Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Warsaw Meadows during CMS and state inspections, most recent first.
A resident with dementia and other conditions was allegedly subjected to verbal abuse by a CNA, who reportedly used profanity during care. The incident was not reported to the Administrator or proper authorities until several days after it occurred, contrary to facility policy requiring immediate reporting of abuse allegations.
A resident with a known history of behavioral issues physically assaulted another resident, causing extensive bruising and emotional trauma, and later verbally abused a second resident, resulting in fear and mental anguish. Staff failed to follow care plan interventions or implement timely supervision, and documentation of required monitoring was lacking.
Food Storage and Serving Sanitation Deficiencies: Staff failed to store and serve food in a sanitary manner. Observations found frozen pancakes with no use-by date, opened pureed chicken placed next to a sanitizing liquid bucket, a staff member thumbing the eating surface of plates while plating food, and expired items in two pantries, including cranberry juice, peanut butter bars, and Med Pass. The Dietary Mgr and QMA acknowledged the issues when interviewed.
The facility failed to develop individualized care plans for a resident with PTSD and delusional behaviors and for another resident after hospitalization for profound anemia and new anticoagulant therapy. The PTSD care plan lacked interventions tied to the resident’s trauma triggers and specific needs, and the other resident had no care plan or monitoring orders for apixaban use or anemia after being diagnosed with severe anemia and DVTs.
Care plan meetings were not held timely and records often lacked proof that residents were invited or attended. Several residents with significant psychiatric, cognitive, and medical diagnoses had care conference notes showing staff and, at times, guardians or representatives present, but no documentation that the resident was invited or included. In one case, the resident said she had never attended a care plan meeting, and in another, quarterly care conferences were not documented as required. An IDT meeting also occurred without the resident or representative and without documentation of invitation.
A resident received Midodrine despite systolic BP readings above the ordered hold parameter, another resident did not receive bowel protocol management consistent with the facility’s constipation protocol after limited BM documentation and abdominal pain, a resident with DM received Lantus when BG was below the ordered hold threshold, and a resident with facial scratches after an altercation had no documented assessment, physician notification, treatment, or ongoing skin monitoring. Staff interviews confirmed the ordered parameters and the lack of required documentation or follow-through.
A resident with bipolar disorder, schizophrenia, anxiety, PTSD, insomnia, non-Alzheimer's dementia, and delusions was ordered multiple psychotropic meds, including Trazadone, Lamotrigine, Lexapro, Clonazepam, and Risperdal. The POA/guardian’s verbal consent for the psychoactive meds was documented only after the orders were written and after the facility had already started giving the meds; the DON stated the consent should have been obtained earlier.
Failure to Report Alleged Abuse: Staff reported that a resident was found with scratches on his face after an altercation with a CNA during the night shift, and a QMA saw the resident bleeding and heard the CNA say she may have scratched him with her nails. The SSD considered it a potential abuse allegation, but the Administrator said he did not report it because he did not view it as abuse, and he stated there was no investigation. The DON and NP were unsure about the details and documentation, and the resident’s chart lacked documentation of the incident or injury assessment.
Failure to Investigate Alleged Abuse: Staff reported a resident was found with facial scratches after an altercation with a CNA, and a QMA said she saw the resident bleeding and heard the CNA say she may have scratched him. The former SSD considered it a potential abuse allegation, but the Administrator said he did not view it as abuse, did not report it, and did not conduct an investigation. The DON was unsure whether the incident had been investigated, and the NP did not document the injury or assessment in the resident’s chart.
Missing Wanderguard for Resident at Elopement Risk: A resident with altered mental status, visual hallucinations, disorientation, and severe cognitive impairment was identified as a moderate wander/elopement risk and had a care plan and MD order for a Wanderguard on the left wrist with daily checks. During repeated observations, the device was not in place near the front exit, and the resident later stated she had cut it off because it was too tight and placed it in her nightstand drawer; RN confirmed the band was cut and found it in the drawer.
A resident with PTSD, dementia, and multiple psychiatric diagnoses did not receive trauma-informed, culturally competent care to reduce triggers and emotional distress. After contact with family, the resident became tearful and escalated to banging on exit doors while sobbing for her parents. Staff used general redirection such as coloring, Bible reading, music, and conversation, but these measures were not consistently effective, and the care plan lacked specific PTSD triggers, personalized interventions, and consistent staff awareness about restrictions on male visitors.
