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 Poplar Hill Health And Rehab during CMS and state inspections, most recent first.
A resident with persistent nausea, vomiting, dizziness, and declining BP did not have the ordered workup consistently completed or documented, including ultrasounds and lab testing, and the chart did not show refusal documentation, discussion of alternatives, or a GI referral despite ongoing symptoms. Nursing notes documented low BP, poor intake, and dizziness, and a later neuro check showed very low BP without physician notification before the resident was found on the floor, became unresponsive, and CPR was initiated.
Incorrect Food Portions Served: A Dietary Manager was observed plating lunch using the wrong scoop size for multiple menu items, and each resident received one scoop of each item instead of the portions listed on the Diet Spreadsheet. The menu and scoop chart specified different portion controls, and the Dietary Manager later acknowledged the correct scoops were not used and residents did not receive the correct portions.
Food Served Below Required Temperature on 400 Unit: The facility failed to serve palatable food at safe hot-holding temperatures. A test tray taken with resident meal trays to the 400 Unit was observed by surveyors, and the Dietary Manager measured several items below the facility's 135 F hot-food standard, including vegetables and potatoes that were described as cold and not palatable.
A kitchen aide was observed preparing resident beverages without a hairnet, and plated cake was left uncovered on a cart in the kitchen. Lunch trays delivered to resident rooms on multiple units were also observed with uncovered cake. The Dietary Mgr stated hairnets are required to prevent contamination and that the cake should have been covered; the aide stated she forgot to put on a hairnet when entering the kitchen.
Failure to notify the provider of a resident’s change in condition. A cognitively intact resident with HTN, PVD, and DM was observed lowering herself to the ground and reported dizziness, with low BP readings documented afterward. The record showed repeated hypotensive readings, but there was no evidence that the MD/NP was notified of the change in condition or blood pressure decline.
A resident with A-fib, HTN, CHF, and DM had multiple ordered meds, including Apixaban, Metoprolol, Cartia XT, Furosemide, and Metformin, administered hours after the scheduled times rather than within the facility’s expected window. The MAR showed the meds were documented later in the day, and there was no progress note explaining the delay; the DON stated the LPN was waiting until the end of the shift to document and was not following the facility standard of care.
A dependent resident with HTN, CHF, DM, and atrial fibrillation had repeated gaps in documented incontinence care across day, evening, and night shifts. The resident was cognitively intact but dependent for several ADLs, and the care plan included assistance with incontinent care. CNAs stated incontinence care should be provided and documented each shift, and one CNA said if it is not documented, it is not done.
Failure to Arrange Follow-Up Ophthalmology Care: A resident with severe cognitive impairment, aphasia, and a cerebral infarction developed herpes zoster ophthalmicus with viral conjunctivitis affecting the left eye. The record showed an ophthalmology referral from a retina specialist, but the facility did not evidence arranging, offering, or discussing a follow-up appt with the resident or family. Staff stated family usually scheduled appts, and the DON said the follow-up was not set up because the NP believed it was not needed.
Medication services failed for two residents when ordered meds were not available for administration. One resident’s Ciprofloxacin for a UTI was delayed for several days despite MAR documentation and nursing notes showing repeated attempts to locate the drug in the med bank and through the pharmacy. Another resident with shingles involving the eye missed scheduled doses of erythromycin ophthalmic ointment because the medication was on order and not administered, even though the eye specialist had prescribed it and staff documented the resident’s eye involvement.
A resident prescribed Metoprolol ER for HTN with hold parameters for low SBP or HR received the medication even though the documented HR was 55, below the ordered threshold. An LPN later confirmed the dose should have been held per the order and noted that the medication should have been documented as held and the NP notified.
