Deficiencies (last 4 years)
Deficiencies (over 4 years)
23.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
467% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
100% occupied
Based on a January 2025 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 31, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging verbal abuse of a resident by a Certified Nursing Assistant (CNA).
Complaint Details
This citation is related to Complaint 2691463. The allegation of verbal abuse was substantiated with delays in reporting by staff members.
Findings
The facility failed to timely report an allegation of verbal abuse involving Resident B and CNA 4. The investigation confirmed delays in reporting the incident to proper authorities and the Administrator suspended the involved staff pending investigation.
Deficiencies (1)
F 0609: The facility failed to timely report suspected verbal abuse involving Resident B by CNA 4, delaying notification to the Administrator and State Survey Agency. The abuse policy requires immediate reporting within two hours for abuse allegations.
Report Facts
Residents reviewed for abuse: 3
Incident Number: 652
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Reported the verbal abuse incident and failed to report it timely to the Administrator |
| CNA 4 | Certified Nursing Assistant | Alleged to have verbally abused Resident B |
| Employee 2 | Notified the Administrator of the abuse allegation | |
| Employee 5 | Weekend Manager | Was not notified of the abuse allegation at the time it occurred |
| Administrator | Received delayed report of abuse and initiated investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 1, 2025
Visit Reason
The investigation was conducted due to allegations of physical and emotional abuse involving residents at the facility.
Complaint Details
The complaint investigation substantiated that Resident B assaulted Resident C physically and emotionally, causing bruising and trauma, and verbally threatened Resident D. Staff failed to implement interventions and supervision to prevent these incidents.
Findings
The facility failed to prevent physical and emotional abuse for 2 of 3 residents reviewed, resulting in one resident sustaining extensive bruising and two residents experiencing mental anguish and fear. Staff did not implement planned interventions or one-to-one supervision to prevent further abuse.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical and emotional abuse. Resident B physically assaulted Resident C causing extensive bruising and emotional trauma, and verbally threatened Resident D resulting in emotional distress. Staff did not follow care plans or implement one-to-one supervision to prevent abuse.
Report Facts
Residents affected: 3
Bruise measurements: Multiple bruises on Resident C with sizes ranging from 1cm x 1cm to 11cm x 6.5cm
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding awareness and supervision related to abuse incidents |
| Executive Director | Executive Director | Interviewed regarding knowledge and response to abuse incidents |
Inspection Report
Routine
Deficiencies: 10
Date: Sep 8, 2025
Visit Reason
Routine state inspection of Warsaw Meadows nursing home to assess compliance with healthcare regulations, including medication management, abuse reporting, care planning, and food safety.
Findings
The facility was found deficient in multiple areas including failure to obtain timely consent for psychotropic medication, failure to report and investigate abuse allegations, incomplete and untimely care plans, failure to follow physician orders for medications and bowel protocols, inadequate supervision and elopement risk management, failure to provide trauma-informed care for a resident with PTSD, and unsanitary food storage and handling practices.
Deficiencies (10)
F 0552: The facility failed to ensure timely consent for psychotropic medication use for 1 of 5 residents reviewed, with consent obtained after medication administration had begun.
F 0609: The facility failed to timely report an allegation of abuse and failed to investigate the incident fully for 1 of 2 residents reviewed for abuse.
F 0610: The facility failed to respond appropriately to an alleged abuse incident by not conducting a thorough investigation or documenting findings for 1 of 2 residents reviewed.
F 0656: The facility failed to develop a person-centered care plan for PTSD and failed to develop a care plan after hospitalization with new anticoagulant medication and severe anemia for 2 of 21 residents reviewed.
F 0657: The facility failed to ensure residents were invited to care plan meetings and that meetings were held timely for 5 of 21 residents reviewed.
F 0684: The facility failed to follow physician orders for hypotensive medication administration, bowel protocols, insulin administration, and failed to assess and document a skin issue for 4 of 18 residents reviewed.
F 0689: The facility failed to ensure physician orders for elopement risk were in place and followed for 1 of 2 residents reviewed for elopement risk.
F 0699: The facility failed to provide culturally competent trauma-informed care to a resident with PTSD, lacking specific interventions and staff education regarding triggers and visitation restrictions.
F 0755: The facility failed to ensure physician ordered medications were available for administration for 1 of 5 residents reviewed for medications.
F 0812: The facility failed to store and serve food in a sanitary manner, including undated and expired foods and improper handling practices in the kitchen and nutritional pantries.
