Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Johnson County Care Center during CMS and state inspections, most recent first.
The facility failed to implement Enhanced Barrier Precautions (EBP) for multiple residents with chronic foot wounds, vascular leg wounds, and documented wound infections, despite having a written EBP policy and CDC guidance requiring gown and glove use during high-contact care such as wound care, hygiene, and dressing changes. Observations showed that the DON performed wound care using gloves and hand hygiene but without a gown, and there were no EBP signs or PPE supplies posted outside resident rooms. Additional residents with diabetic ulcers and chronic plantar wounds received daily wound treatments without EBP measures in place. Interviews with a CMT, an LPN, the DON, the Administrator, and the Infection Preventionist revealed that staff were not educated on EBP, gowns were rarely used for wound care, some nurses were reported to perform wound treatments without gloves, and key leaders were unaware of or had not implemented EBP in the facility.
The facility failed to maintain RN coverage for eight consecutive hours daily from July 2023 to March 2024, with the DON serving as charge nurse despite a census over 60 residents. The DON was the only RN, and the facility lacked a staffing policy document.
The facility failed to maintain a comprehensive infection prevention and control program, lacking a Legionella risk management plan, CDC toolkit, and proper infection tracking. The infection control book was incomplete, missing 12 months of data and details on infections. Additionally, two residents did not receive required TB assessments. The Maintenance Supervisor and DON were unaware of full program requirements.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by incomplete infection tracking logs and missing documentation of lab results and symptoms for antibiotic use. The Director of Nursing, responsible for the program, could not locate necessary records, indicating non-compliance with the facility's policy.
The facility did not designate a qualified individual as the Infection Preventionist (IP) for its Infection Prevention Control Program. The DON was intended to take on the IP role but had not completed the necessary certification classes. The Administrator, who held an IP certificate, had a degree in Social Work, which is not an approved primary professional medical training. The facility also lacked a policy on the required training for the IP role.
A resident with an unstageable pressure ulcer did not receive appropriate care due to the facility's failure to have a policy or physician's order for a low air loss mattress, incorrect mattress settings, and incomplete wound assessments. The care plan was not updated to reflect the current stage of the ulcer, and documentation inconsistently identified the wound type and lacked detailed descriptions. Staff interviews revealed a lack of awareness and adherence to proper procedures.
A facility failed to follow professional standards for verifying gastrostomy tube placement, using outdated methods instead of measuring and documenting tube length. A resident with cerebral palsy, reliant on tube feeding, experienced inconsistencies in feeding infusion due to incorrect physician orders and lack of proper verification by staff. The DON and other staff were unaware of current standards, leading to deficiencies in care.
The facility failed to provide Trauma Informed Care (TIC) assessment and care planning for two residents diagnosed with PTSD. The care plans lacked interventions specific to TIC needs, such as identifying triggers and steps to mitigate them. Staff interviews revealed a lack of awareness and training regarding the residents' PTSD diagnoses and TIC principles. The facility's failure to incorporate TIC assessments and care planning resulted in a deficiency in providing trauma-informed and culturally competent care.
A facility failed to ensure timely physician response to a pharmacist's recommendation for gradual dose reduction (GDR) of psychotropic medications for a resident with severe cognitive impairment and multiple mental health diagnoses. The consultant pharmacist recommended GDRs for several medications, but there was no documented physician response, and a GDR had not been attempted or documented as clinically contraindicated. The DON, responsible for reviewing and implementing pharmacy recommendations, did not follow up with the physician to obtain a reason for not following the recommendation.
