Inspection Reports for
Warsaw Meadows

Complaint IN00444009 was substantiated with federal and state deficiencies cited at F686 related to treatment and services to prevent and heal pressure ulcers.

The facility failed to provide appropriate interventions to prevent the development and worsening of pressure ulcers for one resident (Resident B). Observations, record reviews, and interviews revealed inadequate wound care, lack of adherence to physician orders, insufficient skin assessments, and failure to implement recommended pressure-relieving devices and incontinence care.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. Deficiencies included failure to annually review and update the Emergency Preparedness Plan, Policies and Procedures, Communication Plan, Training and Testing Program, and failure to maintain documentation of annual training. Additionally, a ground fault circuit interrupter (GFCI) receptacle was found not functioning properly.

Complaint IN00434526 was investigated during this survey. Federal/state deficiencies related to the allegations were cited at F600 for failure to prevent resident-to-resident abuse.

The facility was found deficient in multiple areas including failure to prevent resident-to-resident abuse, lack of comprehensive person-centered care plans for residents with delusions, hallucinations, and hospice care, failure to hold baseline and routine care plan meetings, inadequate assistance with activities of daily living, failure to provide individualized activities, improper storage and labeling of medications and respiratory equipment, and unsanitary food storage practices.

Complaint IN00421984 was investigated and federal/state deficiencies related to the allegations were cited at F809 regarding the frequency of meals and snacks at bedtime.

The facility failed to ensure bedtime snacks were offered consistently for residents after the evening meal on 4 of 4 halls, potentially affecting 61 of 62 residents. Observations and interviews revealed snacks were not routinely available or offered, and the facility's posted meal times resulted in over 14 hours between the evening meal and breakfast without consistent bedtime snacks.

Complaint IN00419541 - Federal/state deficiencies related to transfer and discharge requirements were cited at F622 and F623.

The facility failed to establish a discharge plan, ensure accurate documentation, and provide timely notice of discharge for a facility-initiated transfer for Resident B. This resulted in the resident inflicting self-harm due to the impending transfer and being discharged without proper discharge planning or 30-day notice.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. Deficiencies included failure to track on-duty staff during emergencies, exit door latching issues, hazardous area enclosure deficiencies, improper use of extension cords, and improper segregation of oxygen cylinders.

Complaint IN00413660 resulted in federal/state deficiencies related to care plan timing and revision (F657). Complaint IN00412823 had no deficiencies cited.

The facility was found deficient in updating resident care plans for falls and skin issues for 2 residents, and in maintaining sanitary food procurement, storage, and preparation practices in the kitchen, including failure to dispose of expired foods and label opened foods.

Complaints IN00394268, IN00398242, IN00401180, and IN00401783 were investigated with no deficiencies related to the allegations cited. The deficiency cited was unrelated to the complaints.

No deficiencies were cited related to the allegations of the complaints; however, an unrelated deficiency was cited regarding failure to supervise a resident with severe cognitive deficits, resulting in the elopement of Resident E.

The facility was found not in compliance with Life Safety Code requirements due to an obstructed and uneven exit discharge walkway at exit door #9. The walkway had holes and loose asphalt patches, posing a safety hazard. The deficiency was previously cited and a systemic plan of correction was not yet fully implemented.

Complaint IN00388965 was substantiated with no deficiencies cited. Complaint IN00390629 was substantiated with federal/state deficiencies cited at F580 and F689 related to failure to notify and inadequate supervision resulting in resident elopement.

The facility failed to notify the resident's representative and local police of a resident's elopement and failed to provide adequate supervision to a resident at high risk for elopement, resulting in the resident leaving the facility unattended and being found a mile away. The facility implemented corrective actions including 1:1 supervision, updated elopement policies, staff education, and monitoring to prevent recurrence.

The facility was found not in compliance with several Life Safety Code requirements including egress door locking mechanisms, corridor obstructions, exit discharge conditions, hazardous area enclosures, interior wall and ceiling finishes, fire alarm system operation, sprinkler system maintenance, portable fire extinguisher installation and maintenance, corridor door integrity, HVAC system air return usage, combustion air intake for fuel-fired equipment, and improper use of extension cords and power strips.

Complaint IN00382515 was substantiated with deficiencies cited at F695 and F677. Complaint IN00381080 was substantiated with deficiencies cited at F689.

The facility was found to have multiple deficiencies including failure to ensure advance directives were properly signed, incomplete transfer/discharge documentation, incomplete baseline and comprehensive care plans, inadequate skin care and compression stocking use, failure to prevent falls and update care plans accordingly, improper medication administration and monitoring, unsanitary food preparation and storage, inadequate infection control practices, and lack of a certified infection preventionist.