Medications were not available for administration for a resident with bipolar disorder, schizophrenia, anxiety, PTSD, insomnia, cancer, and delusions. The MAR showed multiple missed doses of Prazosin, plus missed doses of Trazodone and Lamotrigine, because the meds were not available or the facility was waiting on pharmacy. Staff interviews showed expected steps included checking the cart and EDK, contacting the pharmacy, notifying the nurse, and informing the DON.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
A resident at risk for skin breakdown developed multiple pressure ulcers due to inadequate interventions and monitoring. Despite being assessed as at moderate risk, the resident's care plan was not effectively implemented, leading to the development of stage 3 and stage 2 pressure ulcers. The facility failed to adhere to physician orders for wound care and incontinence management, contributing to the worsening of the resident's condition.
A resident with Alzheimer's and other psychiatric disorders repeatedly exhibited aggressive behaviors towards other residents, causing harm. Despite being placed on one-on-one supervision and discharged to a psychiatric hospital twice, the facility failed to implement new interventions to prevent further incidents. The Director of Nursing admitted that no new measures were added, violating the facility's abuse prevention policy.
The facility failed to store food under sanitary conditions in the main kitchen, affecting all residents who received food from this kitchen. Surveyors observed unlabeled and undated food items, including frozen meat patties, beverages, bread products, and juice pitchers. The Dietary Manager confirmed that all food and beverages should be labeled with the name and date, as per the facility's policy.
The facility failed to create comprehensive, person-centered care plans for residents with specific needs, including delusions, hallucinations, and hospice care. Despite being prescribed medications for their conditions, the clinical records for these residents lacked appropriate care plans. The Director of Nursing confirmed these omissions, which were contrary to the facility's policy requiring such care plans.
A resident with multiple health conditions, including diabetes and chronic kidney disease, did not receive a baseline or routine care plan meeting since admission. The resident reported not having access to test results until discharge. The Social Service Director confirmed the lack of scheduled meetings and undocumented interactions, contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to provide adequate ADL care for three residents, including insufficient showering opportunities and personal hygiene assistance. A resident reported receiving only two showers in over a month, with inconvenient timing leading to refusals. Another resident missed scheduled showers, and a third was observed with poor hygiene despite needing total assistance. The DON was unaware of these issues, and documentation practices were inadequate.
A resident with cerebral palsy and other conditions did not receive an individualized activities program as outlined in their care plan. Observations showed the resident often without entertainment, despite preferences for TV and music. The facility's policy requires programs to meet individual needs, but interviews confirmed the resident's activities were not provided, leading to a deficiency.
A resident with a urostomy was repeatedly observed with an uncovered drainage bag, despite facility policy requiring it to be covered for dignity. Staff interviews confirmed the expectation for coverage, yet the deficiency persisted over several days.
The facility failed to properly label and store respiratory equipment for three residents, leading to deficiencies in respiratory care. A resident received oxygen therapy with undated tubing and without humidification, contrary to physician orders. Two other residents had improperly stored and undated respiratory equipment, despite having specific physician orders for oxygen therapy. The facility's policy required respiratory equipment to be stored in plastic bags and dated, which was not followed.
The facility failed to ensure narcotics were counted and documented every shift for one of the narcotic count log books. An observation revealed that the narcotic log book for Freedom cart 1 lacked signatures, indicating a missed narcotic count. QMA 2 confirmed that the log sheets should have been signed every shift. The facility's policy requires nursing staff to count controlled medications at the end of each shift, with both the incoming and outgoing nurses participating in the count.
The facility failed to properly store and label medications on two medication carts. Observations revealed improperly stored eye drops, unlabeled Colace and Antacid tablets, loose pills, and wound cleanser stored with medications. Staff acknowledged the errors, and facility policies on medication storage and labeling were provided.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse reporting policy by not reporting an allegation of verbal abuse in a timely manner for one resident. Resident B, who had multiple diagnoses including dementia, anxiety, depression, and cognitive communication deficit, was allegedly subjected to verbal abuse by a CNA who reportedly told the resident to "shut the f--- up" while assisting with toileting. The incident occurred on 12/6/25, but was not reported to the appropriate authorities or the Administrator until 12/10/25. CNA 3, who witnessed the event, initially reported it only to the Weekend Manager and did not escalate the allegation to the Unit Manager or Administrator as required by facility policy. Interviews revealed that the Weekend Manager was not made aware of the abuse allegation at the time it occurred, and the Administrator was not informed until four days later. The facility's abuse policy requires immediate reporting of abuse allegations, but this protocol was not followed. The delay in reporting was confirmed through staff interviews and record review, indicating a breakdown in communication and adherence to established procedures for reporting suspected abuse.