Report Facts
Medication not administered: 12
Care plan meetings missing resident invitation: 5
Expired food items: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 8 | Reported abuse incident involving Resident 18 and described resident behaviors. | |
| Director of Nursing | Director of Nursing | Interviewed regarding consent for psychotropic medication, abuse investigation, medication administration, and policies. |
| Administrator | Administrator | Interviewed regarding abuse incident reporting and investigation. |
| QMA 18 | Witnessed abuse incident and reported to management. | |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan development and resident invitations. |
| RN 6 | Interviewed regarding medication administration and elopement risk. | |
| QMA 10 | Reported resident behaviors and medication availability issues. | |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and sanitation issues. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 23, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a resident accessing and ingesting drain cleaner stored unsecured in the memory care unit, resulting in actual harm.
Complaint Details
This citation relates to Complaint IN002563532 3.1-45(a)(1). The complaint was substantiated as the resident ingested drain cleaner due to unsecured chemical storage, causing actual harm.
Findings
The facility failed to ensure cleaning chemicals were securely stored, allowing a resident with Alzheimer's Disease to ingest drain cleaner, causing pain, nausea, vomiting, and requiring emergency room treatment including anesthesia for a GI endoscopy. The facility corrected the deficiency prior to the survey by securing chemical storage and implementing systemic safety measures.
Deficiencies (1)
F 0689: The facility failed to ensure cleaning chemicals were securely stored on the memory care unit, resulting in a resident ingesting drain cleaner and suffering actual harm requiring emergency medical treatment.
Report Facts
Residents affected: 1
Date of incident: Jul 10, 2025
Plan of correction duration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Assessed resident, notified physician and Poison Control, coordinated emergency response |
| CNA 1 | Certified Nursing Assistant | Found resident with drain cleaner, intervened and called for assistance |
| QMA 3 | Qualified Medication Aide | Assisted during incident and called RN |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00449821 and IN00450477.
Complaint Details
Complaint IN00449821 - No deficiencies related to the allegations are cited. Complaint IN00450477 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations in complaints IN00449821 and IN00450477 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 57
Total Capacity: 57
Medicare Census: 2
Medicaid Census: 53
Other Payor Census: 2
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00444009 completed on 2024-12-20.
Complaint Details
The visit was complaint-related for Complaint IN00444009, and the facility was found to be in compliance.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 20, 2024
Visit Reason
The inspection was conducted in response to complaint IN00444009 concerning the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in a resident.
Complaint Details
Complaint IN00444009 related to inadequate pressure ulcer care and prevention for Resident B was substantiated based on observations, record reviews, and interviews.
Findings
The facility failed to provide appropriate interventions to prevent and treat pressure ulcers for Resident B, who developed multiple stage 2 and stage 3 pressure ulcers. Observations and interviews revealed inconsistent application of prescribed treatments, lack of proper incontinence care, and failure to implement wound clinic recommendations.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident B. Multiple stage 2 and stage 3 pressure ulcers were documented with inadequate treatment adherence and lack of pressure-relieving devices in place.
Report Facts
Pressure ulcer measurements: 0.6
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 1.7
Pressure ulcer measurements: 0.3
Pressure ulcer measurements: 0.7
Pressure ulcer measurements: 1.4
Pressure ulcer measurements: 0.6
Pressure ulcer measurements: 1.2
Incontinence change time: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 2 | Licensed Practical Nurse | Interviewed regarding skin assessment and treatment application for Resident B |
| QMA 3 | Qualified Medication Aide | Interviewed about shower sheets and skin condition communication for Resident B |
| CNA 4 | Certified Nursing Assistant | Interviewed about showering Resident B and use of shower sheets |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 1
Date: Dec 20, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00444009 regarding federal and state deficiencies related to pressure ulcer care.
Complaint Details
Complaint IN00444009 was substantiated with federal and state deficiencies cited at F686 related to treatment and services to prevent and heal pressure ulcers.
Findings
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.
Deficiencies (1)
Failure to provide appropriate interventions to prevent pressure ulcers for Resident B.
