A list of the most recent deficiencies for Warsaw Meadows. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-11-28 | 2023-12-15 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-10-13 | 2023-11-02 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-13 | 2023-11-02 | Y |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-09-11 | 2023-10-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-09-11 | 2023-10-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-09-11 | 2023-10-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-09-11 | 2023-10-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-11 | 2023-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-10 | 2023-08-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-10 | 2023-08-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-31 | 2023-05-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-24 | 2022-10-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-24 | 2022-10-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Have an externally vented heating system. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-12 | 2022-10-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-09-12 | 2022-09-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-08 | 2022-09-09 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-08-08 | 2022-09-09 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-08-08 | 2022-09-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-08 | 2022-09-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-08 | 2022-09-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-08 | 2022-09-09 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-08 | 2022-09-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-08 | 2022-09-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2022-08-08 | 2022-09-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-08-08 | 2022-09-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-08 | 2022-09-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-08-08 | 2022-09-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-08 | 2022-09-09 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-08-08 | 2022-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-08 | 2022-09-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-08-08 | 2022-09-09 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-08-08 | 2022-09-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-08 | 2022-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-08 | 2022-09-09 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-08-08 | 2022-09-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-02 | 2022-03-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-02 | 2022-03-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-02 | 2022-03-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-09 | 2022-03-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-09 | 2022-03-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-09 | 2022-03-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-02-09 | 2022-03-07 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-16 | 2021-12-14 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-16 | 2021-10-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-16 | 2021-10-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Develop a communication plan. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-15 | 2021-07-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-04-30 | 2021-05-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-30 | 2021-05-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-30 | 2021-05-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-04-30 | 2021-05-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-30 | 2021-05-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-30 | 2021-05-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-30 | 2021-05-28 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-04-30 | 2021-05-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-30 | 2021-05-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-30 | 2021-05-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-04-30 | 2021-05-28 | N |
