Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Paddock Springs during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple comorbidities developed repeated abrasions to the knees and lower leg after the bed was placed against the wall as a fall intervention. Despite the use of pillows as a barrier, the resident continued to sustain skin injuries due to contact with the wall, and timely notification to the medical provider and treatment orders were not consistently documented.
A resident with multiple comorbidities and limited mobility developed an unstageable, necrotic pressure ulcer that was not identified until advanced, despite care plans for prevention and regular skin assessments. Documentation and staff interviews revealed missed or delayed skin assessments, lack of timely use of prescribed barrier cream, and delays in both wound treatment and nutritional interventions, contrary to facility policy.
A resident with multiple health conditions was readmitted to a facility with conflicting hospital discharge orders for lisinopril. The facility administered an incorrect dosage, leading to significant medication errors and the resident's hospitalization. Staff interviews revealed the error stemmed from transcribing the wrong dosage from the discharge plan instead of the discharge documentation.
A resident with multiple health conditions had their Bumetanide medication held several times due to low blood pressure and heart rate, but the physician was not notified. Interviews revealed a lack of policy for holding diuretics based on these parameters, and staff acknowledged the need for physician notification and documentation.
A resident with a history of hip fracture and other conditions developed a stage II pressure ulcer due to the facility's failure to implement specific interventions for heel pressure relief. Despite being assessed as low to moderate risk for pressure injuries, the resident's care plans lacked necessary measures like heel offloading. Observations showed the resident's heels were not adequately protected, and recommended booties were not provided, leading to the ulcer's development.
A resident with multiple diagnoses, including anxiety and bipolar disorder, did not receive their prescribed Lorazepam for several days due to it being unavailable. The facility failed to notify the physician or obtain the medication from the Emergency Drug Kit or pharmacy, contrary to their policy.
A facility failed to follow infection control practices during perineal care and insulin administration for a resident. A CNA did not change gloves or wash hands after cleaning fecal matter, and a QMA improperly fanned an insulin injection site. Facility policies were reviewed, but a glove use policy was not provided.
Failure to Implement Effective Interventions to Prevent Skin Abrasions
Penalty
Summary
Resident B, who had diagnoses including Alzheimer's disease, diabetes mellitus type 2, neuropathy, and peripheral angiopathy, was identified as having moderate cognitive impairment and required substantial to maximal assistance for bed mobility. Following a fall, the resident's bed was placed against the wall as a fall prevention intervention. Subsequently, the resident developed bilateral knee abrasions, with documentation indicating the resident was unaware of how the injuries occurred. Initial nursing notes did not reflect timely notification of the medical provider or the presence of a treatment order for the abrasions. The nurse practitioner later assessed the wounds and provided care instructions. Despite the implementation of pillows as a barrier between the resident and the wall, abrasions continued to occur, as the pillows did not always remain in place. Multiple nursing notes documented additional abrasions to the resident's knees and lower leg, attributed to contact with the wall. The care plan was updated to include the use of pillows against the wall, but the intervention was not consistently effective in preventing further skin breakdown. The facility's policy required the use of positioning devices to protect skin integrity, but the interventions in place failed to prevent repeated abrasions.
Failure to Timely Identify and Treat Pressure Ulcer
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, diabetes mellitus type 2, neuropathy, and peripheral angiopathy was identified as being at risk for pressure ulcer development and required substantial assistance for bed mobility. The care plan included weekly skin assessments, use of pressure-reducing devices, and regular repositioning. Despite these interventions, documentation showed that a pressure ulcer was not identified until it had become necrotic and unstageable. There was no documentation of impaired skin during a partial bath the day before the ulcer was discovered, and the as-needed use of a prescribed barrier cream was not documented. When the pressure ulcer was observed, it was already characterized by black eschar and was later measured as an unstageable wound with necrotic tissue. Orders for wound treatment were not implemented immediately, and there was a delay in obtaining and starting recommended nutritional interventions to support wound healing. Staff interviews revealed a lack of awareness of the pressure ulcer and inconsistent skin assessment practices. The facility's policy required daily skin inspections and prompt notification of changes, but these procedures were not followed, resulting in delayed identification and treatment of the pressure ulcer.
Failure to Clarify Medication Orders Leads to Significant Error
Penalty
Summary
The facility failed to clarify conflicting hospital discharge orders and previous medication orders for a resident, leading to a significant medication error. Resident 9, who had diagnoses including congestive heart failure, hypertensive heart disease with heart failure, and essential hypertension, was readmitted to the facility after hospitalization for sepsis, urinary tract infection, and acute kidney injury. Upon her return, there was a discrepancy in the hospital discharge documentation regarding the dosage of lisinopril, a medication used to treat high blood pressure. The discharge documentation listed two conflicting dosages: 10 mg daily and 40 mg daily. The facility's Medication Administration Record (MAR) incorrectly recorded and administered 80 mg of lisinopril on two consecutive days, which was significantly higher than the intended dose. As a result of the medication error, Resident 9 experienced lethargy, hypotension, and bradycardia, necessitating her return to the hospital. The hospital's report indicated that the resident had altered mental status, low blood pressure, and a slow heartbeat upon arrival. The nursing home staff had noted low blood pressure readings since her readmission, and the lisinopril medication was held on two occasions due to these low readings. Interviews with facility staff revealed that the error occurred due to the transcription of the incorrect dosage from the discharge plan rather than the discharge documentation. The facility's policy on medication orders required accurate recording of medication type, route, dosage, frequency, and strength, which was not adhered to in this case.
