parties to be notified both verbally and in writing prior to any roommate changes, which did not occur in this case.
Failure to Conduct Level II PASRR for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to refer a resident with a serious mental illness for a Level II Preadmission Screening and Resident Review (PASRR). The resident was admitted and later readmitted to the facility, and on a specified date, was diagnosed with delusional disorder. A Level I PASRR determination letter indicated that no further screening was required unless a significant change in the resident's status occurred. Despite the diagnosis of a serious mental illness, there was no documentation of a Level II PASRR referral for the resident. Interviews with the Social Worker and Admissions Director revealed a lack of awareness and oversight regarding the need for a Level II PASRR screening upon the resident's readmission. The Admissions Director admitted to failing to check the resident's PASRR status upon readmission, acknowledging that the resident met the criteria for a serious mental illness and should have been referred for further screening. The Administrator was also unaware of the oversight, acknowledging it as a problem.
Expired Medication Found in Medication Cart
Penalty
Summary
The facility failed to dispose of expired medications in one of the three medication carts observed for medication storage. During an observation of the 600 Hall medication cart, an opened bottle of Senna-Plus with an expiration date of October 2024 was found. Medication Aide #2 acknowledged that the medication should have been discarded and stated that the medication aide or nurse assigned to the cart was responsible for checking for expired medications each shift. Both the Director of Nursing (DON) and the Administrator confirmed that the responsibility for checking and removing expired medications from the cart lay with the medication aides and nurses assigned to the cart.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the Ombudsman regarding the transfer of four residents to the hospital. This deficiency was identified during a record review and staff interviews. The residents involved were transferred to the hospital on various dates in 2023 and 2024, but there was no documentation indicating that the Ombudsman received the required written notification for these transfers. The residents returned to the facility after their hospitalizations, but the lack of notification persisted. Interviews with facility staff revealed a lack of awareness regarding the requirement to notify the Ombudsman. The Social Worker admitted to not sending discharge information to the Ombudsman for residents transferred to the hospital, stating she was unaware of this obligation. The Administrator also acknowledged that he was not aware that the Social Worker had not submitted the necessary discharge reports to the Ombudsman, indicating a gap in communication and understanding of responsibilities within the facility.
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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) |
|---|---|---|---|---|
| Camellia Gardens Center For Nursing And Rehab | 15.3 mi | ★★★★★ | 7 | 1 |
| Kerr Lake Nursing And Rehabilitation Center | 15.6 mi | ★★★★★ | 2 | 0 |
| Senior Citizens Home | 18 mi | ★★★★★ | 3 | 0 |
| Louisburg Healthcare & Rehabilitation Center | 21.3 mi | ★★★★★ | 0 | 0 |
| Franklin Oaks Nursing And Rehabilitation Center | 22.8 mi | ★★★★★ | 0 | 0 |
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