Deficiency Records for Warsaw Meadows
Updated as of August 01, 2020
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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2019-12-10 | 2019-12-23 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-17 | 2019-08-09 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-04-16 | 2019-05-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-16 | 2019-05-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-16 | 2019-05-16 | 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 | 2019-04-16 | 2019-05-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-16 | 2019-05-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-16 | 2019-05-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-04-16 | 2019-05-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-16 | 2019-05-16 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-04-16 | 2019-05-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-16 | 2019-05-16 | 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 | 2019-03-12 | 2019-04-11 | 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 | 2019-03-12 | 2019-04-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-12 | 2019-04-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-03-12 | 2019-04-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-03-12 | 2019-04-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-03-12 | 2019-04-11 | 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 | 2019-03-12 | 2019-04-11 | 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 | 2019-03-12 | 2019-04-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-12 | 2019-04-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-12 | 2019-04-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-12 | 2019-04-11 | 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 | 2019-03-12 | 2019-04-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-03-12 | 2019-04-11 | 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 | 2019-03-12 | 2019-04-11 | N |
| Provide or obtain dental services for each resident. | Health | 2019-03-12 | 2019-04-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-12 | 2019-04-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-12 | 2019-04-11 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-12 | 2019-04-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2019-02-25 | 2019-03-27 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-25 | 2019-03-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-02-25 | 2019-03-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-25 | 2019-03-27 | Y |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-02-25 | 2019-03-27 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-10-10 | 2018-11-09 | Y |
| Post nurse staffing information every day. | Health | 2018-10-10 | 2018-11-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-10 | 2018-11-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-10 | 2018-11-09 | Y |
| 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 |
| 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 necessary and PRN use is limited. | 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 |
| 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 |
| 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 |