Failure to Follow Up on Persistent Nausea, Dizziness, and Declining Blood Pressure
Penalty
Summary
The facility failed to follow professional standards of care for a resident who had persistent complaints of decreased blood pressure, dizziness, nausea, and vomiting with little to no improvement over time. The resident was cognitively intact, with a BIMS score of 15, and was documented as her own responsible party. Provider notes show ongoing evaluation for nausea and vomiting, including orders for ondansetron, vital signs monitoring, CBC/BMP testing, and abdominal ultrasound studies to rule out possible causes such as obstruction, cholecystitis, or biliary tract obstruction. Despite these ongoing symptoms and repeated provider concerns, the record did not show a completed abdominal ultrasound on the first ordered date and did not show completion or refusal of later ordered ultrasounds. The record also showed that the resident refused bloodwork even after education, and the comprehensive care plan did not document refusal of care or treatments. There was no evidence in the clinical record that alternatives to treatment were discussed with the resident regarding the lack of improvement in symptoms or options outside the facility, and there was no documented referral to GI even though it was repeatedly referenced in provider notes. Nursing documentation showed episodes of low blood pressure, dizziness, nausea, poor oral intake, and refusal of fluids, with one note documenting a low BP and another documenting that the resident complained of nausea and dizziness. A neuro check form documented very low blood pressures, but the assessment did not show physician notification. The resident later had a decline with a fall to the floor, was found with pale lower extremities and bluish lips, and CPR was initiated before EMS pronounced death. Interviews with the LPN, NP, DON, attending physician, and medical director confirmed the resident had persistent symptoms, refused parts of the plan of care, and that alarming signs such as decreasing blood pressure should have prompted further provider notification and discussion of declining status.
Incorrect Food Portions Served
Penalty
Summary
Facility staff failed to provide residents with the correct amount of food according to the facility’s menu in one of one facility kitchens. On 05/12/2026 at approximately 12:00 p.m., an observation in the kitchen showed the Dietary Manager plating lunch for residents. The lunch menu included whole chicken leg quarters, whole mixed vegetables, cubed potatoes, chopped chicken, pureed chicken, mashed potatoes, and pureed mixed vegetables. During the observation, the Dietary Manager was using a green handle scoop to portion whole mixed vegetables, cubed potatoes, chopped chicken, ground chicken, pureed chicken, mashed potatoes, and pureed mixed vegetables, and she placed one scoop of each listed food item on each resident’s lunch plate. The facility’s Diet Spreadsheet for lunch on 05/12/2026 documented specific portion sizes, including 4 oz servings for seasoned diced potatoes and four-way mixed vegetables, and #8 scoop portions for ground baked chicken breast with thick gravy, pureed baked chicken quarter, and mashed potatoes with gravy. The kitchen’s Scoop Size Chart showed that the #8 scoop was grey and equal to 4 oz, while the green handle scoop was not the correct size for those items. On 05/13/2026 at approximately 9:19 a.m., the Dietary Manager stated the Scoop Size Chart posted above the steam table was used to ensure residents received the correct portion according to the Diet Spreadsheet, and she acknowledged the correct size scoops were not used for the residents’ lunch on 05/12/2026 and that the residents did not receive the correct portion of food.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
The facility failed to serve palatable food at a safe and appetizing temperature on the 400 Unit. On 05/12/2026 at 12:00 p.m., the Dietary Manager obtained holding temperatures for lunch items at the steam table, including whole chicken leg quarter at 168 F, whole mixed vegetables at 187 F, diced potatoes at 159 F, chopped chicken at 160 F, ground chicken at 166 F, pureed chicken at 158 F, mashed potatoes at 177 F, and pureed mixed vegetables at 172 F. Later that day, a test tray with the listed food items was placed on a cart with resident meal trays and taken to the 400 Unit. At 1:10 p.m., the last lunch tray was served on the 400 Unit, and the Dietary Manager removed the covers from the test plates and took temperatures while two surveyors observed. The temperatures had dropped to whole chicken leg quarter 127 F, whole mixed vegetables 112 F, diced potatoes 123 F, pureed chicken 127 F, mashed potatoes 118 F, and pureed mixed vegetables 122 F. When asked to describe the taste, the Dietary Manager stated the whole mixed vegetables and cubed potatoes were cold and not palatable. The facility's Safe Food Handling Practices policy stated hot foods are to be served at 135 degrees or higher and cold foods at 41 degrees or lower.
