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 Aspire Senior Living Warsaw during CMS and state inspections, most recent first.
Two residents with cognitive impairment and significant physical needs were subjected to rough, forceful transfers by a CNA who did not use a gait belt or follow proper protocols, resulting in physical and psychological distress. Staff witnesses reported the CNA's angry and aggressive behavior, and documentation confirmed that the transfers were performed in a manner inconsistent with the residents' care plans and facility policy.
The facility failed to maintain a complete water management program, failed to complete an annual review of its IPCP policies, failed to use EBP for two residents who required it, and failed to provide colostomy care using infection control practices. Observations showed out-of-range chlorine results without documented corrective action, missing EBP signage and staff not wearing gowns or gloves during high-contact care, and a CNA placing clean supplies on a bed, using the same soiled gloves for dirty-to-clean tasks, and handling dirty scissors without cleaning them.
Delayed Refunds of Resident Funds After Discharge: Facility staff failed to refund discharged residents’ funds within the required timeframe for 16 of 50 sampled residents. An aging report showed the facility was holding $17,578.26 in resident money in the operating account, and interviews confirmed the FSA and Financial Specialist knew refunds were behind, with some delays tied to copay finalization and others due to staffing/workload issues. The Administrator acknowledged some refunds were overdue by months, including discharges dating back to Dec. 2024.
Facility staff failed to ensure accurate insulin administration for one resident when an LPN primed an insulin pen needle, removed it, and then used a new needle without re-priming. Staff also failed to accurately transcribe a verbal insulin order for another resident, leaving conflicting insulin doses in the record and no progress note for the change. In addition, staff failed to document an appropriate diagnosis for lorazepam use for a resident whose record listed depression but no anxiety diagnosis.
A resident with severe cognitive impairment and behavioral symptoms was subjected to physical and sexual abuse when a CNA pinched and twisted the resident's chest in the presence of two other staff members. The incident occurred while the resident was in bed, and the CNA did not provide care but instead engaged in inappropriate conduct after the resident reportedly grabbed at the CNA. The facility's policy prohibits such actions, but the resident was not protected from abuse.
A resident with osteoporosis was improperly moved in bed by a nursing aide, resulting in bruising and rib fractures. The facility's policy requires two staff members and a draw sheet for such maneuvers, which was not followed. The incident was reported by an RN, and the DON was notified. The resident experienced discomfort, and X-rays confirmed rib fractures. Staff interviews confirmed the deviation from standard procedure.
The facility did not employ a full-time qualified dietitian or clinically qualified nutrition professional, resulting in the Dietary Supervisor (DS) lacking necessary qualifications. The DS had not started Certified Dietary Manager (CDM) classes or other food safety manager courses, and the facility struggled to find a Certified Dietary Manager. The administrator believed the DS had a year to obtain the CDM credential, leading to inaction on alternative solutions.
The facility failed to allow sanitized dishes to air dry before stacking, as observed with Dishwasher Q handling wet dishes. Additionally, a crack in the kitchen ceiling above the food prep area was not repaired, despite being known for over a year. The Registered Dietician and maintenance director acknowledged these issues, but corrective actions were not implemented.
Facility staff failed to follow infection control protocols, including hand hygiene and PPE use, leading to potential bacterial spread among residents. Staff did not change gloves or wash hands during care, and appropriate PPE was not worn for residents with wounds. Additionally, precaution signs were not posted on resident doors, contributing to the oversight. The DON acknowledged the responsibility for ensuring these signs were posted.
The facility failed to maintain a safe, clean, and homelike environment, with observations of damaged and unsanitary conditions in resident rooms and bathrooms. Issues included loose bathroom door guards, stained floors, chipped paint, and improperly reported maintenance needs. Staff reported damages verbally, but the maintenance supervisor and DON emphasized using the electronic system for tracking repairs.
A resident accused an LPN of making threats with medications, but the facility failed to investigate the allegation promptly. The incident was not reported to DHSS within the required timeframe, and the investigation only began weeks later during a chart audit. The Administrator, who was on vacation, did not ensure the report was made, and the LPN did not fully inform the DON about the incident.