Report Facts
Census: 57
Total Capacity: 57
Pressure Ulcer Measurements: 0.6
Pressure Ulcer Measurements: 1.2
Pressure Ulcer Measurements: 0.1
Pressure Ulcer Measurements: 2
Pressure Ulcer Measurements: 1
Pressure Ulcer Measurements: 0.1
Pressure Ulcer Measurements: 0.4
Audit Frequency: 5
Audit Frequency: 1
Audit Frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan A Jackson | Administrator | Signed the inspection report |
| LPN 2 | Nurse who admitted not visually assessing Resident B's buttock and leaving treatment cream application to CNAs | |
| QMA 3 | Reported use of shower sheets and communication of skin conditions to nurses | |
| CNA 4 | Provided showering assistance to Resident B and used shower sheets to communicate skin issues |
Inspection Report
Follow-Up
Census: 63
Capacity: 80
Deficiencies: 0
Date: Oct 16, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 08/29/24.
Findings
At this Post Survey Revisit, Warsaw Meadows was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare and Medicaid. The facility was fully sprinklered except for certain detached storage areas.
Report Facts
Certified beds: 80
Census: 63
Emergency generator capacity: 50
Inspection Report
Re-Inspection
Census: 80
Capacity: 80
Deficiencies: 0
Date: Oct 2, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and to the Investigation of Complaint IN00434526 completed on August 13, 2024.
Complaint Details
Complaint IN00434526 was investigated and found to be corrected.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 483, subpart B and with 410 IAC 16.2-3.1 in regards to the PSR to the Recertification and State Licensure Survey and the Investigation of Complaint IN00434526.
Report Facts
Census SNF/NF beds: 80
Total Census: 80
Medicare Census: 3
Medicaid Census: 58
Other Payor Census: 19
Inspection Report
Life Safety
Census: 62
Capacity: 80
Deficiencies: 7
Date: Aug 29, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 08/29/2024.
Findings
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.
Deficiencies (7)
Failed to review and update the Emergency Preparedness Plan at least annually.
Failed to review and update the Emergency Policies and Procedures at least annually.
Failed to review and update the Communications Plan at least annually.
Failed to ensure the emergency communication plan includes names and contact information for staff, entities providing services under arrangement, patients' physicians, and volunteers.
Failed to review and update the Emergency Preparedness Program Testing and Training program at least annually.
Failed to show documentation of annual training conducted for the Emergency Preparedness Program.
Failed to ensure 1 of 1 ground fault circuit interrupter (GFCI) was properly maintained for protection against electric shock.
Report Facts
Certified beds: 80
Census: 62
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan A Jackson | Administrator | Named in relation to exit conference and review of findings |
| Maintenance Director | Interviewed regarding Emergency Preparedness Plan and GFCI receptacle findings |
Inspection Report
Recertification
Census: 69
Capacity: 69
Deficiencies: 10
Date: Aug 13, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00434526.
Complaint Details
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.
Findings
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.
Deficiencies (10)
Failed to implement effective interventions to prevent physical and verbal Resident to Resident abuse from recurring.
Failed to ensure a comprehensive person-centered plan of care was created for residents with delusions, hallucinations, and hospice care.
Failed to provide a baseline care plan meeting and routine care plan meeting for a resident.
Failed to provide adequate activities of daily living (ADL) care including showering, grooming, and shaving assistance.
Failed to implement an individualized activities program for a resident.
Failed to ensure a resident's urostomy drainage bag was covered to maintain dignity.
Failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders.
Failed to ensure narcotics were counted and documented every shift.
Failed to ensure medications were stored appropriately, had resident labels, and medication carts were free of loose pills.
Failed to store food under sanitary conditions related to undated and unlabeled foods and drinks in the kitchen.
Report Facts
Census: 69
Total Capacity: 69
Survey Dates: August 7, 8, 9, 12 & 13, 2024
Narcotic count missing signature: 1
Residents reviewed for care plans: 21
Residents reviewed for ADL care: 3
Residents reviewed for respiratory care: 5
Residents reviewed for narcotic logs: 4
Residents reviewed for medication storage: 2
Residents in facility: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan A Jackson | Administrator | Signed the inspection report |
| QMA 10 | Indicated oxygen tubing should be dated | |
| QMA 2 | Indicated narcotic log sheets should be signed every shift | |
| LPN 3 | Indicated medication labeling and storage issues | |
| Director of Nursing | Provided multiple policies and interviews regarding care deficiencies | |
| Activity Director | Provided information on individualized activities program | |
| Dietary Manager | Provided information on food storage practices |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 13, 2024
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to care planning, activities of daily living, medication management, respiratory care, food storage, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive person-centered care plans for residents with delusions, hallucinations, and hospice care; inadequate care planning meetings; insufficient assistance with activities of daily living; improper storage and labeling of medications; failure to cover urostomy drainage bags; improper respiratory equipment storage and labeling; and unsanitary food storage practices in the kitchen.