The facility did not post daily staffing information, including staff titles and hours worked, on the second and third floors, potentially affecting all residents. The MDS Coordinator noted the information was posted by the time clock on the first floor, not visible to upper floors. The DON stated the BOM was responsible for posting it visibly for all residents and visitors.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy and CDC-recommended practices for residents with wounds and infection risks. The facility’s EBP policy required gown and glove use for residents with certain infections, wounds, and/or indwelling medical devices during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens and briefs, toileting assistance, device care, and wound care. CDC guidance similarly called for hand hygiene for everyone entering and leaving the room and gown and glove use for high-contact care activities for residents who meet EBP criteria. Surveyors found that EBP was not being used for any of the sampled residents with wounds, and staff and leadership reported they had not discussed or implemented EBP in the facility. One resident had diabetes, a skin infection, and a non-pressure chronic ulcer of the left foot, with a documented diabetic foot ulcer and wound infection. The care plan identified skin impairment related to diabetes and a chronic wound, and the treatment record showed ongoing wound care to the left great toe, including cleansing and application of Iodoflex and dressings. A wound care provider note documented a chronic left great toe wound, prior IV antibiotics for chronic osteomyelitis, and a long-standing diabetic ulcer with specific measurements and wound characteristics including serosanguineous exudate, slough, granulation tissue, and necrotic tissue. During observed wound care by the DON, there were no EBP signs or PPE outside the room, the DON wore gloves and performed hand hygiene but did not wear a gown, and the DON stated they had not talked about or used EBP at the facility. Another resident with diabetes had documented abrasions to both knees and a vascular wound to the left lower leg, with physician orders for daily cleansing and application of calcium alginate and foam dressings to the left lower extremity wound. Observation showed dressings on both shins and no EBP signage or PPE outside the room. The DON again stated that EBP had not been discussed or used. A third resident had an open wound on the left foot, osteomyelitis, and a chronic foot wound, with care plan entries for risk of infection and actual skin integrity impairment related to a chronic foot wound. Treatment orders included cleansing and dressing of plantar areas on both feet and application of calcium alginate to an open wound on the right foot, with skin observation documenting a callous on the left foot and a chronic wound on the right plantar surface. During observation, there were no EBP signs or PPE outside the room, the DON reported the resident had wounds on the bottom of both feet, and confirmed that EBP had not been discussed or used. Staff interviews further demonstrated the lack of implementation of EBP and incomplete use of PPE during wound care. A Certified Medication Technician reported hardly ever seeing nurses use gloves during wound treatments, seeing nurses perform wound treatments without gowns, and not knowing where gowns were located. The DON stated they had not talked about EBP and had not used EBP for any residents. The Administrator reported that EBP had not been done and did not believe the facility had an EBP policy, despite the written policy reviewed by surveyors. The Infection Preventionist stated they had never heard of EBP prior to the survey date. An LPN reported that administration had not instructed staff to use EBP, that they only wore gloves during wound treatments, and that they did not wear gowns when performing wound care. These observations and interviews show that the facility did not implement EBP for residents with wounds as required by its policy and CDC guidance.
Deficiency in RN Staffing and DON Role Compliance
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, during multiple months spanning from July 2023 to March 2024. This deficiency was identified through observation, interviews, and record reviews, which revealed that there were several days each month without RN coverage for the required hours. Additionally, the Director of Nursing (DON) was found to be serving as the charge nurse on days when the facility census exceeded 60 residents, which is against regulatory requirements. The facility census was noted to be 69 residents during these instances. The facility's staffing issues were further highlighted by the fact that the DON was the only RN available and had to cover shifts as the charge nurse due to the lack of other RNs. The facility had an RN available on a PRN basis, but this individual did not work many hours. The administrator acknowledged the staffing shortfall and indicated efforts were being made to hire more RNs. The absence of a facility RN staffing policy and procedure document prior to the survey exit further compounded the issue.