Uncovered Food and Missing Hairnet During Meal Preparation
Penalty
Summary
Facility staff failed to prepare and serve food in a sanitary manner in the kitchen. On 05/12/2026 at approximately 11:30 a.m., an observation of OSM #3, a kitchen aide, showed her placing covers on approximately 20 cups of beverage for residents' lunch while not wearing a hairnet. At the same time, trays holding approximately 12 plated slices of cake each were observed on a ladder cart next to the kitchen steamer and in front of a food preparation table, and the cart was not covered over the individual slices of cake. Later that day, lunch trays delivered to resident rooms on the 200, 300, and 400 units were observed with cake served uncovered. On 05/13/2026, the Dietary Manager stated hairnets are used to prevent hair from falling into food and contamination, and that OSM #3 should have been wearing one. She also stated the cake should have been covered to prevent contamination. OSM #3 stated she forgot to put on a hairnet when she entered the kitchen. The facility's policy required dietary employees to wear a hairnet covering all hair completely and required all food items on room trays, including drinks and desserts, to remain covered until they reached the resident.
Failure to Notify Provider of Change in Condition
Penalty
Summary
The facility failed to notify the medical provider of a change in condition for Resident #1 when the resident became dizzy and was observed lowering herself to the ground on 3/25/2026. The resident was cognitively intact with a BIMS score of 15, was her own responsible party, and had diagnoses including hypertension, peripheral vascular disease, and diabetes mellitus. A late entry note documented that the resident denied hitting her head, was alert and responsive, had no visible injuries, and had low vital signs with a blood pressure of 95/54. She was assisted back to bed, encouraged to drink fluids, and refused oral intake. The record also showed repeated low blood pressure readings on the neuro check assessment form, including 81/50, 100/63, 100/61, and 80/51, but the assessment did not evidence physician notification of the blood pressure changes. During interview, the attending physician stated nursing should have contacted the NP for alarming signs or symptoms, including a drop in blood pressure, and that blood pressure should be repeated in ten minutes until it returned to baseline. The facility's Notification of Changes policy stated that the facility must promptly inform the resident, consult the physician, and notify the resident's representative when there is a significant change in condition, including deterioration in health or life-threatening conditions.
Delayed Medication Administration and Documentation
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality when medications were not administered in accordance with physician orders for one resident. The resident was admitted with diagnoses including paroxysmal atrial fibrillation, hypertension, congestive heart failure, and diabetes mellitus. The resident’s care plan directed staff to administer cardiac medications per physician order and to administer medications as prescribed. Physician orders included Apixaban 5 mg twice daily, Metoprolol 25 mg twice daily at 9:00 AM, Cartia XT 180 mg daily at 9:00 AM, Furosemide 20 mg daily at 8:00 AM, and Metformin 500 mg twice daily at 9:00 AM. A medication time audit showed that these medications were administered at 3:24 PM on one reviewed date, rather than at the ordered times, and there was no progress note documenting the delay. During interview, the DON stated medications are to be administered within one hour before or after the scheduled time and documented in the MAR, and stated that if medications are given outside that time frame there should be a written progress note explaining the delay. The DON also stated the LPN who administered the medications was not following the facility standard of care by waiting until the end of the shift to document administration.
Failure to Provide Documented Incontinence Care
Penalty
Summary
Facility staff failed to provide ADL care, specifically incontinence care, for a dependent resident. The resident was admitted with diagnoses including paroxysmal atrial fibrillation, HTN, CHF, and DM. The most recent MDS quarterly assessment coded the resident as cognitively intact with a BIMS score of 15 out of 15, and Section GG showed dependence for transfer, hygiene, bathing/dressing, and set-up for eating. The care plan identified an alteration in self-care related to co-morbidities and noted that the resident frequently refused showers, getting out of bed, and at times refused to be changed; interventions included assistance with dressing, bathing, incontinent care, bed mobility, and transfers, along with education on the risks vs benefits of not being changed timely. Review of the ADL record showed missing evidence of incontinence care on multiple day, evening, and night shifts across several dates from January through April. During interviews, CNAs stated that resident rounding for incontinence care and repositioning occurs every one to two hours and that care should be documented in the ADL form or PCC; one CNA stated that if it is not documented, it is not done. The DON stated there was a performance improvement plan related to call bells and incontinent care, and the facility’s incontinence policy stated that residents incontinent of bladder or bowel will receive appropriate treatment to prevent infections and restore continence to the extent possible.