Failure to Prevent Resident-to-Resident Abuse and Emotional Distress
Penalty
Summary
The facility failed to prevent both physical and emotional abuse among residents, specifically involving two residents who were subject to abuse by another resident with a known history of behavioral issues. One resident, who had diagnoses including schizophrenia, alcohol abuse, and major depressive disorder, had a care plan in place due to a history of striking out at staff and peers. Despite this, staff did not follow the planned interventions, such as removing the resident from situations at the first signs of agitation and providing a safe space. This failure led to an incident where the resident physically assaulted another resident, resulting in extensive bruising to multiple areas of her body, including her forearm, elbow, breast, palm, wrist, fingers, and shoulders. The assaulted resident, who had a history of PTSD and other psychiatric diagnoses, experienced significant emotional trauma, including fear, crying, shaking, and symptoms that triggered her PTSD. Following the initial physical altercation, the same resident verbally abused and threatened another resident, causing her to experience mental anguish and fear. This resident, who was cognitively intact but had physical disabilities, reported feeling unsafe, kept a grabber stick under her pillow for protection, and expressed distrust in the facility. Staff interviews confirmed that the resident who committed the abuse had a pattern of angry outbursts and altercations, and that staff were aware of his behavioral history. However, one-to-one supervision and other preventative interventions were not implemented until after the second incident of abuse occurred. Documentation and communication lapses were also evident. The DON was not informed of the full extent of the altercations or the interventions that were (or were not) implemented. The executive director was aware of the incidents but could not produce documentation of one-to-one supervision. Staff interviews revealed concerns about the resident's behavior and the adequacy of supervision, but these concerns were not acted upon in a timely manner. The facility's own abuse policy required supervision and intervention for residents with behavioral needs, but these measures were not effectively carried out, resulting in physical harm and emotional distress to two residents.
Food Storage and Serving Sanitation Deficiencies
Penalty
Summary
The facility failed to store and serve food in a sanitary manner. During the initial kitchen tour, two bags of frozen pancakes were observed in the stand-up freezer with no use-by date, and the Dietary Manager stated there should have been a use-by date on the pancakes. On a follow-up kitchen tour, an opened container of pureed chicken was placed on the counter top next to a bucket of sanitizing liquid, and the Dietary Manager stated food items should not be near the sanitizing water bucket. During a later observation, a staff member was seen placing her thumb on the eating surface of plates while plating food, and she stated she should not have placed her thumb on the food surfaces of the plates. In the Heritage and Freedom Hall pantries, expired items were also observed, including cranberry juice with a use-by date of 9/7/2025, five peanut butter bars expired on 9/5/2025, and a container of Med Pass expired on 9/7/2025. The QMA stated the expired items should have been removed from the pantries.
Incomplete Care Planning for PTSD, Anticoagulant Use, and Anemia
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with PTSD and failed to develop a care plan after hospitalization for another resident who was newly started on an anticoagulant and diagnosed with severe anemia. For the resident with PTSD, the record showed diagnoses including cancer, non-Alzheimer's dementia, anxiety, depression, psychotic disorder, bipolar disorder, schizophrenia, and PTSD, and the admission MDS indicated the resident could express ideas and wants, experienced delusions, and received antipsychotic, antidepressant, anticonvulsant, and opioid medications. The current care plan addressed psychosocial well-being and a history of trauma or PTSD, but the interventions were limited to allowing time to answer questions, verbalize feelings, consulting pastoral care, social services, and psych services, and encouraging participation in decision-making; it did not include interventions specific to the resident's trauma triggers or individual needs, and it did not address the resident's delusional behavioral issues. For the resident who had been hospitalized, the record showed a hemoglobin level of 2 g/dL, transfusion with four units of packed red blood cells, diagnosis of profound anemia and potential hemorrhagic shock, and discovery of deep vein thromboses in the right upper and lower extremities. The resident was later ordered apixaban 5 mg twice daily for a blood clot and ferrous sulfate 325 mg daily for anemia, and the MDS indicated the resident was cognitively intact and received an anticoagulant. There were no current orders for observation of anticoagulant side effects and no care plan addressing anticoagulant use or the anemia diagnosis, and the MDS Coordinator stated that a care plan had not been written for those conditions.
