Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Warrensburg Manor Care Center during CMS and state inspections, most recent first.
The facility failed to maintain RN services for eight hours daily and did not have a full-time DON, relying on an interim DON and corporate RN for coverage. The facility's PBJ report showed multiple days without RN hours, and the ADON/LPN acted as DON with RN oversight. The administrator acknowledged staffing challenges and incomplete documentation of corporate RN hours.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in care planning. One resident's MDS did not reflect the use of oxygen therapy at night, while another resident's MDS failed to capture significant swallowing and weight loss issues. Interviews with staff revealed expectations for accurate documentation were not met, impacting the quality of care.
A facility failed to develop comprehensive care plans for two residents, one with edema and another with nutritional concerns. The care plan for a resident with congestive heart failure did not include necessary interventions for edema management, while another resident's plan lacked documentation of nutritional issues despite significant weight loss and dysphagia. Staff interviews revealed inconsistencies in updating care plans, contributing to the deficiencies.
A resident with dementia and depression experienced an unwitnessed fall, resulting in a head injury. The facility failed to conduct a thorough investigation or update the resident's care plan with new fall prevention measures. Staff interviews revealed a lack of awareness regarding fall prevention strategies, and the MDS Coordinator was unsure if the care plan had been updated. The facility had not yet conducted an interdisciplinary team meeting to review the fall and finalize the care plan.
The facility failed to manage oxygen equipment properly for three residents, leading to infection control issues. A resident with COPD had oxygen tubing not stored correctly, while another with asthma had outdated tubing not replaced. A third resident with heart failure had an oxygen concentrator with equipment dated from July. Staff interviews revealed confusion over responsibilities, resulting in non-compliance with facility policy.
A resident with dementia and depression was found to have bleach and laundry soap stored under their sink, contrary to facility policy. Despite multiple staff members being unaware of the chemicals' presence, no action was taken to remove them, highlighting a failure in monitoring and enforcing safety protocols.
Deficiency in RN and DON Staffing
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) were utilized for eight hours per day, seven days a week, and did not have a Director of Nursing (DON) or interim DON onsite full-time for a minimum of 40 hours per week. The facility's policy required RN staffing for at least eight consecutive hours daily and a full-time DON, but these requirements were not met. The facility census was 43 residents, and the facility's Payroll-Based Journal (PBJ) report for the fiscal year 2024 showed four or more days within the quarter with no RN hours reported. Interviews with staff revealed that the facility had not had a full-time DON for over a year, and the interim DON was working less than 38 hours a week. The facility relied on a corporate RN to assist with RN and DON duties, but these hours were not included in the PBJ reports. The facility's staffing coordinator confirmed that the last full-time DON was hired in September 2023 and left in November 2023. Since then, the Assistant Director of Nursing (ADON), who was a Licensed Practical Nurse (LPN), had been acting as the DON with oversight by RN staff. The facility administrator acknowledged the challenges in maintaining RN and DON coverage, stating that the interim DON worked only four days a week and the ADON/LPN was acting as DON with RN oversight. The administrator also admitted to not documenting the corporate RN hours, which were not included in the PBJ reports. The facility did not have a waiver for DON or RN coverage and was experiencing difficulty maintaining adequate staffing levels.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in care planning. For one resident, the MDS did not reflect the use of oxygen therapy at night, despite a physician's order and the resident's own confirmation of using oxygen at 3 liters per minute. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed an expectation that the MDS should accurately indicate oxygen therapy use, which was not met in this case. Another resident's MDS assessment failed to capture significant issues related to swallowing and weight loss. The resident had a history of choking and was on a trial of honey-thickened liquids due to swallowing difficulties. Despite these issues, the MDS did not document any chewing or swallowing problems during the lookback period. Interviews with facility staff, including the MDS Coordinator and the DON, highlighted that the MDS should have reflected the resident's nutritional status and swallowing issues, which were documented in nursing notes and care plans. The inaccuracies in the MDS assessments for both residents indicate a failure in the facility's processes for ensuring timely and accurate documentation of residents' care needs. This deficiency in documentation could potentially impact the quality of care provided to the residents, as the MDS is a critical tool for care planning and ensuring appropriate interventions are in place.
