Deficiency Records for Warsaw Meadows
Updated as of July 01, 2018
This is not the most recent data for Warsaw Meadows. For the most recent information, click here.
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 smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-04-19 | 2018-06-15 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-04-19 | 2018-05-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-03-08 | 2018-04-07 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-03-08 | 2018-04-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-08 | 2018-04-07 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-08 | 2018-04-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-08 | 2018-04-07 | 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 | 2018-03-08 | 2018-04-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-08 | 2018-04-07 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2018-03-08 | 2018-04-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-03-08 | 2018-04-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-03-08 | 2018-04-07 | 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 ne | Health | 2018-03-08 | 2018-04-07 | N |
| 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 | 2018-03-08 | 2018-04-07 | N |
| Provide or obtain dental services for each resident. | Health | 2018-03-08 | 2018-04-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-03-08 | 2018-04-07 | N |
| Respond appropriately to all alleged violations. | Health | 2018-03-08 | 2018-04-07 | Y |
| 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 | 2017-06-12 | 2017-07-12 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2017-06-12 | 2017-07-12 | 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 | 2017-06-12 | 2017-07-12 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Construct fire resistant interior walls. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-06-12 | 2017-07-12 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-05-15 | 2017-06-14 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-05-15 | 2017-06-14 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-05-15 | 2017-06-14 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-05-15 | 2017-06-14 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-05-15 | 2017-06-14 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-05-15 | 2017-06-14 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-05-15 | 2017-06-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-07-19 | 2016-08-08 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-07-19 | 2016-08-08 | Y |
| Provide activities to meet the interests and needs of each resident. | Health | 2016-04-04 | 2016-05-11 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-04-04 | 2016-05-09 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-04-04 | 2016-05-09 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-04-04 | 2016-05-09 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2016-04-04 | 2016-05-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-04-04 | 2016-05-09 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-04-04 | 2016-05-03 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-04-04 | 2016-05-03 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-04-04 | 2016-05-03 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-04-04 | 2016-05-03 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2016-04-04 | 2016-05-03 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-04-04 | 2016-05-03 | N |