Care plan meetings not held timely and resident invitation documentation missing
Penalty
Summary
The facility failed to ensure residents were invited to care plan meetings and that care conferences were held timely for 5 of 21 residents reviewed. The deficiency involved residents with diagnoses including bipolar disorder, schizophrenia, anxiety, PTSD, cancer, insomnia, delusions, renal disease, non-Alzheimer’s dementia, depression, hypertension, vascular dementia, chronic respiratory failure, CHF, diabetes, PVD, morbid obesity, polyneuropathy, COPD, and major depressive disorder. The record review and interviews showed that care plan documentation often lacked evidence that the resident had been invited or attended, even when the resident was able to communicate clearly or make herself understood. For one resident, the record showed care conferences in May and June 2025, but the forms documented attendance by staff and the guardian by phone without showing that the resident had been invited or present; nursing progress notes also lacked documentation of invitation or attendance. The resident stated she had never been to a care plan meeting. For another resident, multiple care conference notes from 2024 and 2025 documented attendance by staff and, at times, the guardian, but the record lacked documentation that the resident had been invited or attended. The MDS nurse stated the SSD was responsible for completing care plan documentation and invitations for the locked unit and dementia unit. For a third resident, the record showed care plan conferences in September 2024, March 2025, and June 2025, but there was no documentation of a December 2025 conference. For another resident, care plan meetings were documented over the prior year, but they were not held quarterly; one interdisciplinary team meeting included pharmacy, nurse practitioners, social services, dementia program coordinator, and DON, but did not include the resident or representative and lacked documentation that they had been invited. The SSD stated care conferences should have been held every 3 months and should have included notification of the resident or representative, and the facility policy stated the interdisciplinary team must review and update the care plan at least quarterly.
Failure to Follow Medication, Bowel, Insulin, and Skin Care Orders
Penalty
Summary
The facility failed to follow a physician’s order for Midodrine for a resident with atrial fibrillation, hypotension, and coronary artery disease. The order, dated 4/3/2025, directed that Midodrine 10 mg by mouth three times daily be held if the systolic blood pressure was greater than 110 mmHg. Review of the July and August 2025 MARs showed multiple administrations of Midodrine when the resident’s systolic blood pressure was above that parameter, including readings such as 127/63, 119/64, 123/68, 118/68, 124/64, 126/76, 122/71, 131/65, 119/59, 119/60, 123/73, 123/68, 122/78, 123/78, 130/76, and 122/69 mmHg. RN 6 stated the medication should not have been given when the systolic blood pressure was greater than 110 mmHg. The facility also failed to follow bowel protocol and physician-directed constipation interventions for a resident with neuroleptic induced Parkinsonism, schizoaffective disorder, bipolar disorder, and impulse control issues. The resident’s record showed limited bowel movement documentation, including hard/constipated stools on 7/22/2025 and 7/24/2025, followed by a medium bowel movement on 8/16/2025 with no further bowel movements recorded in the reviewed period. A KUB x-ray on 7/21/2025 showed abundant fecal material in the large bowel loops and constipation was included in the differential diagnosis. The resident later complained of abdominal pain, and suppositories were ordered for constipation. The MAR showed administration of routine laxatives and PRN interventions, but the record also showed refusals of an enema and refusal to go to the hospital for evaluation. RN 6 stated the facility had a bowel movement protocol that called for intervention when a resident had no bowel movement for three days, and that small bowel movements did not count as documented bowel movements. The facility failed to follow insulin parameters for a resident with type 2 diabetes mellitus. A physician’s order directed Lantus 38 units subcutaneously twice daily, with instructions to hold the insulin if blood glucose was less than 100 mg/dL and to call the NP if blood glucose was above 450 mg/dL. Review of blood glucose values showed Lantus was administered when the resident’s blood glucose was 97, 97, 91, 99, 97, 90, and 87 mg/dL. The DON stated the insulin should have been held on those days. The facility also failed to assess, document, and monitor a skin issue for a resident with hypertension, diabetes, hip fracture, Alzheimer’s disease, non-Alzheimer’s dementia, and depression. Staff reported that the resident had scratches all over his face after an altercation involving the resident and a staff member. The DON and Administrator stated there was no further investigation and no documentation in the clinical record regarding the injuries. The NP stated she had been informed of the incident and had viewed a photograph showing the scratches, but she did not assess the resident or document the injuries because the resident was not her resident. The record lacked documentation that the attending physician was notified, that treatment was obtained for the scratched areas, or that the skin issue was monitored until healed.