Facility staff failed to develop comprehensive care plans for several residents, missing critical information and interventions. Observations showed residents with raised bed rails not reflected in care plans. Interviews revealed CNAs were unaware of care plan specifics, indicating a disconnect between assessments and care. The DON and Administrator acknowledged the deficiencies, noting care plans should be updated by the MDS nurse, but current access issues may contribute to oversight.
The facility failed to provide adequate personal hygiene and care for several residents, resulting in observations of greasy hair, long fingernails, body odor, and facial hair. Residents reported not receiving showers for extended periods, and staff interviews revealed understaffing as a contributing factor. The facility's policies on hygiene and grooming were not followed, leading to dissatisfaction among residents and inadequate care.
Facility staff failed to provide daily activities for residents on the secured unit, as scheduled activities were not conducted. Observations showed residents were often left without engagement, and interviews revealed staffing constraints hindered the consistent provision of activities. The activity director and nursing staff shared responsibility, but activities were not always documented or completed.
Facility staff failed to safely propel two residents in wheelchairs, with one resident's foot dragging on the floor and another without foot pedals. Additionally, the facility did not ensure the employee bathroom door on the secured unit was locked, posing potential hazards. Staff interviews confirmed these unsafe practices.
The facility failed to obtain informed consent and conduct necessary assessments for side rail use for several residents. Observations showed residents using side rails or grab bars without documented consent or assessments, contrary to facility policy. Interviews revealed confusion over responsibility for obtaining consents, with the administrator unable to locate the forms.
The facility failed to obtain timely advance directives for several residents, resulting in inappropriate medical interventions. A resident who elected to be a DNR received CPR due to the absence of a signed directive. The process for obtaining and documenting advance directives was not clearly executed, leading to inconsistencies in residents' medical records.
A resident accused an LPN of threatening them with medication and attempting to kill them. The incident was documented but not reported to DHSS within the required two-hour timeframe, as discovered during a chart audit weeks later. The LPN failed to communicate the full details to the DON, and the administrator, who was on vacation, did not recall the incident.
The facility failed to comply with laws requiring unlimited year history Criminal Background Checks (CBC) for new employees. The contracted company only conducted CBCs within a seven-year timeframe for misdemeanors, while felony checks were as far back as state law allows. The Financial Specialist Assistant, responsible for CBCs, was unaware of the unlimited history requirement, leading to non-compliance.
Failure to Protect Residents from Physical Abuse During Transfers
Penalty
Summary
Facility staff failed to protect two residents from physical abuse when a Certified Nurse Aide (CNA) forcefully transferred them from their beds to their wheelchairs. Multiple staff members, including two CNAs and an LPN, witnessed the CNA acting in an angry and agitated manner, roughly grabbing the residents under their arms and moving them without the use of a gait belt. The transfers were performed quickly and forcefully, causing visible distress and fear in the residents. The CNA did not communicate with the residents during the transfers and did not follow proper transfer protocols as outlined in the residents' care plans. Both residents involved were assessed as cognitively impaired and required extensive assistance with activities of daily living, including transfers. Their care plans specifically required the use of two staff members and a mechanical lift or extensive assistance for transfers, as well as the use of gentleness and clear communication to reduce anxiety and pain. Despite these requirements, the CNA transferred the residents alone, without a gait belt, and in a manner that caused one resident to complain of arm pain and the other to require pain medication for moaning. Staff documentation and resident interviews confirmed that the transfers were performed in a rough and unsafe manner, resulting in physical and psychological distress. The incident was reported by staff who were visibly upset by what they witnessed. The residents' medical histories included dementia, anxiety, depression, osteoarthritis, and osteoporosis, making them particularly vulnerable to injury and distress from improper handling. The facility's own investigation and staff statements corroborated that the CNA's actions violated established safety protocols and resident rights, directly leading to the deficiency.