Deficiencies in Care Planning for Residents with Edema and Nutritional Concerns
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for Resident #8, who was diagnosed with congestive heart failure and experienced edema. The care plan, dated February 1, 2024, lacked specific interventions and goals related to the resident's active edema and did not include orders for compression pumps or wraps, which were necessary for managing the condition. The MDS Coordinator acknowledged that these orders should have been included in the care plan to ensure staff were aware of the devices and their operation. Resident #1's care plan was also found to be incomplete, as it did not address the resident's nutritional status despite a history of weight loss and dysphagia. The resident, who had multiple diagnoses including COPD, CHF, and Alzheimer's Disease, experienced significant weight loss over several months. The care plan failed to document the resident's nutritional issues, such as chewing and swallowing difficulties, and did not include interventions to address these concerns. The MDS Coordinator admitted that care plans were updated quarterly, but sometimes not within a week of new interventions being implemented. Interviews with facility staff, including the Assistant Director of Nursing and the Director of Nursing, revealed that care plans should reflect the current care needs of residents and be updated as conditions change. However, the facility's process for updating care plans was inconsistent, with some updates taking up to 30 days. The lack of timely updates and comprehensive documentation in the care plans for Residents #8 and #1 contributed to the deficiencies identified during the survey.
Failure to Investigate and Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation and follow-up after a resident's fall, which resulted in a head injury. The resident, who had diagnoses of dementia and major depression, experienced an unwitnessed fall in their room. The incident report noted that the resident attempted to close their door due to bright hallway lights and slipped on the way back to bed. Immediate actions included assessing the resident, contacting the Assistant Director of Nursing, and calling 911 for hospital evaluation. However, the report lacked documentation of the root cause analysis and any interventions implemented before or after the fall. The resident's care plan and fall risk evaluation were not updated following the incident. Despite the resident's known risk for falls, as indicated in their care plan and fall risk evaluation, no new interventions were documented to prevent future falls. Interviews with staff revealed a lack of awareness regarding fall prevention measures for the resident, and the MDS Coordinator was unsure if the care plan had been updated post-fall. The Interim DON expected care plans to be updated within 48 hours of a fall, but this was not done. The facility's failure to update the care plan and implement new fall prevention strategies was evident in the lack of documentation and staff awareness. The ADON and other staff members acknowledged that the fall incident report and follow-up investigation did not include necessary interventions or root cause analysis. The facility had not yet conducted an interdisciplinary team meeting to review the fall and finalize the care plan, indicating a delay in addressing the resident's fall risk adequately.
Inadequate Oxygen Equipment Management
Penalty
Summary
The facility failed to adhere to proper infection control practices for oxygen equipment storage and timely replacement for three residents. Resident #1, diagnosed with COPD, heart failure, and Alzheimer's Disease, was observed with oxygen tubing not stored in a plastic bag when not in use, contrary to facility policy. Interviews with staff revealed a lack of clarity on responsibilities for changing and storing oxygen equipment, with discrepancies in understanding between shifts. Resident #40, with diagnoses including asthma and coronary artery disease, had oxygen tubing dated over a month old, wrapped around the bed rail, and not stored in a bag when not in use. The resident's care plan lacked documentation for oxygen therapy, and staff interviews indicated a failure to notice and replace outdated equipment. The night shift was identified as responsible for changing the tubing, but this was not consistently executed. Resident #37, with congestive heart failure and COPD, had an oxygen concentrator with tubing and a water bottle dated from July, despite not using oxygen consistently. Observations showed the equipment was not updated, and staff interviews confirmed the equipment should have been changed more frequently. The facility's policy was not followed, leading to outdated equipment remaining in use.
Failure to Securely Store Cleaning Chemicals in Resident's Room
Penalty
Summary
The facility failed to ensure the safe and secure storage of cleaning chemicals, specifically liquid laundry soap and bleach, in the room of a resident diagnosed with dementia and major depression. The resident, who was at risk for harm due to cognitive impairments, was found to have these chemicals stored under the sink in their room. Despite the facility's policy prohibiting residents from having personal chemicals in their rooms, the bleach and laundry soap were observed on multiple occasions, and the resident was unaware of why they were present. Interviews with various staff members, including a Certified Medication Technician, Housekeeper, Laundry Aid, LPN, Assistant Director of Nursing, and Interim Director of Nursing, revealed a lack of awareness and communication regarding the presence of these chemicals in the resident's room. Staff members acknowledged that the chemicals should not have been there and should have been removed immediately. However, no action was taken to address the safety hazard, indicating a failure in monitoring and enforcing the facility's chemical storage policy.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | 0.2 mi | — | 0 | 0 |
| Ridge Crest Nursing Center | 0.9 mi | — | 16 | 0 |
| Johnson County Care Center | 1.1 mi | — | 17 | 0 |
| Holden Manor Health & Rehabilitation | 15.5 mi | — | 1 | 0 |
| Lutheran Nursing Home | 17.3 mi | — | 4 | 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 August 2026) and official state health department websites.