Delayed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely informed consent for psychotropic medication use for Resident 15. The resident had diagnoses including bipolar disorder, schizophrenia, anxiety, PTSD, insomnia, non-Alzheimer's dementia, and delusions, and was ordered multiple psychotropic medications, including Trazadone for insomnia, Lamotrigine for bipolar disease, Lexapro for depression, Clonazepam for anxiety, and Risperdal for schizophrenia. A psychoactive medication therapy informed consent form, dated 6/17/2025, showed the POA/guardian gave verbal consent for the use of these medications, but the consent was obtained after the medication orders had already been written and after the facility had already started administering the medications. During interview, the DON stated the consent should have been obtained earlier and was not.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse for 1 of 2 residents reviewed for abuse, involving a resident with hypertension, diabetes, a hip fracture, Alzheimer's disease, non-Alzheimer's dementia, and depression. A quarterly MDS dated 8/22/2025 indicated the resident could make his needs known, had no behaviors, used a wheelchair for mobility, was independent with sitting on the side of the bed and wheeling his wheelchair, and only required set-up help for bed-to-chair and chair-to-bed transfers. Staff interviews described an incident in which the resident was found with scratches on his face after an altercation with CNA 17 during the night shift. CNA 8 stated she was told the resident had been redirected back to his room during the night and that the night nurse showed her a picture of the resident with scratches all over his face, while also reporting that the nurse had seen the resident and CNA 17 fighting. The former SSD said the night staff reported an altercation between CNA 17 and the resident during incontinence care, and when asked if she considered it a potential abuse allegation, she answered yes. QMA 18 stated she heard the resident yelling, saw CNA 17 with the resident, noticed a bleeding scratch on his face, and was told by CNA 17 that she may have scratched him with her nails. The Administrator stated he was aware of the altercation but did not report it because he did not consider it potential abuse, and he said there was no investigation on his part. The DON stated she could not recall the incident well, was unsure when the scratches occurred, and was not sure whether anyone investigated. The NP stated she was informed of the incident and that there was no documentation regarding what happened to cause the scratches, and she did not document the report or assess the injuries because the resident was not her resident. The facility policy stated allegations of abuse and injuries of unknown source are to be reported immediately, but no later than 2 hours if abuse is alleged, and that such reports are to be thoroughly investigated by the administrator or designee.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to fully investigate an allegation of abuse involving a resident with diagnoses of hypertension, diabetes, hip fracture, Alzheimer's disease, non-Alzheimer's dementia, and depression. A quarterly MDS dated 8/22/2025 indicated the resident could make his needs known, had no behaviors, used a wheelchair for mobility, was independent with sitting on the side of the bed and wheeling his wheelchair, and required only set-up help for bed-to-chair and chair-to-bed transfers. Staff interviews described an incident in which the resident was found with scratches on his face after an altercation with a CNA during the night shift. A CNA reported that the night nurse showed a picture of the resident with scratches all over his face and said she had seen the resident and the CNA fighting. A QMA stated she heard the resident yelling, saw the CNA with him in the room, noticed a bleeding scratch on his face, and was told by the CNA that she may have scratched him with her nails. The QMA reported the incident to the night nurse and was told to notify management and take a picture for proof. The former SSD stated she considered the incident a potential abuse allegation and had asked the Administrator about the investigation, but was told it was being dealt with. The Administrator stated he did not report the incident because he did not consider it potential abuse and acknowledged there had been no investigation on his part. The DON was unsure whether anyone had investigated the resident injury and did not recall interviewing other staff who were working that night. The NP stated she was informed of the incident but had not documented the report or assessed the scratches in the resident's chart because he was not her resident. The facility policy stated all reports of resident abuse, neglect, exploitation, mistreatment, and injuries of unknown source shall be reported to local and federal agencies and thoroughly investigated by the administrator or designee.
Missing Wanderguard for Resident at Elopement Risk
Penalty
Summary
The facility failed to ensure physician orders for elopement risk were in place for 1 of 2 residents reviewed for elopement risk. Resident 65 had diagnoses including altered mental status, visual hallucinations, and disorientation, and the admission MDS dated 7/3/2025 indicated severe cognitive impairment. An Elopement/Wander Risk Evaluation dated 6/27/2025 and 7/21/2025 identified the resident as a moderate wander/elopement risk, and the care plan initiated on 6/27/2025 directed that a Wanderguard be in place on the left wrist with staff checking placement every day shift. During multiple observations, Resident 65 was seen seated in the common area near the front exit door without a Wanderguard observed on the wrists or ankles. On 9/5/2025, the resident was observed walking in a hallway and stated, "I'm on the wrong hallway." On 9/8/2025, the resident again had no Wanderguard visible, and later told RN 6 that she had cut the Wanderguard off because it had been too tight and placed it in the drawer of her bedside nightstand; RN 6 found the band in the upper drawer and noted it had been cut. A physician's order dated 8/18/2025 directed a Wanderguard to the left wrist and daily staff checks for proper functioning, and RN 6 stated the resident should have had a Wanderguard on her left wrist.
