Aspire Senior Living Warsaw

In the surveyor’s words

From the most serious findings on record at Aspire Senior Living Warsaw, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Apr 6, 2021

  Based on observation, interview, and record review, the facility staff failed to routinely assess one resident's skin (Resident #4) under a [NAME] brace (hard brace used to stabilize a fracture to the upper arm while leaving the elbow free, allowing motion in the forearm and hand), causing a Stage IV pressure ulcer to develop to the resident's left upper arm. Furthermore, facility staff failed to notify the resident's physician for two days after the pressure ulcer was identified to obtain treatment orders. In addition, facility staff failed to keep the resident's air mattress set at the recommended setting, causing the mattress to be too firm. […]

• Actual harm, isolatedF600Oct 29, 2025

  Based on interview and record review, facility staff failed to keep two residents (Resident #1 and #2) free from physical abuse when Certified Nurse Aide (CNA) A forcefully transferred the residents from their beds to their wheelchairs. The facility census was 83.The administrator was notified on 10/29/25 of past Non-Compliance, which occurred on 10/22/25 when staff reported the allegation. Staff immediately suspended CNA A pending the results of the investigation; assessed the resident for physical and psychological harm; investigated; in-serviced staff on abuse, neglect, proper transfer techniques, and resident rights; and terminated the employee on 10/28/25. 1. […]

• Actual harm, isolatedF689Nov 4, 2024

  Based on interview and record review, facility staff failed to properly assist one resident (Resident #1) up in bed, when Nursing Aide (NA) B wrapped his/her arms around the resident and moved the resident up in bed, which results in a injury. The facility census was 87. The administrator was notified on 11/1/24 of past Non-Compliance which occurred on 10/24/24. On 10/24/24 it was reported NA B wrapped his/her arms around Resident #1 on 10/23/24, and moved him/her up in bed which resulted in bruising to his/her left and right sides. Upon discovery on 10/24/24, staff started an investigation, inserviced staff on proper techniques for assisting residents while in bed, notified the physician and suspended the NA. Staff corrected the deficient practice on 10/24/24. 1. […]

• Actual harm, isolatedF600Mar 6, 2023

  Based on interview and record review, facility staff failed to ensure one resident (Resident #1) remained free from neglect when Nurse Aide (NA) A attempted to transfer the resident, who staff assessed required assistance from two staff members for safe transfers, without assistance, and without the use of a gait belt, resulting in the resident sustaining a fractured femur. The facility census was 81. The administrator was notified on 3/06/23 of past Non-Compliance which occurred on 2/27/23. On 2/28/23, the administrator identified NA A attempted to transfer Resident #1 without assistance, or the use of a gait belt, resulting in the resident sustaining a fractured femur. […]

• Actual harm, isolatedF600Nov 16, 2022

  Based on observation, interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from physical abuse when a Certified Nursing Assistant (CNA) A grabbed Resident #1 by the left arm, pushed the resident to the bed, and slapped his/her right hand, which resulted in bruises to the resident's arm and hand. The facility census was 83. The administrator was notified on 11/16/2022 of Past Non-Compliance which occurred on 10/31/22. On 10/31/22, the administrator identified Certified Nurse Assistant (CNA) A physically abused Resident #1 when a staff member grabbed and squeezed the resident's left arm, pushed the resident back down to his/her bed, and slapped the resident's right hand, which caused bruises. […]