Deficiencies (9)
F 0656: The facility failed to develop and implement comprehensive person-centered care plans for residents with delusions, hallucinations, and hospice care needs.
F 0657: The facility failed to provide baseline and routine care plan meetings for 1 of 3 residents reviewed for care planning.
F 0677: The facility failed to provide adequate assistance with activities of daily living including showering, nail and hair care for 3 residents reviewed.
F 0679: The facility failed to implement an individualized activities program for 1 of 3 residents reviewed for activities.
F 0691: The facility failed to ensure a resident's urostomy drainage bag was covered with a dignity bag for 1 resident reviewed.
F 0695: The facility failed to provide safe and appropriate respiratory care including proper storage, labeling, and provision of respiratory equipment for 3 residents reviewed.
F 0755: The facility failed to ensure narcotics were counted and documented every shift for 1 of 4 narcotic count logs reviewed.
F 0761: The facility failed to ensure medications were stored appropriately, labeled with resident identifiers, and medication carts were free of loose pills for 2 medication carts observed.
F 0812: The facility failed to store food under sanitary conditions related to undated and unlabeled foods and drinks in the main kitchen, potentially affecting all residents.
Report Facts
Residents reviewed for comprehensive care plans: 21
Residents affected by deficiencies: 3
Residents affected by food storage issue: 69
Dates of showers documented: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding care planning, ADL assistance, respiratory care, medication policies, and food storage |
| QMA 2 | Qualified Medication Aide | Observed medication cart and narcotic log deficiencies |
| QMA 10 | Qualified Medication Aide | Interviewed about oxygen tubing labeling and resident preferences |
| LPN 3 | Licensed Practical Nurse | Observed medication cart deficiencies including loose pills and unlabeled medications |
| Activity Director | Activity Director | Interviewed regarding individualized activities program for Resident 1 |
| Social Service Director | Social Service Director | Interviewed regarding care plan meetings for Resident 53 |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage labeling and sanitation |
| Executive Director | Executive Director | Provided food storage policy |
| QMA 15 | Qualified Medication Aide | Interviewed regarding urostomy dignity bag care |
| ADON | Assistant Director of Nursing | Interviewed regarding urostomy dignity bag care and respiratory equipment storage |
| RN 14 | Registered Nurse | Interviewed regarding ADL care for Resident 1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of resident-to-resident abuse involving Resident B and others.
Complaint Details
This Federal tag relates to complaint IN00434526.
Findings
The facility failed to implement effective interventions to prevent recurring physical and verbal abuse by Resident B, resulting in harm to three residents. Multiple incidents of physical contact and aggression by Resident B were documented, with insufficient new interventions added to prevent recurrence.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse by Resident B, which caused harm to three residents. Interventions to prevent recurrence were not effectively implemented.
Report Facts
Residents affected: 3
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Date: Mar 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429400.
Complaint Details
Complaint IN00429400 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 59
Total Capacity: 59
Medicaid Census: 53
Other Payor Census: 6
Inspection Report
Re-Inspection
Census: 62
Capacity: 62
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00419541 completed on 10/13/23.
Complaint Details
Complaint IN00419541 was investigated and found to be corrected.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00419541. The complaint was corrected.
Report Facts
Census: 62
Total Capacity: 62
Medicaid Census: 51
Other Payor Census: 11
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 9, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00421984 completed on November 28, 2023.
Complaint Details
Complaint IN00421984 was investigated and found to be in compliance as of the review date January 9, 2024.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00421984 regarding allegations related to the frequency of meals and snacks at bedtime.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility failed to ensure bedtime snacks were offered consistently for residents after the evening meal on 4 of 4 halls.
Report Facts
Residents affected: 61
Total residents: 62
Meal time lapse: 14
Residents on Independence and Freedom halls: 39
Residents on Liberty hall: 13
Residents on Heritage hall: 10
Individually labeled snack bins on Liberty hall: 8
Individually labeled snack bins on Heritage hall: 7
Sandwiches observed in refrigerator: 5
Small plastic containers with yellow substance: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Jackson | Administrator | Signed the report and provided facility policy titled 'Snacks'. |
| Director of Nursing | Mentioned in interviews regarding snack availability and staff knowledge. | |
| CNA 2 | Interviewed about snack availability on Independence and Freedom halls. | |
| QMA 3 | Interviewed about snack availability and inability to access kitchen. | |
| CNA 4 | Interviewed about snack availability on Liberty hall. | |
| CNA 5 | Interviewed about snack availability on Heritage hall. |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
The inspection was conducted in response to complaint IN00421984 regarding the facility's failure to consistently offer bedtime snacks to residents after the evening meal.