Failure to Arrange Follow-Up Ophthalmology Care
Penalty
Summary
The facility failed to assist in arranging follow-up ophthalmology services for a resident with significant cognitive and communication impairment. The resident’s MDS documented a BIMS score of 2 out of 15, indicating severe impairment in daily decision-making, and listed diagnoses including aphasia and cerebral infarction. Clinical notes showed the resident developed herpes zoster on the left forehead, face, nose bridge, and left eye, with herpes zoster ophthalmicus and viral conjunctivitis, and an ophthalmology consult was ordered STAT along with antiviral treatment and isolation precautions. A retina specialist’s visit summary documented herpes zoster ophthalmicus of the left eye and included a referral to an ophthalmologist. The record did not show that the facility arranged, offered, or discussed a follow-up appointment with the referred ophthalmologist for the resident or the resident’s family. A nursing note stated the resident’s daughter would schedule the eye appointment and transportation, and staff later documented that the resident had been seen by an eye doctor the next day after the initial rash was identified. During interviews, an LPN stated that family members normally scheduled appointments, though she assisted as needed, and that she would usually obtain the physician’s note and coordinate with family for needed follow-up. The DON stated the facility had not set up the follow-up ophthalmology appointment because the NP said the resident did not need it. The NP stated her priority was getting the resident to the eye doctor right away and that she did not think follow-up was necessary because she had been checking the resident’s eyes and the resident reported having vision in the eye.
Medication Not Available for Ordered Antibiotic and Eye Ointment
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of each resident when medication was not available for administration for two residents. For Resident #3, a physician ordered Ciprofloxacin 500 mg twice daily for 5 days for a urinary tract infection, and the March 2026 MAR reflected the same order. Nursing documentation showed the medication was waiting for pharmacy delivery on 3/23/26, was still not available on 3/24/26, and remained unavailable on 3/25/26 despite checks of the med bank and pharmacy contact. The first dose was not documented as received until 3/26/26. The facility’s med bank list indicated the machine should have contained at least ten tablets of Ciprofloxacin 250 mg, but staff documented that the medication was not on hand. During interview, an LPN stated that if a medication is not available, staff should obtain it from the med bank and, if not there, call the pharmacy for a stat delivery separate from routine deliveries. The administrator and DON were informed of the concern on 5/13/26. For Resident #5, the physician ordered Erythromycin ophthalmic ointment to the left eye four times daily for 7 days for shingles, and the eMAR showed missed doses on 4/3/26 at 9:00 AM and 12:00 PM because the medication was not available. Progress notes documented herpes zoster involving the left forehead, face, nose bridge, and left eye, with herpes zoster ophthalmicus and viral conjunctivitis, and the resident was seen by an eye specialist who prescribed the ointment. Nursing documentation stated the medication was on order and not administered, and interviews confirmed staff were aware of the order but did not explain why the medication was unavailable when doses were due.
Medication Given Despite Hold Parameter
Penalty
Summary
The facility failed to follow a physician’s medication order for Resident #5, who was prescribed Metoprolol Succinate ER 25 mg daily for hypertension with instructions to hold the medication if systolic blood pressure was below 100 or heart rate was below 60. Review of the eMAR for 4/1-4/30/2026 showed that the medication was administered on 4/25/2026 at 9:00 AM even though the resident’s heart rate was documented as 55 at that time, which was below the ordered hold parameter. During interview, an LPN stated that vital signs should be checked before medication administration and the order reviewed to determine whether the medication should be held or given. After reviewing the eMAR, the LPN stated the Metoprolol should have been held because the heart rate was below 60, and that the nurse should have documented the medication as held and notified the nurse practitioner. The facility policy stated that vital signs should be obtained and recorded when applicable or per physician orders, and medications should be held when vital signs are outside prescribed parameters.
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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) |
|---|---|---|---|---|
| Brookside Rehab & Nursing Center | 1.3 mi | ★★★★★ | 5 | 0 |
| Lake Manassas Health & Rehabilitation Center | 9.6 mi | ★★★★★ | 5 | 1 |
| Gainesville Health And Rehab Center | 12.6 mi | ★★★★★ | 0 | 0 |
| Manassas Health And Rehab Center | 16.8 mi | ★★★★★ | 9 | 0 |
| Birmingham Green | 19.4 mi | ★★★★★ | 0 | 0 |
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