Failure to Provide Trauma-Informed, Culturally Competent Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure a resident with diagnoses including cancer, non-Alzheimer's dementia, anxiety, depression, psychotic disorder, bipolar disorder, schizophrenia, and PTSD received culturally competent, trauma-informed care to reduce triggers for behaviors and emotional distress. The resident's admission MDS dated 6/2/2025 indicated delusions and use of an antipsychotic, antidepressant, anticonvulsant, and opioids. A nurse's progress note documented that after receiving a call from her mother, the resident became moody and tearful, then escalated near dinner time by walking to the exit doors and repeatedly banging on them with closed fists while sobbing and stating she wanted to see her mom and dad. Interviews with CNA staff showed they attempted to talk with the resident, redirect her to coloring, writing notes, reading the Bible, or listening to music, but these interventions were not consistently effective. Staff also reported being told that the resident's father was not allowed to visit and that a written note had been posted at the nurse's desk with instructions not to allow male visitors, but there was no consistent education to ensure staff were aware of this restriction. The care plan identified psychosocial well-being concerns related to a history of personal trauma or PTSD and included general interventions such as allowing time to answer questions, consulting pastoral care, social services, and psychological services, and encouraging participation in decision-making, but it did not include specific PTSD triggers or personalized interventions.
Medications Not Available for Administration
Penalty
Summary
The facility failed to ensure physician-ordered medications were available for administration for Resident 15. Resident 15’s record showed diagnoses including bipolar disorder, schizophrenia, anxiety, PTSD, insomnia, cancer, and delusions. Current physician orders included Lamotrigine 50 mg twice daily for bipolar disease, Trazodone 50 mg at bedtime for insomnia, and Prazosin 2 mg at bedtime for PTSD. The May, June, and July MARs documented multiple missed doses of Prazosin because it was not available, including 5/30 and 5/31, 6/5 through 6/11 and 6/19, and 7/1, 7/11, 7/12, and 7/17/2025. The MAR also showed Trazodone was not administered on 7/17/2025 because it was not available, and Lamotrigine was not administered on 7/28/2025 because the facility was waiting on pharmacy. During interviews, QMA 10 stated that if a medication was not available, she would check whether it had been ordered, order it if needed, document that it was out and reordered, and notify the nurse. QMA 16 stated she would check the bottom of the medication cart, the EDK, call the pharmacy, and inform the DON. The DON stated nursing staff should have checked the EDK and, if the medication was not there, called the pharmacy and the MD. The facility provided its policy on Emergency Pharmacy Service and Emergency Kits, which stated emergency medication needs are met through the approved emergency medication supply or special order from the pharmacy.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate interventions to prevent the development of pressure ulcers for a resident identified as being at risk. The resident, who had a history of peripheral vascular disease, diabetes mellitus type 2, heart failure, and lymphedema, was assessed to be at moderate risk for skin breakdown. Despite this, the resident developed multiple pressure ulcers, including a stage 3 ulcer on the left gluteal area, a stage 2 ulcer near the coccyx, and an unstageable wound on the left ischial area. The facility's care plan included interventions such as a pressure relief mattress and assistance with turning and repositioning, but these were not effectively implemented. The resident's pressure ulcers were not adequately monitored or treated according to physician orders. The resident reported that dressings were not changed routinely, and the prescribed treatment cream was not applied as ordered. Additionally, the resident's incontinence care was insufficient, with reports of infrequent brief changes leading to contamination of the wounds with stool. This lack of adherence to the treatment plan and inadequate incontinence management likely contributed to the worsening of the resident's pressure ulcers. Observations revealed that the resident did not have a low air loss mattress in place, contrary to the care plan, and there was no documentation of the resident refusing this intervention. Interviews with staff indicated a reliance on shower sheets for skin assessments, which were not consistently documented or available. The facility's policy on skin and wound management was not followed, as ongoing monitoring and preventative interventions were not effectively implemented for the resident at risk for skin compromise.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement effective interventions to prevent physical and verbal resident-to-resident abuse, resulting in harm to three residents. Resident B, diagnosed with Alzheimer's disease, psychotic disorder with delusions, depression, and dementia with agitation, exhibited physically abusive behaviors towards other residents. On multiple occasions, Resident B made physical contact with other residents, including incidents where he grabbed a resident's walker, causing her to fall, and hit another resident with a photo album. Despite these incidents, the facility did not add new interventions to prevent further occurrences. Resident B's aggressive behaviors were documented in several notes, indicating a pattern of physical and verbal aggression. The facility's records show that Resident B was placed on one-on-one supervision and was discharged to a psychiatric hospital twice, but these measures did not prevent further incidents upon his return. The facility's failure to identify triggers and implement additional interventions contributed to the recurrence of abuse. The Director of Nursing acknowledged that no new interventions were added for Resident B following the altercations. The facility's abuse policy, which mandates processes for screening, training, prevention, identification, and protection against abuse, was not effectively implemented in this case. This deficiency highlights the facility's inability to protect residents from abuse by other residents, as required by their policy.