Infection Prevention, Water Management, EBP, and Colostomy Care Deficiencies
Penalty
Summary
The facility failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of its water systems to inhibit the growth of waterborne pathogens and reduce the risk of Legionella exposure. The facility’s Water Management Program policy required a water management team, facility-specific risk analysis, control measures, and corrective actions when monitoring was outside established limits, but the program did not contain facility-specific risk areas or corrective actions for out-of-range control measures. Review of the facility’s water management documentation showed daily water flow testing tasks and semiannual pH and free chlorine checks, and results from chlorine testing showed 24 of 38 sampled areas were outside the specified range without documentation of corrective action or water management team review. During interview, the maintenance director stated he/she was not aware of the facility-specific Legionella-related policies, was not familiar with the water management team or risk areas, and was not aware of corrective actions when chlorine levels were out of range. The facility also failed to conduct an annual review of its Infection Prevention and Control Program and update policies as necessary. Review of the Infection Prevention and Control Manual, Hand Hygiene policy, Colostomy/Ileostomy Care policy, and Enhanced Barrier Precautions policy showed no documentation that the policies had been reviewed and updated annually. The administrator stated the corporate office was responsible for annual review and updating of policies, and that there was no audit system in place to ensure the review occurred. The facility failed to implement Enhanced Barrier Precautions for two residents who required them. One resident was cognitively intact and had a tracheostomy and feeding tube; staff suctioned the tracheostomy and administered medication through the feeding tube without wearing a gown or gloves. Another resident was cognitively intact, required substantial/maximal assistance for transfers, and had a surgical wound and diabetic foot ulcer; the resident’s room did not have EBP signage, and CNAs assisted with mechanical lift transfers without wearing gowns or gloves. Staff interviews confirmed the signage was missing and that the resident required EBP. The facility also failed to provide colostomy care in a manner that prevented spread of infection for one resident with a colostomy related to colon cancer. During observation, a CNA placed colostomy care supplies directly on the bed without a barrier, used the same soiled gloves while moving from dirty to clean tasks, touched clean supplies with contaminated gloves, and placed dirty scissors on top of the medication cart. The CNA stated he/she should have performed hand hygiene and glove changes after removing the colostomy bag and before touching clean supplies, should not have placed clean supplies on the bed, and should have cleaned the scissors before leaving the room.
Delayed Refunds of Resident Funds After Discharge
Penalty
Summary
Facility staff failed to refund resident funds within 30 days of discharge for 16 residents out of 50 sampled residents. Review of the facility’s resident trust policy showed refunds are to be conveyed upon death or discharge within 30 days or within the timeframe prescribed by state regulation. An aging report dated 09/03/25 showed the facility was holding a total of $17,578.26 in the operating account for these discharged residents, with individual balances ranging from $20.00 to $5,704.00. During interviews, the Financial Specialist Assistant stated he/she oversees resident funds and petty cash and acknowledged there were discharged residents with delayed refunds, explaining that some were waiting for copay finalization while others were simply behind. The Financial Specialist said the facility was behind on processing resident refunds because only one person was handling refunds and business demands and summer vacations caused delays, and stated it was not due to extraordinary events. The Administrator stated refunds should be made within two weeks to 30 days after discharge and after copays are finalized, and acknowledged awareness that some refunds were overdue, including some discharges dating back to December 2024, describing the delay as excessive.
Medication Administration and Order Documentation Deficiencies
Penalty
Summary
Facility staff failed to ensure Resident #3 received an accurate insulin dosage during administration of insulin from a pen device. The resident’s quarterly MDS showed a diagnosis of diabetes mellitus and that the resident received insulin. During observation, an LPN attached a needle to the resident’s insulin pen, primed the needle with two units of insulin, removed that primed needle, applied a new needle, and then administered the insulin without priming the new needle. The LPN stated he/she had been trained to replace the needle after priming, and the ADON and DON stated that changing the needle after priming was not standard practice and could result in inaccurate dosing. Facility staff also failed to accurately transcribe a verbal insulin order for Resident #36 in the eMAR/POS. The resident’s annual MDS showed a diagnosis of diabetes mellitus and that the resident received insulin. Observation showed the resident received 17 units of insulin aspart. The electronic POS contained an order for 20 units after meals with instructions to hold if the resident ate less than 60%, while the paper POS showed 17 units with the same special instruction still stating 20 units. The LPN stated a verbal order had changed the dose from 20 units to 17 units, but the special instruction to give 20 units was not removed, and there was no progress note from the time the order was received. Facility staff also failed to document an appropriate diagnosis for psychotropic medication use for Resident #101. The resident’s POS showed an order for lorazepam 0.5 mg for the treatment of depression, but the record did not contain an anxiety diagnosis. The IP stated staff were required to obtain an appropriate diagnosis for prescribed medication and contact the doctor if one was not present. The administrator and DON stated the resident was admitted from the hospital with lorazepam, staff knew there was not an appropriate diagnosis for the medication, and they kept the medication until the resident became acclimated to the facility.