Inadequate Infection Control and TB Screening in LTC Facility
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program, specifically for Legionella and other water-borne pathogens, as required by CMS guidelines. During inspections, it was observed that the facility lacked a facility-specific risk management plan, a completed CDC toolkit, and a schematic or flowchart of the water system with explanations and assessments of potential stagnation locations. Additionally, there were no documented testing protocols, control measures, or site log books for maintenance activities. Interviews revealed that the Maintenance Supervisor was responsible for the Legionella program but had only received basic education on the requirements. The facility's infection control surveillance policy was outdated, and the infection control book lacked 12 months of tracking and trending data. The logs did not specify whether infections were facility-acquired or present upon admission, nor did they include information on the resolution of infections, the type of infectious organisms, or the utilization of an antibiotic stewardship program. The Director of Nursing, who took over the infection control book in February 2024, was unaware of the full scope of information required for tracking and trending logs. Furthermore, the facility did not have a policy for resident TB testing and screening. Two residents were identified as not having completed TB assessments as required. One resident did not have a two-step TB skin test upon admission, and another resident's last TB assessment was outdated. The Director of Nursing acknowledged the oversight and stated that TB tests should be completed by the admitting charge nurse upon admission, with annual screenings documented in the medical record.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship protocol and a system to monitor appropriate antibiotic use for its residents. The facility's existing Antibiotic Stewardship policy, dated 2018, aimed to apply best practices for monitoring antibiotic use, ensuring appropriate prescriptions, and reducing the risk of adverse events from unnecessary or inappropriate antibiotic use. However, the facility's Infection Control tracking log was incomplete, lacking 12 months of infection tracking or antibiotic use logs, with only records from February to August 2024 available. The logs were supposed to document essential details such as the date, room number, resident name, infection type, antibiotic name, order, labs, and organism, but they did not include lab results or logs indicating signs or symptoms of infections for antibiotic use. During an interview, the Director of Nursing, who had been responsible for the Infection Control tracking log and antibiotic stewardship program since February 2024, admitted to entering prescribed antibiotics on the log along with the resident's room number and type of infection. However, the Director could not locate lab or X-ray results in the tracking book, and the book did not include signs or symptoms of infections being treated with antibiotics. This lack of documentation and monitoring indicates a failure to adhere to the facility's own antibiotic stewardship policy, which included protocols for common infections and criteria for initiating antibiotic use.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified individual with the required primary professional training as the Infection Preventionist (IP) for its Infection Prevention Control Program. The Director of Nursing (DON) was intended to assume the role of the IP but had not completed any certification classes necessary for the position. Additionally, the facility did not have a policy outlining the required primary professional training for the IP role. The Administrator, who held an IP certificate and dedicated a few hours weekly to infection control duties, had a degree in Social Work, which is not among the approved primary professional medical trainings. The previous IP had left the facility, and the current DON was expected to become the primary IP without having completed the necessary training.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to ensure proper pressure ulcer care and prevention for a resident with an unstageable pressure ulcer. The facility did not have a policy or physician's order addressing the settings for a low air loss (LAL) mattress, which is crucial for distributing the patient's body weight to prevent and treat pressure wounds. The resident's care plan was not updated to reflect the current stage of the pressure ulcer, and there was no documentation of the LAL mattress settings in the resident's treatment administration record (TAR). The LAL mattress was set incorrectly at 350 pounds, despite the resident weighing significantly less. The facility also failed to complete weekly wound/skin assessments with detailed descriptions, measurements, and accurate staging of the pressure ulcer. The documentation inconsistently identified the type of wound, often incorrectly labeling it as a stasis ulcer, and failed to include comprehensive details about the wound bed, drainage, odor, and measurements. There were significant gaps in the documentation of wound assessments, with no assessments completed between certain dates, and the resident's care plan did not mention the unstageable pressure ulcer or the LAL mattress settings. Interviews with facility staff, including the wound nurse, LPN, MDS/Care Plan Coordinator, and DON, revealed a lack of awareness and adherence to proper procedures for pressure ulcer management. The staff did not monitor the LAL mattress settings, and there was no physician's order for the LAL mattress. The care plan was not individualized to include the current stage of the resident's pressure ulcer, and the facility's pressure ulcer documentation lacked essential information. The DON acknowledged that the documentation should have included detailed descriptions of the wound, and the care plan should have been updated to reflect the resident's current condition.
Deficiency in Feeding Tube Management and Documentation
Penalty
Summary
The facility failed to adhere to professional standards for verifying the correct placement of gastrostomy (G-tube) feeding tubes, as evidenced by the lack of a comprehensive tube feeding policy. The policy did not instruct licensed nursing staff to measure and document the length of the feeding tube, nor did it provide guidance on verifying tube placement using current professional standards. Instead, outdated methods such as auscultation and aspiration were used, which are considered unreliable. This deficiency was observed in the care of a resident who was receiving tube feeding, where the facility did not ensure the physician's order was correct or that the tube feeding was infused according to the order. The resident in question had a diagnosis of cerebral palsy and was severely cognitively impaired, relying on a feeding tube for more than 51% of their caloric intake. Observations revealed that the resident's tube feeding was not consistently infused as ordered, with instances where the feeding pump was not running. The Director of Nursing (DON) was observed administering water through the G-tube without first verifying its placement, citing a lack of a stethoscope as the reason for not performing the check. The DON admitted to being unaware of the professional standard requiring the measurement and documentation of the tube's length. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the MDS Care Plan Coordinator, highlighted inconsistencies in the understanding and implementation of tube feeding protocols. The LPN acknowledged that the physician's order in the resident's electronic medical record was incorrect and needed correction. The MDS Care Plan Coordinator confirmed that aspiration was the only method known for checking tube placement and that this method was not included in the resident's care plan. These lapses in protocol and documentation contributed to the deficiency in providing appropriate care for the resident with a feeding tube.