Complaint Details
This concern relates to complaint IN00421984.
Findings
The facility failed to ensure bedtime snacks were offered consistently on 4 of 4 halls, potentially affecting 61 of 62 residents who consumed food in the facility. Observations and interviews revealed snacks were often unavailable or not routinely offered, despite facility policy requiring bedtime snacks to reduce the long interval between dinner and breakfast.
Deficiencies (1)
F 0809: The facility failed to ensure meals and snacks were served according to residents' needs and preferences. Bedtime snacks were not consistently offered on all halls, affecting 61 of 62 residents who consumed food.
Report Facts
Residents affected: 61
Total residents consuming food: 62
Residents on Independence and Freedom Halls: 39
Residents on Liberty Hall: 13
Residents on Heritage Hall: 10
Inspection Report
Complaint Investigation
Census: 60
Capacity: 60
Deficiencies: 0
Date: Nov 3, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00421002, IN00418748, IN00418409, and IN00418108 at Warsaw Meadows.
Complaint Details
Complaints IN00421002, IN00418748, IN00418409, and IN00418108 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. Warsaw Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Report Facts
Census: 60
Total Capacity: 60
Medicare Census: 2
Medicaid Census: 50
Other Payor Census: 8
Inspection Report
Re-Inspection
Census: 62
Capacity: 80
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/11/23.
Findings
At this Post Survey Revisit, Warsaw Meadows was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 2
Date: Oct 13, 2023
Visit Reason
This visit was conducted for the investigation of complaint IN00419541 regarding federal and state deficiencies related to transfer and discharge requirements.
Complaint Details
Complaint IN00419541 - Federal/state deficiencies related to transfer and discharge requirements were cited at F622 and F623.
Findings
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.
Deficiencies (2)
Failure to establish a discharge plan and ensure documentation was accurate and allowed at least 30 days prior to the transfer for a facility initiated transfer and failure to allow a resident to remain in the building when the resident verbalized opposition to the transfer.
Failure to provide timely written notification of facility initiated discharge as required by regulation.
Report Facts
Census: 57
Total Capacity: 57
Discharge notice timeframe: 30
Resident admission date: Aug 10, 2023
MDS assessment date: Aug 28, 2023
Discharge date: Oct 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding discharge planning and facility policies | |
| Social Service Director | Interviewed regarding discharge planning and resident interactions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 13, 2023
Visit Reason
The inspection was conducted in response to complaint IN00419541 regarding the facility's discharge and transfer practices for Resident B.
Complaint Details
Complaint IN00419541 related to inadequate discharge planning and failure to provide timely discharge notice for Resident B.
Findings
The facility failed to establish an adequate discharge plan, did not provide a 30-day notice for a facility-initiated transfer, and discharged Resident B despite his opposition. This resulted in actual harm when the resident inflicted self-harm due to the impending transfer.
Deficiencies (2)
F 0622: The facility failed to establish a discharge plan and ensure documentation was accurate and allowed at least 30 days prior to a facility-initiated transfer. Resident B was discharged despite verbal opposition, resulting in self-harm.
F 0623: The facility failed to provide timely notification of discharge to Resident B, issuing no 30-day notice for a facility-initiated discharge.
Report Facts
Residents Affected: 1
Dates of key events: Discharge planning notes and events occurred between 8/10/2023 and 10/10/2023, with discharge on 10/10/2023.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Named in multiple progress notes regarding discharge planning and resident interactions. | |
| Director of Nursing | Interviewed regarding discharge planning and facility policies. |
Inspection Report
Life Safety
Census: 54
Capacity: 80
Deficiencies: 5
Date: Sep 11, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
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.
Deficiencies (5)
Failed to ensure emergency preparedness policies include a system to track the location of on-duty staff during and after an emergency.
Exit door from the scale room contained two latching mechanisms instead of one, violating means of egress requirements.
Storage room with combustible materials was not protected as a hazardous area because the door did not self-close and latch.
Flexible cords were used as a substitute for fixed wiring in the Liberty Hallway by resident room 36.
Empty oxygen cylinders were not segregated from full cylinders and were not marked to avoid confusion.