Failure to Protect Resident from Physical and Sexual Abuse by CNA
Penalty
Summary
Facility staff failed to protect a resident from physical and sexual abuse when a Certified Nursing Assistant (CNA) pinched and twisted the resident's chest. Two nursing assistants witnessed the incident, with one describing the action as physical abuse and the other considering it sexual abuse due to the intimate area involved. The incident occurred while the resident, who has severe cognitive impairment, traumatic brain injury, and behavioral symptoms such as inappropriate comments and sexual inappropriateness, was in bed and being assisted by staff. The CNA in question did not assist with care but instead engaged in the inappropriate conduct after the resident reportedly grabbed at the CNA. The facility's policy strictly prohibits abuse, including physical and sexual abuse, and defines such actions as willful infliction of injury or non-consensual sexual contact. The resident's care plan noted behaviors such as exposing the chest and sexual inappropriateness, with staff directed to use redirection and calm communication. Despite these measures, the CNA's actions violated the policy and resulted in the resident not being protected from abuse.
Improper Resident Handling Leads to Injury
Penalty
Summary
Facility staff failed to properly assist a resident in bed, leading to an injury. A nursing aide (NA) moved the resident by wrapping their arms around the resident and pulling them up in bed, contrary to the facility's policy which requires using a draw sheet and two staff members for such maneuvers. This improper handling resulted in bruising on the resident's left and right sides. The resident, who was cognitively intact and diagnosed with osteoporosis, required two-person assistance for transfers. The resident reported discomfort during the incident, and subsequent X-rays revealed fractures to the sixth and seventh ribs. The facility's investigation revealed that the incident was reported by a registered nurse (RN) to a licensed practical nurse (LPN), who then notified the director of nursing (DON). Interviews with staff confirmed that the standard procedure was not followed, as the resident should have been moved using a draw sheet and with the assistance of two staff members. The nursing aide involved denied the allegations but acknowledged receiving training on proper positioning and moving techniques following the incident. The physician confirmed that the method used to move the resident, combined with their existing medical conditions, could have contributed to the rib fractures.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to designate a qualified Director of Food and Nutrition Services, as they did not employ a full-time qualified dietitian or other clinically qualified nutrition professional. The Dietary Supervisor (DS), who had been in the role for about two months, had not started Certified Dietary Manager (CDM) classes and had not taken any other food safety manager courses. The DS had only attended food safety handling classes four or five years ago and was not provided with a training completion timeline or CDM course enrollment paperwork. The Registered Dietician (RD) confirmed the facility's difficulty in finding a Certified Dietary Manager and stated that the DS was not scheduled for any food service manager training other than the CDM course. The facility administrator acknowledged the challenge in hiring a CDM and believed the DS had one year from the hire date to obtain the CDM credential, thus not considering alternative solutions.