Failure to Store Food Under Sanitary Conditions
Penalty
Summary
The facility failed to store food under sanitary conditions in the main kitchen, which had the potential to affect all 69 residents who received food from this kitchen. During an initial tour, surveyors observed several issues: two opened bags of frozen meat patties in the double-door freezer were unlabeled and undated; a tray of beverages in the double-door cooler was unlabeled, with only one cup bearing a date; multiple bread products in the dry pantry, including hot dog buns, hamburger buns, and English muffins, were without labels or dates; and two pitchers of juice in the walk-in fridge were also without dates or labels. The Dietary Manager confirmed that all food and beverages should have labels with the name of the item and dates. The facility's policy, provided by the Executive Director, stated that all food should be dated at the time of receipt and inventoried using the first-in, first-out method, with unserved leftovers labeled, dated, and stored for no more than three days.
Deficiencies in Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in meeting their specific needs. Resident 36, diagnosed with psychotic disorder with delusions, depression, dementia with agitation, and anxiety, was receiving antipsychotic and antidepressant medications. However, the clinical record lacked a person-centered care plan addressing the resident's delusions. The Director of Nursing acknowledged the absence of such a care plan during an interview. Similarly, Resident E, who had diagnoses including dementia, depression, and psychotic disorder, was noted to have delusions according to an Admission Minimum Data Set assessment. Despite being prescribed Depakote for delusions, the resident's clinical record did not include a person-centered care plan for this condition. The Director of Nursing confirmed the omission of the necessary care plan during an interview. Resident 55, with diagnoses of malnutrition, bipolar disorder, visual hallucinations, and depression, was receiving antipsychotic medication for visual hallucinations. However, the clinical record lacked a person-centered care plan for hallucinations. Additionally, Resident 16, who was receiving hospice care for end-stage cerebral atherosclerosis, had a care plan that was not person-centered, as confirmed by the Director of Nursing. The facility's policy required comprehensive, person-centered care plans, but these were not implemented for the residents in question.
Failure to Conduct Care Plan Meetings for a Resident
Penalty
Summary
The facility failed to provide a baseline care plan meeting and routine care plan meeting for a resident, identified as Resident 53, who was reviewed for care planning. During an interview, the resident reported that he had not been allowed to access his test results until discharge and had not participated in any care plan meetings since his admission. A review of the resident's electronic medical record confirmed the absence of documentation regarding a baseline or routine care plan meeting. The resident's diagnoses included alcohol abuse, diabetes mellitus type 2, idiopathic acute pancreatitis, cannabis use, iron deficiency anemia, and chronic kidney disease. The Social Service Director acknowledged that the resident had likely not had a baseline care plan meeting and that no meeting had been scheduled since admission. Despite frequent visits to the Social Service Director's office, these interactions were not documented. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, involving the interdisciplinary team and the resident or their representative.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, as observed and documented in the report. Resident 53 reported receiving only two showers in the past month and a half, with showers being offered at inconvenient times between 11 P.M. and 3 A.M., which he refused. The resident's care plan indicated a need for assistance with bathing due to various health conditions, but there was no documentation of his shower time preferences. The Director of Nursing (DON) was unaware of the issue and noted that refusals were documented, but accepted showers were not. Resident 9 also experienced inadequate showering opportunities, reporting missed showers on scheduled days. The resident's care plan required assistance with ADLs due to multiple health issues, including dementia and schizophrenia. The documentation showed sporadic shower occurrences and several refusals, but the resident was not care planned for refusals. The DON acknowledged the resident's tendency to refuse showers but did not have a system in place to document accepted showers. Resident 1 was observed with poor personal hygiene, including long, dirty fingernails, unkempt facial hair, and greasy hair. The resident required total assistance for ADLs due to severe cognitive impairment and multiple health conditions. Despite being dependent on staff for personal hygiene, the resident's care needs were not met, as confirmed by RN 14, who was unaware of the resident's shower schedule. The DON confirmed that the resident should have scheduled showers and grooming assistance, but these were not provided as per the facility's policy.