Report Facts
Facility capacity: 80
Census: 54
Deficiencies cited: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Jackson | Administrator | Signed the report and is mentioned in the exit conference |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness and life safety code deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to care plan deficiencies and food safety concerns at the nursing home.
Complaint Details
This Federal tag relates to complaint IN00413660.
Findings
The facility failed to update resident care plans for falls and skin issues for 2 residents and failed to maintain proper food storage and sanitation in the kitchen, including unlabeled and expired foods and grease build-up.
Deficiencies (2)
F 0657: The facility failed to develop and update complete care plans within 7 days of comprehensive assessments for residents at risk of pressure ulcers and falls. New interventions were not added to care plans after significant changes in resident conditions.
F 0812: The facility failed to ensure the kitchen 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, potentially affecting all residents eating in the kitchen.
Report Facts
Residents affected: 2
Residents affected: 53
Sutures: 7
Dates: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided information about resident care plan deficiencies and policy | |
| Dietary Manager | Provided information about kitchen food labeling and sanitation issues | |
| Executive Director | Provided current policies on storage areas and cleaning and sanitation of food service areas |
Inspection Report
Annual Inspection
Census: 53
Capacity: 53
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00413660 and IN00412823.
Complaint Details
Complaint IN00413660 resulted in federal/state deficiencies related to care plan timing and revision (F657). Complaint IN00412823 had no deficiencies cited.
Findings
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.
Deficiencies (2)
Failed to update resident care plans for falls and skin issues for 2 of 26 residents reviewed (Residents 29 and B).
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 in the kitchen.
Report Facts
Survey dates: 5
Residents reviewed for care plans: 26
Residents affected by care plan deficiency: 2
Residents potentially affected by kitchen sanitation deficiency: 53
Expired pre-packaged lettuce bags: 2
Random audits for care plan monitoring: 5
Random audits for kitchen sanitation monitoring: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Jackson | Administrator | Signed the report |
| Director of Nursing | Interviewed regarding care plan deficiencies and corrective actions | |
| Dietary Manager | Interviewed regarding kitchen sanitation deficiencies and corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
Paper Compliance Review to the Recertification and State Licensure Survey and Investigation of Complaint IN00413660 completed on August 10, 2023.
Complaint Details
Investigation of Complaint IN00413660.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance Review to the Recertification and State Licensure Survey and Complaint Investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 10, 2023
Visit Reason
The inspection was conducted in response to complaint IN00413660 regarding failure to update resident care plans for falls and skin issues.
Complaint Details
Complaint IN00413660 was substantiated, relating to failure to update resident care plans for falls and skin issues for 2 of 26 residents reviewed.
Findings
The facility failed to update care plans for two residents related to falls and skin issues. Interviews and record reviews confirmed that new interventions were not added to the care plans as required.
Deficiencies (1)
F 0657: The facility failed to develop and update complete care plans within 7 days of comprehensive assessments for residents at risk of pressure ulcers and falls. New interventions related to skin breakdown and fall prevention were not added to the care plans for two residents.
Report Facts
Residents affected: 2
Residents reviewed: 26
Sutures: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided interviews and facility policy related to care plan deficiencies |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 57
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00410822 and IN00406054.
Complaint Details
Complaint IN00410822 and Complaint IN00406054 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00410822 and IN00406054 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 57
Total Census: 57
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 47
Census Payor Type - Other: 9
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 13, 2023
Visit Reason
Paper compliance review related to the investigation of multiple complaints (IN00394268, IN00398242, IN00401180, and IN00401783) completed on March 31, 2023.
Complaint Details
The visit was related to complaint investigations identified by complaint numbers IN00394268, IN00398242, IN00401180, and IN00401783. Compliance was confirmed.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance to the complaint investigation.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 1
Date: Mar 31, 2023
Visit Reason
This visit was conducted for the investigation of four complaints (IN00394268, IN00398242, IN00401180, and IN00401783) related to the facility.
Complaint Details
Complaints IN00394268, IN00398242, IN00401180, and IN00401783 were investigated with no deficiencies related to the allegations cited. The deficiency cited was unrelated to the complaints.
Findings
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.
Deficiencies (1)
Failure to supervise a resident with severe cognitive deficits and wandering behaviors, resulting in the elopement of Resident E.