Failure to Notify Physician of Held Medications
Penalty
Summary
The facility failed to notify the physician about medications held for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, heart failure, and hypertension. The resident was prescribed Bumetanide, a diuretic, to be taken twice daily for congestive heart failure. However, the medication was held on several occasions due to low blood pressure and heart rate, as documented in the Medication Administration Records (MAR) for June, August, and September 2024. Despite these instances, there was no documentation indicating that the physician had been informed of the medication being withheld. Interviews with facility staff revealed that there was no policy or physician orders specifying parameters for holding diuretics based on blood pressure or heart rate for this resident. The Qualified Medication Aide (QMA) and the Director of Nursing (DON) both acknowledged that the nursing staff should have notified the physician and documented this notification in the Electronic Medical Record (EMR). The facility's policy on physician notification guidelines, provided by the DON, emphasized the importance of informing the physician of any change in the resident's condition in a timely manner.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to implement appropriate interventions to prevent a deep tissue injury (DTI) wound for Resident 105, who was admitted with a right hip fracture, diabetes, chronic congestive heart failure, and depression. Upon admission, the resident was assessed as having no skin issues to the heels, and a pressure ulcer risk assessment indicated a low to moderate risk for pressure injuries. However, the facility's documentation was inconsistent, as a Wound Management Detail Report incorrectly noted a DTI to the right heel as present on admission, which was later identified as an in-house acquired wound. The care plans developed for Resident 105 did not include specific interventions to prevent pressure on the heels, such as floating the heels or using offloading devices, despite the presence of a DTI. Physician's orders included preventative measures like skin prep and foam dressing, but these were not effectively implemented. Observations revealed that the resident's heels were not adequately offloaded, and recommended heel booties were not provided, leading to the development of a stage II pressure ulcer. Interviews with the Director of Nursing (DON) and other staff highlighted a lack of adherence to the facility's policies on pressure ulcer prevention and wound care. The DON acknowledged the documentation error and the absence of specific interventions in the care plan. Despite recommendations from the wound nurse practitioner for offloading procedures, the resident was observed without the necessary protective measures, indicating a failure in executing the prescribed care plan and interventions.
Failure to Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to administer a physician-ordered medication, Lorazepam 0.5 mg daily, to a resident diagnosed with heart failure, dementia, anxiety, depression, and bipolar disorder. The Medication Administration Record (MAR) for August 2024 indicated that the resident did not receive the medication from August 4 to August 12, 2024, due to it being marked as 'Med Not Available.' This lapse in medication administration was not communicated to the attending physician, nor were alternative measures taken to obtain the medication from the facility's Emergency Drug Kit (EDK) or the pharmacy. Interviews with the Director of Nursing and an LPN revealed that the facility's protocol for unavailable medications was not followed. The Director of Nursing acknowledged that the physician should have been notified of the missed doses, and the nurse should have attempted to obtain the medication from the EDK or contacted the pharmacy. The facility's policy on unavailable medications requires notifying the attending physician, obtaining a new order, and informing the pharmacy, none of which were done in this instance.
Infection Control Deficiencies in Perineal Care and Insulin Administration
Penalty
Summary
The facility failed to adhere to proper infection control practices during perineal care and insulin administration for Resident 15. During an observation, a CNA provided incontinence care to the resident but did not change gloves or wash hands after cleaning the resident's buttocks, which had fecal matter present. The CNA only removed her gloves and washed her hands after completing the entire care process, which was not in line with infection control protocols. Additionally, a QMA was observed administering insulin to the same resident. After cleansing the injection site on the resident's abdomen with an alcohol pad, the QMA fanned the area with an open hand, which is not a recommended practice. The facility's policies on perineal care and injectable medication administration were reviewed, but a specific policy on glove use was not provided during the survey.
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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 Warsaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Warsaw Meadows | 0.3 mi | ★★★★★ | 16 | 0 |
| Miller's Merry Manor | 1.4 mi | ★★★★★ | 0 | 0 |
| Mason Health Care Center | 1.6 mi | ★★★★★ | 31 | 0 |
| Grace Village Health Care Facility | 2.9 mi | ★★★★★ | 0 | 0 |
| Waters Of Syracuse Skilled Nursing Facility, The | 13.6 mi | ★★★★★ | 22 | 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.