Warsaw Meadows

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with orders for G-tube feedings (a method of delivering nutrition directly into the stomach using a Gastrostomy tube), post feed flushes, G-tube bag and tubing changes, and G-tube placement checks, were completed and documented by licensed nursing staff. Some QMAs (Qualified Nursing Aide) documented that they had administered G-tube feeding, post feed flushes, G-tube bag and tubing changes, and G-tube placement checks, which was outside of the QMAs' Scope of Practice, for 1 of 1 residents reviewed for G-tube feeding, (Resident B).

Inspectors wroteBased on interviews and record review, the facility failed to implement their policy to report an allegation of verbal abuse in a timely manner for 1 of 3 residents reviewed for abuse, (Resident B).

Inspectors wroteBased on observation, record review and interview, the facility failed to prevent physical and emotional abuse for 2 of 3 residents reviewed for abuse prevention. (Residents C & D) This deficient practice resulted in 1 of 3 residents sustaining extensive bruising (Resident C) and 2 of 3 residents experiencing mental anguish and fear. (Residents C & D)

Inspectors wroteBased on observation, interview and record review, the facility failed to store and serve food in a sanitary manner, related to undated foods, expired foods and thumbing of the plates for 1 of 1 kitchen and 2 of 2 nutritional pantries. This deficient practice had the potential to affect 63 of 63 residents who receive meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to develop a person centered care plan for (Post Traumatic Stress Disorder) PTSD and failed to develop a care plan after a hospitalization with a new initiation of an anticoagulant medication and a diagnosis of severe anemia for 2 of 21 residents reviewed for care plans. (Resident 15 and 6)

Inspectors wroteBased on interview, record review and interview, the facility failed to ensure residents were invited to care plan meetings and meetings were held timely for 5 of 21 residents reviewed for care plans. (Residents 15, 21, 17, 4 & 30)

Inspectors wroteBased on observation, record review and interview, the facility failed to follow a physician's order for a hypotensive medication, failed to administer bowel protocols for constipation, failed to follow physician's orders for insulin administration and failed to assess and document a skin issue for 4 of 18 residents reviewed for care needs. (Residents 5, 3, 7 & 18)

Inspectors wroteBased on record review and interview, the facility failed to ensure a consent for psychotropic medication use was obtained timely for 1 of 5 residents reviewed for psychotropic medications. (Resident 15)

Inspectors wroteBased on interview, observation and record review, the facility failed to report an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident 18)

Inspectors wroteBased on interview, observation and record review, the facility failed to fully investigate an allegation of abuse for 1 of 2 residents reviewed for abuse. (Resident 18)

Inspectors wroteBased on observation and record review, the facility failed to ensure physician orders for elopement risk were in place for 1 of 2 residents reviewed for elopement. (Resident 65)

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident survivor of PTSD (Post Traumatic Stress Disorder) received culturally competent trauma informed care to reduce triggers for behaviors and reduce emotional distress for 1 of 1 residents reviewed for PTSD (Resident 15) The record for Resident 15 was reviewed on 9/4/2025 at 9:53 A.M. Diagnoses included but were not limited to cancer, non-Alzheimer's dementia, anxiety, depression, psychotic disorder, bipolar, schizophrenia and PTSD (post-traumatic stress disorder). An admission MDS (Minimum Data Set) assessment, dated 6/2/2025, indicated Resident 15 had delusions and received the following medications: antipsychotic, antidepressant, anticonvulsant, and opioids. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure physician ordered medications were available for administration for 1 of 5 residents reviewed for medications. (Resident 15)

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure cleaning chemicals were stored securely on the memory care unit. This failure resulted in a resident with Alzheimer's Disease and dementia that accessed an unlocked water conditioner closet, handling and ingesting drain cleaner. The resident suffered pain, nausea, vomiting and required emergency room services, that included undergoing anesthesia for a gastro-intestinal (GI) endoscopy procedure to evaluate for damages. This affected 1 of 3 residents reviewed for accidents, (Resident B). The deficient practice was corrected on 7/11/25, prior to the start of the survey, and was therefore past noncompliance.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide appropriate interventions to prevent the development of pressures ulcers for 1 of 2 residents reviewed for pressure ulcers (Resident B).

Inspectors wroteBased on observation, record review, and interview, the facility failed to store food under sanitary conditions related to undated and unlabeled foods and drinks in 1 of 1 kitchens (Main kitchen). This issue had the potential to affect 69 of 69 residents who resided in the facility and received food from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive person-centered plan of care was created for residents with delusions (Residents 36 & E) a resident with hallucinations (Resident 55), and for a resident receiving hospice care (Resident 16) for 4 of 21 residents reviewed for comprehensive care plans.

Inspectors wroteBased on interview and record review, the facility failed to provide a baseline care plan meeting and routine care plan meeting for 1 of 3 residents reviewed for care planning. (Resident 53)

Inspectors wroteBased on observation, record review and interview, the facility failed to provide activities of daily living (ADLs) regarding shower/bathing opportunities (Residentt 53 and 9) and nail, hair and shaving assistance (Resident 1) for 3 of 3 residents reviewed for ADL care.

Inspectors wroteBased on observation, record review and interview the facility failed to implement an indiviualized activities program for 1 of 3 Residents reviewed for activities. (Resident 1)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a residents' urostomy drainage bag was covered for 1 of 1 resident reviewed for urostomies. (Resident 264)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for 3 of 5 residents reviewed for respiratory care (Resident 30, 46, and 215).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure narcotics were counted and documented every shift for 1 of 4 narcotic count log books reviewed. (Freedom cart 1)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored appropriately, had resident labels, and medication carts were free of loose pills for 2 of 2 medication carts observed.(Freedom medication carts 1 and 2)

Inspectors wroteBased on record review and interview, the facility failed to implement effective interventions to prevent physical and verbal Resident to Resident abuse from recurring. This deficient practice resulted in Resident B exhibiting physically abusive behaviors which caused harm to 3 of 3 residents reviewed for abuse. (Residents C, D, & E)

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure bedtime snacks were offered consistently for residents after the evening meal on 4 of 4 halls. This deficient practice had the potential to affect 61 of 62 residents who consumed food in the facility. (Independence, Freedom, Liberty and Heritage)

Inspectors wroteBased on record review and interviews, the facility failed to establish a discharge plan and to ensure documentation was accurate and allowed at least 30 days prior to the transfer for a facility initiated transfer and failed to allow a resident to remain the building when the resident verbalized opposition to the transfer for 1 of 3 discharged records reviewed. (Resident B) This deficient practice resulted in the resident inflicting self harm due to the impending transfer.

Inspectors wroteBased on record review and interview, the facility failed to ensure a timely notice of discharge was issued for a facility initiated discharge for 1 of 3 discharged residents reviewed. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the spice cabinet and range/oven were free of food debris and grease build-up, failed to dispose of expired foods, and failed to label and date opened foods for 1 of 1 kitchen. This had the potential to affect 53 of 53 residents who ate their food in the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to update resident care plans for falls and skin issue for 2 of 26 residents whose care plans were reviewed. (Resident 29 & B)