Warsaw Rehabilitation and Healthcare Center

Inspectors wroteBased on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of indwelling urinary catheter,hospice care, smoking and prescribed medication, for 4 of 18 residents reviewed for MDS accuracy (Resident #10, #71, #43 and #8). 1. Resident #10 was admitted to the facility on [DATE]. Resident #10 did not have a diagnosis for the use of an indwelling urinary catheter. Review of Resident #10's physician orders did not reveal an order for an indwelling urinary catheter. Resident #10's significant change Minimum Data Set (MDS), dated [DATE], revealed the resident was coded as having an indwelling urinary catheter. A telephone interview was conducted with MDS Coordinator #1 on 6/3/26 at 2:05 PM. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to protect private health information of Resident #37 leaving confidential medical information visible and accessible to the public on an unattended medication cart for 1 of 4 medication carts (unit 4 hall medication cart).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete the annual Minimum Data Set (MDS) to address the preferences of 1 of 18 residents reviewed for MDS accuracy (Resident #45).

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to assist a resident with a bath (Resident #45) and failed to provide showers as scheduled and failed to wash the hair of a resident who was totally dependent on staff assistance for showers and bathing (Resident #4). Resident #4 was observed on 6/1/26 with matted hair on the back of her head and knotted ends of sections that were standing up on the top and sides of her head. This was found for 2 of 26 residents reviewed for activities of daily living (ADL). 1. Resident #4 was admitted to the facility on [DATE] with diagnoses which included anoxic brain damage, persistent vegetative state, other disorders of the autonomic nervous system, and contracture of muscles, multiple sites. [...]

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure a dependent resident's toenails were trimmed and podiatry services were arranged for 1 of 3 residents reviewed for foot care (Resident #9).

Inspectors wroteBased on observation, record reviews, and interviews with Police Officer, staff, Resident, Psychiatric Nurse Practitioner, and Physician, the facility failed to protect a Resident's right to be free from staff to resident abuse perpetrated by Nurse Aide (NA) #3 while giving care to a resident with a history of being combative. On 03/08/2025 during morning rounds, Medication Aide #2 observed Resident #9 in his bed with scratches on the left side of his forehead, side of face, nose and left eye redness (bruising). This affected 1 of 4 Residents reviewed for abuse (Resident #9).

Inspectors wroteBased on record review, and staff and resident interviews, the facility failed to act upon grievances that were reported by the Resident Council, resolve repeat grievances, and to communicate the facility's efforts to address grievances voiced during Resident Council meetings for 6 of 6 consecutive months: October 2024, November 2024, December 2024, January 2025, February 2025 and March 2025.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide a CMS-10055 (Center for Medicare and Medicaid Services) Skilled Nursing Facility Advance Beneficiary notice of Non-Coverage (SNF ABN) prior to discharge from Medicare part A services for 2 of 3 residents (Residents #27 and #280) reviewed for SNF Beneficiary Protection Notification Review.

Inspectors wroteBased on record review and staff interviews, the facility failed to follow and implement abuse policies for identifying and intervening in situations of abuse for 1 of 4 residents reviewed for abuse (Resident #9). When Nurse Aide (Nurse Aide) #2 thought he heard a physical altercation between NA #3 and Resident # 9, NA #2 did not enter the room, did not intervene, or report NA #3. Resident #9 was observed with scratches to his forehead, nose and eye. His eye was swollen and it would not fully open.

Inspectors wroteBased on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of level II Preadmission Screening and Resident Review (PASRR) for 1 of 3 residents (Resident #57) reviewed for PASRR.

Inspectors wroteBased on observation, record review, resident, and staff interviews, the facility failed to apply a left-hand splint for 1 of 3 sampled residents reviewed for limited range of motion (Resident #3).

Inspectors wroteBased on record review, and staff, Pharmacist, Nurse Practitioner and Medical Director interviews the facility failed to document the continuing need of a psychotropic medication in the Electronic Medical Record for 1 of 2 residents reviewed for psychotropic medication (Resident #34).

Inspectors wroteBased on record review, staff, pharmacist, and police interviews the facility failed to protect residents right to be free from the diversion of a controlled narcotic pain reliever on three occasions for 2 out of 3 residents (Resident #1 and #6) reviewed for narcotic diversion.

Inspectors wroteBased on observation, record review and staff interviews the facility failed to update the care plan to address a resident who was known to keep medication in his room and did not have an order or assessment for self-administration of medication for 1 of 7 (Resident #1) residents reviewed for care plans.

Inspectors wroteBased on observations, record review and staff interviews the facility failed secure medications observed at bedside for 1 of 1 resident reviewed for medication storage (Resident #1).

Inspectors wroteBased on record review, and resident, Physician, Surgical Technician, and staff interviews, the facility failed to leave Resident #4 in place to be assessed by a medical professional following a fall in the facility ' s transportation van. Resident #4 was transported to a medical appointment in the facility transport van and when Transporter #1 arrived at the appointment site and parked, Resident #4 stated he was sliding from his wheelchair. Transporter #1 was not trained for transferring residents and went to back of van and transferred Resident #4 from the floor of the van back into his wheelchair. Transporter #1 did not inform the facility about the fall until he returned Resident #4 to the facility from his follow up appointment with the surgeon for a left leg above the knee amputation completed on 10/12/24. [...]

Inspectors wroteBased on observation, record review, and resident, staff and physician interviews, the facility failed to ensure Resident #4 was safely secured in the transportation van. During transport on 11/15/24 Resident #4 reported to the driver, Transporter #1, he felt like he was sliding out of his wheelchair. Transporter #1 had arrived at the resident's doctor's office and came to a complete stop at the front entrance to the appointment location at the time the resident reported this to him. Transporter #1 got into the back of the van and removed the seatbelt securement system. Resident #4 continued to slide down from wheelchair and onto the floor of the van with Transporter #1's assistance. Transporter #1 stated Resident #4 was almost at the very edge of the wheelchair when he went to assist, and he felt that Resident #4 would have continued to slide if the seatbelt had not been removed. [...]

Inspectors wroteBased on a lunch meal tray line observation, staff interviews and record review the facility failed to follow the approved menu in that pureed bread was not served to 6 of 6 residents on a minced and moist diet and 5 of 5 residents on a pureed diet. Residents on a pureed diet only received one scoop of pureed meat instead of 2 scoops per the menu. This had the potential to affect 11 residents with diet orders for minced and moist and pureed texture diets.

Inspectors wroteBased on record review, observations, staff and resident interviews, and test tray, the facility failed to provide palatable food to residents on a regular diet that was appetizing in temperature for 1 of 1 meal reviewed for food palatability. This failure had the potential to affect 58 residents on a regular diet.