Failure to Provide Trauma Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide Trauma Informed Care (TIC) assessment and care planning for two residents diagnosed with Post Traumatic Stress Disorder (PTSD). The facility's policy required a self-assessment and trauma questionnaire to be completed before admission, with updates every three years, and the use of the Brief Trauma Questionnaire for screening. However, for Resident #18, there was no documentation of the Brief Trauma Questionnaire, PTSD Checklist, or Psychological Well-Being evaluation in the medical records. The resident's care plan lacked interventions specific to TIC needs, such as identifying triggers and steps to mitigate them. Resident #18 had a history of extensive sexual abuse and other psychiatric diagnoses, including major depression and anxiety. Despite being cognitively intact and socially isolated, the resident's care plan did not address PTSD needs or include strategies to prevent triggers. Interviews with staff revealed a lack of awareness and training regarding the resident's PTSD diagnosis and TIC principles. The Social Services Director and other staff members were unaware of the resident's triggers and had not conducted a TIC assessment. Similarly, Resident #53's care plan did not include interventions specific to TIC needs, and there was no documentation of the required trauma assessments. The resident was also diagnosed with PTSD, anxiety, depression, and a personality disorder. The facility's failure to incorporate TIC assessments and care planning into the residents' care plans resulted in a deficiency in providing trauma-informed and culturally competent care.
Failure to Implement Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely physician response to a pharmacist's recommendation for gradual dose reduction (GDR) of psychotropic medications for a resident. The resident, who was severely cognitively impaired and had symptoms of depression, hallucinations, and diagnoses including anxiety disorder, depression, manic depression, and schizophrenia, was receiving multiple psychotropic medications. The consultant pharmacist recommended potential GDRs for several medications, including Escitalopram, Olanzapine, Trazodone, and Haloperidol. However, there was no documented response from the physician regarding these recommendations, and a GDR had not been attempted or documented as clinically contraindicated. The Director of Nursing (DON) was responsible for reviewing pharmacy recommendations and implementing GDRs. The DON took over this duty after discovering that pharmacy recommendations were not being addressed. The consultant pharmacist visited the facility monthly and emailed recommendations to the DON, who then contacted the physician. If the physician agreed to the recommendation, changes were made in the resident's electronic medical record (EMR). If the physician disagreed, a reason should have been documented. In this case, the physician did not provide a reason for not following the pharmacist's recommendation, and the DON did not follow up to obtain one.
Failure to Post Daily Staffing Information
Penalty
Summary
The facility failed to ensure that daily staffing information was posted correctly at the beginning of each shift, which could potentially affect all residents. The facility census was 69 residents. Observations on multiple days showed that the required staffing information, including staff titles and total hours worked, was not posted on the second or third floors. During an interview, the MDS Coordinator indicated that the staffing information was posted by the employee time clock on the first floor, which was not visible to residents on the upper floors. The Coordinator was unaware of who was responsible for posting the information but expected it to be available for residents and visitors. The DON stated that the BOM was responsible for posting the staffing information outside their office daily and expected it to be visible to all residents and visitors on the second and third floors.
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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 Warrensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Club Rehab And Healthcare Center | 1 mi | — | 0 | 0 |
| Ridge Crest Nursing Center | 1 mi | — | 16 | 0 |
| Warrensburg Manor Care Center | 1.1 mi | — | 0 | 0 |
| Holden Manor Health & Rehabilitation | 14.4 mi | — | 1 | 0 |
| Lutheran Nursing Home | 17.9 mi | — | 4 | 0 |
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