Report Facts
Census: 51
Total Capacity: 51
Medicare Census: 2
Medicaid Census: 38
Other Payor Census: 11
Incident Number: 523
Elopement Assessment Date: Nov 15, 2023
Care Plan Date: Sep 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Jackson | Administrator | Signed the report |
| Dietary Aide 2 | Witnessed resident knocking on exit door and reported resident outside | |
| CNA 3 | Last staff to see Resident E before elopement | |
| Maintenance Director | Provided information about door alarm malfunction and repairs | |
| Social Service Director | Reported on Social Worker's exit through door and resident retrieval |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 31, 2023
Visit Reason
The inspection was conducted following a complaint related to the elopement of a resident with severe cognitive deficits and wandering behaviors who exited the facility unsupervised.
Complaint Details
The complaint investigation was substantiated as the facility failed to supervise Resident E, who eloped through an unlatched exit door. The door alarm was malfunctioning and repairs were pending. Resident E was at high risk for elopement according to clinical assessments and care plans.
Findings
The facility failed to supervise Resident E, who eloped through an exit door that was found to be unlatched and malfunctioning. The door latch was repaired after the incident, and staff interviews and record reviews confirmed the resident's high risk for elopement and the facility's failure to ensure door security and adequate supervision.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent the elopement of a resident with severe cognitive impairment and wandering behavior.
Report Facts
Residents Affected: 1
Incident Date: Feb 27, 2023
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00393756.
Complaint Details
Complaint IN00393756 was unsubstantiated due to lack of evidence.
Findings
Complaint IN00393756 was unsubstantiated due to lack of evidence. Warsaw Meadows was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Report Facts
Census SNF/NF beds: 63
Census total residents: 63
Census Medicare residents: 3
Census Medicaid residents: 48
Census Other payor residents: 12
Inspection Report
Re-Inspection
Census: 58
Capacity: 80
Deficiencies: 1
Date: Nov 2, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/12/22 was performed to assess compliance with fire safety and licensure requirements.
Findings
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.
Deficiencies (1)
Failed to ensure 1 of 12 exit discharges had an unobstructed level walking surface; exit door #9 had an uneven asphalt walkway with holes and loose patches.
Report Facts
Facility capacity: 80
Census: 58
Number of exit discharges: 12
Residents potentially affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Jackson | Administrator | Named in relation to exit discharge deficiency and exit conference |
| Maintenance Director | Interviewed regarding exit discharge walkway condition |
Inspection Report
Follow-Up
Census: 62
Capacity: 62
Deficiencies: 0
Date: Oct 28, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00390629 completed on 9/24/22.
Complaint Details
Complaint IN00390629 - Corrected.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00390629.
Report Facts
Census: 62
Total Capacity: 62
Medicare Census: 4
Medicaid Census: 48
Other Payor Census: 10
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 2
Date: Sep 21, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00388965 and IN00390629, resulting in a Partially Extended Survey due to Substandard Quality of Care with Immediate Jeopardy.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failed to notify resident's representative and local police department of resident's elopement when aware the resident was missing.
Failed to provide adequate supervision to a resident with disorientation/dementia and known exit-seeking behavior, resulting in elopement.
Report Facts
Survey dates: September 21, 22, 23, and 24, 2022
Census: 59
Total capacity: 59
Resident elopement risk score: 12
Resident medication administration time: 20
Distance resident found from facility: 1
Temperature: 69
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 21, 2022
Visit Reason
Paper Compliance to the Licensure and Recertification Survey and Investigation of Complaints IN00382515 and IN00381080.
Complaint Details
Investigation of Complaints IN00382515 and IN00381080.
Findings
Warsaw Meadows was found to be in compliance with 42 CFR Part 83, Subpart B and 410 IAC 16.2-3.1 regarding the Paper Compliance to the Licensure and Recertification Survey and Investigation of Complaints IN00382515 and IN00381080.
Inspection Report
Life Safety
Census: 58
Capacity: 80
Deficiencies: 14
Date: Sep 12, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 09/12/2022.
Findings
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.
Deficiencies (14)
Storeroom door in laundry locked with a padlock from outside with no release from inside.
Means of egress through 4 of 12 exit doors were magnetically locked with incorrect codes posted.
Corridor obstructions due to unsecured chairs reducing clear width in 3 of 6 corridors.
Exit discharge from door #9 had uneven, hole-ridden, moss-covered walkway.
Laundry room and kitchen ceilings had unsealed holes and cracks compromising hazardous area enclosures.
Interior wall finishes in dining room and ADON office lacked documentation of flame spread rating.
Fire alarm control panel had incorrect time and date displayed.
Ceiling holes near sprinklers could delay sprinkler activation.