Improper Dish Drying and Ceiling Maintenance Issues
Penalty
Summary
The facility failed to adhere to proper food handling and storage procedures, as observed during a survey. Specifically, the staff did not allow sanitized dishes to air dry before stacking them, which is against the facility's policy. Multiple observations were made where Dishwasher Q stacked wet dishes, including plate covers, plates, cups, sheet pans, service trays, and plate warmers. The Registered Dietician acknowledged the issue, noting that new shelving had been purchased but not installed, which could have facilitated proper air drying. Additionally, the facility did not maintain the kitchen ceiling in good repair, which could potentially lead to food contamination. An open crack was observed along the sheetrock seam above the steam table and food prep counter. Despite being aware of the crack for over a year, the maintenance director had not repaired it, citing difficulty working in the kitchen during cooking hours. The administrator was unaware of the ceiling crack and confirmed that kitchen wares should not be stacked wet, indicating a lack of communication and oversight in addressing these issues.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility staff failed to adhere to infection prevention and control protocols, resulting in the potential spread of bacteria among residents. Specifically, staff did not perform hand hygiene and change gloves during the provision of care for three residents. For instance, a Certified Nurse Aide (CNA) did not change gloves or wash hands after providing perineal care to a resident with a wound, and another CNA failed to perform hand hygiene between glove changes while caring for a resident with a catheter. These actions were contrary to the facility's hand hygiene policy, which mandates handwashing before and after resident contact and between glove changes. Additionally, the staff did not wear appropriate Personal Protective Equipment (PPE) for a resident with a wound, as required by the facility's Enhanced Barrier Precautions (EBP) policy. A CNA entered a resident's room to provide care without donning a gown, despite the resident having a wound that necessitated such precautions. The CNA admitted to not being aware of the EBP requirements and failed to follow the protocol due to being nervous and the resident's resistive behavior. Furthermore, the facility did not post precaution signs on the doors of resident rooms to alert staff and visitors of the necessary precautions for residents requiring EBP. This oversight affected multiple residents with wounds or indwelling medical devices, as their doors lacked the required signage. The Director of Nursing acknowledged the responsibility for ensuring these signs were posted but noted that the task fell on them due to the wound nurse being new. The absence of these signs contributed to staff not following the necessary precautions, as evidenced by the interviews with the staff and the administrator.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of damaged and unsanitary conditions in resident rooms and bathrooms. Specific issues included loose and sharp-edged plastic scratch guards on bathroom doors, heavily stained bathroom floors, chipped paint on doorframes, stained shower tiles, torn privacy curtains, and call lights taped to walls. Additionally, there were gouges and chipped paint on walls, loose baseboards, rust-colored rings in sink bowls, cracked and lifted floor tiles, and black stains in grout lines. Some doors did not close and latch easily, requiring force to shut, and there were chipped floor tiles with gray and black stains. In some bathrooms, sink pipes were wrapped in black tape, tubs under pipes were filled with gray water, and there were gouges and missing baseboards with crumbled drywall. Interviews with facility staff revealed that while CNAs and housekeepers reported damages verbally to the maintenance supervisor, the maintenance supervisor and the Director of Nursing emphasized the importance of using the electronic maintenance tracking system (TELS) for reporting repairs. The maintenance supervisor acknowledged awareness of the needed repairs but noted that staff chose to report issues verbally instead of using the electronic system. The administrator confirmed that the maintenance supervisor was responsible for building repairs and stressed that any immediately dangerous damage should be addressed promptly.
Failure to Investigate Resident's Allegation of Threats
Penalty
Summary
The facility staff failed to conduct a thorough investigation following an allegation made by a resident against an LPN. The resident accused the LPN of making threats with medications after a disagreement over pain management and room conditions. The incident was not reported to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe, as per the facility's policy. The LPN documented the incident in the nurse's notes, but the investigation did not commence until several weeks later when the Regional Nurse and the Director of Nursing (DON) discovered the note during a random chart audit. The Administrator, who was on vacation at the time of the incident, did not recall the conversation with the LPN and did not ensure the report was made to DHSS. The LPN admitted to notifying the Administrator about the resident leaving against medical advice (AMA) but failed to mention the resident's allegations to the DON. The facility's policy mandates immediate reporting of such allegations to the Administrator and relevant state agencies, which was not adhered to in this case.
Deficient Care Planning in LTC Facility
Penalty
Summary
The facility staff failed to develop comprehensive person-centered care plans for five residents, as required by their policy. The care plans were missing critical information and interventions necessary to address the residents' medical and nursing needs. For instance, Resident #17's care plan lacked directions for cognitive loss, activities of daily living (ADL) function, urinary incontinence, and other essential care aspects, despite the resident being assessed with fluctuating cognitive impairment and requiring assistance for mobility. Similarly, Resident #20's care plan did not include directions for ADL function, catheter care, or the use of bed rails, even though the resident was assessed as dependent on staff for all mobility and hygiene. Observations revealed that residents were often found in bed with raised bed rails, yet their care plans did not reflect this intervention. For example, Resident #21 was observed with grab bars in the up position, but the care plan did not provide guidance on their use. Interviews with Certified Nurse Aides (CNAs) indicated a lack of awareness regarding the care plans, as they admitted to not knowing the specifics about side rails for the residents. This lack of knowledge and guidance in the care plans suggests a disconnect between the assessments and the actual care provided. The facility's Director of Nursing (DON) and Administrator acknowledged the deficiencies, noting that care plans should be initiated by the MDS nurse and updated to reflect changes in the residents' conditions. However, the care plans were not consistently updated or accessible to staff, leading to gaps in care. The DON stated that it is their responsibility to ensure staff follow the care plans, but the current system requires CNAs to leave their units to access the plans, which may contribute to the oversight in care delivery.
