Warsaw Meadows

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 24, 2022

  Based on observation, interview and record review, the facility failed to provide supervision to a resident with disorientation/dementia due to a brain mass, with known exit seeking behaviors and identified as an elopement risk, resulting in an elopement of 1 of 3 residents reviewed, who were at risk for elopement. The immediate jeopardy began, on 9/18/22 at 8:14 P.M., when the facility failed to ensure a system was in place, to prevent the elopement of a resident, who had a history of exit seeking wandering, prior to admission, and deemed a high risk for elopement upon admission related to aimless wandering, and expression of a desire to go home, as a result the resident was able to exit the facility where he was found a mile from the facility and taken to a local hospital by a local… […]

• Actual harm, isolatedF600Oct 1, 2025

  Based on observation, record review and interview, the facility failed to prevent physical and emotional abuse for 2 of 3 residents reviewed for abuse prevention. (Residents C & D) This deficient practice resulted in 1 of 3 residents sustaining extensive bruising (Resident C) and 2 of 3 residents experiencing mental anguish and fear. (Residents C & D)Findings include:1.A record review for Resident B was completed on 9/29/2025 at 10: 46 A.M. Diagnoses included, but were not limited to: schizophrenia, alcohol abuse, epilepsy, drug induced dyskinesia, major depressive disorder and mood disorder.A Quarterly MDS assessment, dated 9/29/2025, indicted Resident B was cognitively intact, transferred independently, received antipsychotic, antidepressant and anticonvulsant medication, had exhibited… […]

• Actual harm, isolatedF689Jul 23, 2025

  Based on record review, observation and interview, the facility failed to ensure cleaning chemicals were stored securely on the memory care unit. This failure resulted in a resident with Alzheimer's Disease and dementia that accessed an unlocked water conditioner closet, handling and ingesting drain cleaner. The resident suffered pain, nausea, vomiting and required emergency room services, that included undergoing anesthesia for a gastro-intestinal (GI) endoscopy procedure to evaluate for damages. This affected 1 of 3 residents reviewed for accidents, (Resident B). […]

• Actual harm, isolatedF600Aug 13, 2024

  Based on record review and interview, the facility failed to implement effective interventions to prevent physical and verbal Resident to Resident abuse from recurring. This deficient practice resulted in Resident B exhibiting physically abusive behaviors which caused harm to 3 of 3 residents reviewed for abuse. (Residents C, D, & E) Findings included: 1. On 8/13/2024 at 1:37 P.M., a review of a facility reported incident 8/13/2024 at 1:37 P.M., indicated the following: Incident date: 5/29/2024 at 6:30 P.M. Residents involved: Resident C with the diagnoses of dementia with mood disorder, depression and anxiety. Resident B with the diagnoses of Alzheimer's disease, psychotic disorder with delusions, depression and dementia with agitation. […]

• Actual harm, isolatedF622Oct 13, 2023

  Based on record review and interviews, the facility failed to establish a discharge plan and to ensure documentation was accurate and allowed at least 30 days prior to the transfer for a facility initiated transfer and failed to allow a resident to remain the building when the resident verbalized opposition to the transfer for 1 of 3 discharged records reviewed. (Resident B) This deficient practice resulted in the resident inflicting self harm due to the impending transfer. Finding includes: The record for Resident B was reviewed on 10/13/2023 at 9:45 A.M. […]