Portable fire extinguisher in riser room unsecured; K-class extinguisher overcharged in kitchen.
Quiet room corridor door had holes compromising smoke and fire resistance.
Four of five fuel-fired water heaters lacked current inspection certificates.
Three egress corridors used as return air plenums for HVAC system.
Laundry room fuel-fired dryers had fresh air intake blocked by a blanket.
Extension cords used as substitute for fixed wiring in resident rooms; power strips used for high power draw equipment.
Report Facts
Beds: 80
Census: 58
Exit doors with locking issues: 4
Corridors with obstructions: 3
Exit discharge door with uneven walkway: 1
Fuel-fired water heaters without current inspection: 4
Egress corridors used as HVAC return air plenums: 3
Rooms with extension cords: 3
Power strips used for high power draw equipment: 2
Inspection Report
Recertification
Census: 60
Capacity: 60
Deficiencies: 18
Date: Aug 8, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey including the Investigation of Complaints IN00382515 and IN00381080.
Complaint Details
Complaint IN00382515 was substantiated with deficiencies cited at F695 and F677. Complaint IN00381080 was substantiated with deficiencies cited at F689.
Findings
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.
Deficiencies (18)
Failed to ensure an Advanced Directive was in place and signed by the physician for 1 of 24 charts reviewed.
Failed to provide Transfer/Discharge Form for 2 of 6 residents reviewed for discharge and hospitalization.
Failed to provide hospital transfer form and transfer discharge paperwork for 1 of 3 residents reviewed for hospitalization.
Failed to develop and implement a baseline care plan for 3 of 22 residents reviewed for care plans.
Failed to develop and implement a comprehensive care plan for 5 of 19 sampled residents.
Failed to ensure appropriate skin care treatment for 1 of 1 resident and failed to ensure compression stockings were properly sized and worn for 1 of 1 resident.
Failed to ensure discharge planning was developed for 1 of 2 residents reviewed for discharge.
Failed to provide grooming/shaving and oral care assistance for 1 of 3 residents reviewed for ADL assistance.
Failed to ensure proper respiratory/tracheostomy care and sanitary maintenance of oxygen equipment and supplies for 4 residents reviewed for oxygen use and 1 resident reviewed for tracheostomy care.
Failed to ensure a criminal history inquiry was completed for 1 of 5 newly hired employees and failed to ensure physical examinations were completed by a physician or nurse practitioner for 3 of 5 newly hired employees.
Failed to ensure medication monitoring and care planning for medications for 1 of 5 residents reviewed for medications.
Failed to ensure insulin pen was primed prior to administration for 1 of 6 residents observed receiving medications.
Failed to ensure fortified mashed potatoes recipe was followed for 1 of 4 residents reviewed for nutrition.
Failed to ensure food procurement, storage, preparation and serving were sanitary including dated/labeling of food, disposal of expired food, cleanliness of kitchen equipment and storage, and proper drying of dishes.
Failed to ensure infection control protocols were followed for aerosol treatments including proper PPE use for 1 of 3 nursing staff observed.
Failed to ensure a certified Infection Preventionist was on staff responsible for the facility's infection control program.
Failed to ensure residents were free from major injury from falls and failed to update care plans after falls for 2 of 3 residents reviewed for falls.
Failed to ensure significant weight loss was prevented for 1 of 4 residents reviewed for nutrition.
Report Facts
Census: 60
Total Capacity: 60
Deficiencies cited: 17
Weight loss percent: 21.17
Blood glucose: 380
Fall Risk Evaluation score: 10
Fall interventions reviewed: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 12 | Licensed Practical Nurse | Observed administering insulin and aerosol treatment with infection control deficiencies |
| Director of Nursing | Director of Nursing | Responsible for infection control, fall follow-up, and care plan oversight |
| Admissions Director | Admissions Director | Interviewed regarding missing advance directive |
| Social Service Director | Social Service Director | Responsible for transfer/discharge forms and care conferences |
| Medical Record Coordinator | Medical Record Coordinator | Responsible for transfer/discharge form uploads |
| MDS Coordinator | MDS Coordinator | Responsible for care plan development and monitoring |
| Human Resources Manager | Human Resources Manager | Interviewed regarding employee files and criminal history checks |
| Cook 4 | Cook | Interviewed regarding food preparation and sanitation |
| Cook 5 | Cook | Interviewed regarding food preparation and sanitation |
| Unit Manager | Unit Manager | Performed trach button care with improper technique |
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