Inadequate Personal Hygiene and Care in LTC Facility
Penalty
Summary
The facility staff failed to provide appropriate personal hygiene, bathing, and incontinence care for seven residents out of 18 dependent sampled residents. The facility's policies on hygiene and grooming, shaving, and nail care were not adequately followed, leading to residents being observed with greasy, disheveled hair, long fingernails, body odor, and facial hair. Some residents reported not receiving showers for extended periods, and observations confirmed these reports, with residents appearing unkempt and expressing dissatisfaction with their care. Resident #3, who was cognitively intact and required substantial assistance with bathing, was observed with greasy, disheveled hair and reported not having received a shower in over two weeks. Resident #20, also cognitively intact and dependent on staff for personal hygiene, was observed with body odor, long fingernails, and facial hair over several days, expressing a desire to be clean and without facial hair. Resident #21, with a diagnosis of Alzheimer's disease and dependent on staff for personal hygiene, was observed with long fingernails, facial hair, and a saturated brief, indicating inadequate incontinence care. Staff interviews revealed that the facility was understaffed, leading to difficulties in providing the necessary care. CNAs and LPNs acknowledged that showers were not being provided as frequently as required, and the Director of Nursing and Administrator confirmed that the facility was not meeting its care standards. The lack of sufficient staff in the memory care unit was specifically mentioned as a reason for the inadequate care provided to residents.
Failure to Provide Daily Activities for Residents on Secured Unit
Penalty
Summary
The facility staff failed to provide daily activities for residents on the secured unit, as observed on multiple occasions. The facility's policies outlined that activities should be meaningful and consistent with each resident's background and interests, yet observations showed that scheduled activities such as folding laundry, counting numbers, and ring toss were not conducted. Residents were often seen sitting at the dining room table, wandering the halls, or remaining in their rooms without engagement in planned activities. Interviews with staff revealed that the responsibility for conducting activities was shared between the activity director and nursing staff, but due to staffing constraints, activities were not consistently provided. The CNA mentioned that there was usually only one staff member available on the secured unit, which made it challenging to conduct activities while managing other responsibilities like toileting, feeding, and managing resident behaviors. The activity director acknowledged that while a calendar was provided as a guide, activities were not always documented or completed, and the Director of Nursing confirmed that activities were ideally performed once or twice a day, primarily by the activity director.
Unsafe Wheelchair Propulsion and Unlocked Hazardous Area
Penalty
Summary
Facility staff failed to safely propel two residents in wheelchairs, leading to potential accident hazards. Resident #25, who was severely cognitively impaired and required partial assistance for long distances, was observed being propelled by an LPN without foot pedals on the wheelchair. Similarly, Resident #52, who was totally dependent on a wheelchair and diagnosed with Alzheimer's disease and dementia, was observed being moved by another LPN with one foot dragging on the floor. Both LPNs acknowledged the unsafe practice of not using footrests, which was confirmed by the Director of Nursing and the facility administrator. Additionally, the facility failed to maintain a safe environment in the secured unit by not ensuring the employee bathroom door was locked at all times. The unlocked room contained potential hazards such as a mop bucket with water and a toilet, and lacked a call light string for emergencies. Staff interviews revealed that residents often attempted to enter the room, and there was no key available since the locks were changed. The administrator was unaware of the issue, which posed a risk of residents wandering into the room and potentially getting hurt.