Failure to Implement Individualized Activities Program
Penalty
Summary
The facility failed to implement an individualized activities program for a resident, leading to a deficiency. Observations over several days revealed that the resident was often found in his room, either in bed or in a chair, without any form of entertainment such as television or music, despite being awake. The resident's care plan, dated June 4, 2024, emphasized the importance of engaging in activities like watching favorite TV shows, listening to music, and having access to books and newspapers. However, these preferences were not consistently met, as evidenced by the lack of stimulation observed during the survey. The resident's medical history includes cerebral palsy, epilepsy, intellectual disabilities, and other conditions, which necessitate a tailored approach to activities. The facility's policy on activity recreation programs, dated March 2015, mandates that programs should meet individual resident needs and reflect their schedules and choices. Interviews with the Activity Director and the Director of Nursing confirmed that the resident's television should have been on to allow him to watch his favorite shows, and staff should have monitored for overstimulation. Despite these requirements, the resident did not receive the activities he enjoyed, resulting in a failure to adhere to the care plan and facility policy.
Failure to Cover Urostomy Drainage Bag with Dignity Bag
Penalty
Summary
The facility failed to ensure that a resident's urostomy drainage bag was covered with a dignity bag, as observed on multiple occasions. Resident 264, who has a medical history including spina bifida, depression, paraplegia, morbid obesity, obstructive sleep apnea, stoma of the urinary tract, and colostomy status, was observed on several dates with an uncovered urostomy drainage bag. These observations occurred on 8/7/2024, 8/8/2024, 8/12/2024, and 8/13/2024, indicating a consistent failure to maintain the resident's dignity by not covering the drainage bag. Interviews with facility staff, including a Qualified Medication Aide (QMA) and the Assistant Director of Nursing (ADON), confirmed that the urostomy bag should have been covered with a dignity bag. The facility's policy on indwelling urinary catheter care, provided by the Director of Nursing (DON), emphasized the importance of keeping the drainage bag hidden under clothing to help the patient feel more comfortable. Despite this policy, the facility did not adhere to these guidelines, resulting in the deficiency.
Improper Labeling and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for three residents. Resident 30 was observed receiving oxygen therapy with undated tubing and without humidification, despite physician orders requiring these elements. The resident, who had multiple diagnoses including COPD and chronic respiratory failure, refused humidification due to discomfort, but the tubing was still required to be dated. The Director of Nursing confirmed that the oxygen tubing should have been dated, as per the facility's policy. Resident 215's respiratory equipment, including a nebulizer and oxygen nasal cannula, was improperly stored and undated. The resident, diagnosed with systemic lupus, COPD, and heart failure, had physician orders for continuous oxygen therapy and nebulizer treatments. Similarly, Resident 46's oxygen nasal cannula was found undated and improperly stored. This resident had emphysema and COPD, with orders for oxygen therapy as needed. The facility's policy required respiratory equipment to be stored in plastic bags and dated, which was not adhered to in these cases.
Failure to Document Narcotic Counts
Penalty
Summary
The facility failed to ensure that narcotics were counted and documented every shift for one of the four narcotic count log books reviewed, specifically for the Freedom cart 1. During a medication storage observation of the Freedom hall medication cart, it was noted that the narcotic log book lacked signatures on 8/3/2024, indicating that a narcotic count was not completed. In an interview, QMA 2 confirmed that the narcotic log sheets should have been signed every shift. The Director of Nursing provided the facility's policy on controlled substances, which stated that nursing staff must count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty making the count together.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications on two medication carts, leading to deficiencies in medication management. During an observation of medication storage on Freedom hall med cart 1, a box of Xalanta eye drops was improperly stored with injectable medications. Additionally, a bottle of Colace pills and an opened bottle of Antacid tablets lacked resident identifiers or labels. The Qualified Medication Aide (QMA) acknowledged that the medications should have been labeled and stored correctly. On Freedom hall medication cart 2, three loose pills were found in two drawers, and a bottle of Derma Klenze wound cleanser was stored with liquid medications. Furthermore, two opened and undated bottles of lax granules and an opened package of Ipratropium Bromide ampules lacked resident identifiers. The Licensed Practical Nurse (LPN) confirmed that there should be no loose pills, medications should be labeled, and wound cleansers should not be stored with medications. The facility's policies on medication storage and labeling were provided by the Director of Nursing, indicating the requirements for labeling and storage of medications.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 166 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Warsaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paddock Springs | 0.3 mi | ★★★★★ | 4 | 0 |
| Miller's Merry Manor | 1.1 mi | ★★★★★ | 0 | 0 |
| Mason Health Care Center | 1.8 mi | ★★★★★ | 31 | 0 |
| Grace Village Health Care Facility | 2.8 mi | ★★★★★ | 0 | 0 |
| Waters Of Syracuse Skilled Nursing Facility, The | 13.9 mi | ★★★★★ | 22 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.