Failure to Obtain Consent and Assessments for Side Rail Use
Penalty
Summary
The facility staff failed to obtain informed consent, complete entrapment assessments, and conduct side rail assessments for nine residents who were observed using side rails or grab bars. The facility's policy requires that side rails be addressed in the care plan and that informed consent be obtained from the resident or their representative before use. However, the facility did not provide the necessary assessments or consents upon request, indicating a lack of compliance with their own policy. For Resident #17, the Admission Minimum Data Set (MDS) indicated that the resident required partial to moderate assistance for mobility and did not use side rails or restraints. Despite this, observations showed the resident in bed with side rails raised on multiple occasions, and the medical record lacked a signed consent or assessments for side rail use. Similarly, Resident #20, who was cognitively intact and used grab bars for personal care, also had no documented consent or assessments, yet was observed with grab bars in the raised position over several days. Other residents, including those with cognitive impairments or requiring assistance for mobility, were also observed with side rails or grab bars in use without the necessary documentation or assessments. Interviews with the Director of Nursing and the administrator revealed confusion over responsibility for obtaining consents and maintaining records, with the administrator unable to locate the consent forms. This lack of documentation and assessment poses a significant deficiency in the facility's adherence to safety protocols for side rail use.
Failure to Obtain Timely Advance Directives
Penalty
Summary
The facility failed to obtain timely advance directives for several residents, leading to inappropriate medical interventions. Resident #238, who had elected to be a Do Not Resuscitate (DNR), received cardiopulmonary resuscitation (CPR) because the facility did not have a signed DNR or Full Code directive on file. The resident was admitted on a Thursday, signed a DNR form, but the physician was unavailable to review it until the following Monday, during which time the resident expired and CPR was initiated. The CPR was only stopped after the physician faxed the signed DNR to the facility. This incident highlights a breakdown in communication and procedure regarding the timely processing of advance directives. Additionally, the facility failed to document the code status consistently for three other residents, as their medical records did not contain signed DNR or Full Code directives. Interviews with staff revealed that the responsibility for obtaining and processing advance directives was not clearly executed, with the admissions coordinator and social service designee providing conflicting accounts of their roles. The administrator expected the process to be completed within 24 hours, or by the next business day if over a weekend, but this expectation was not met, leading to the deficiencies noted.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident who claimed that a staff member attempted to kill them. The incident was not reported to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility's policy mandates that all allegations of abuse and instances resulting in serious bodily injury must be reported within two hours. However, the incident, which occurred on June 1, 2024, was not reported to DHSS until June 26, 2024, when it was discovered during a random chart audit by the Regional Nurse and the Director of Nursing (DON). The resident involved had expressed distress and accused an LPN of threatening them with medication and attempting to kill them. The LPN documented the incident in the nurse's notes but failed to report the full details to the DON, only mentioning that the resident left against medical advice (AMA). The administrator, who was on vacation at the time, did not recall the conversation with the LPN and stated that they would have referred the LPN to the DON. The LPN acknowledged receiving training on abuse/neglect reporting and understood the requirement to report such incidents within two hours, yet the report to DHSS was delayed significantly.
Non-compliance with Criminal Background Check Requirements
Penalty
Summary
The facility administration failed to comply with Federal, State, and local laws, regulations, and codes by not conducting unlimited year history Criminal Background Checks (CBC) for all new employees, as required. The facility's policy on Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, and Exploitation, dated 10/24/22, mandates a thorough background investigation, including searching all relevant registries for potential findings of abuse, neglect, mistreatment, exploitation, or misappropriation against potential employees. However, the contracted company responsible for conducting CBCs only searches within a seven-year timeframe for misdemeanor records, while felony convictions are reported as far back as the state allows. During an interview, the Financial Specialist Assistant, who is responsible for completing the CBCs, revealed a lack of awareness regarding the requirement for unlimited year history checks. The assistant stated that the current system, which has been in use for about a year, was implemented following the last survey and is based on corporate instructions. The assistant was unaware that the CBC checks only covered a seven-year period and did not meet the requirement for unlimited history checks, leading to non-compliance with the applicable laws and regulations.
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Lincoln Community Care Center | 10.1 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Care Center | 16.9 mi | ★★★★★ | 0 | 0 |
| Truman Lake Manor Inc | 20.6 mi | ★★★★★ | 7 | 0 |
| Windsor Healthcare & Rehab Center | 21.4 mi | ★★★★★ | 0 | 0 |
| Hermitage Nursing & Rehab | 21.8 mi | ★★★★★ | 13 | 1 |
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