Warsaw Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Warsaw Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Dec 9, 2024

  Based on record review, and resident, Physician, Surgical Technician, and staff interviews, the facility failed to leave Resident #4 in place to be assessed by a medical professional following a fall in the facility ' s transportation van. Resident #4 was transported to a medical appointment in the facility transport van and when Transporter #1 arrived at the appointment site and parked, Resident #4 stated he was sliding from his wheelchair. Transporter #1 was not trained for transferring residents and went to back of van and transferred Resident #4 from the floor of the van back into his wheelchair. […]

• Immediate jeopardy, isolatedF689Dec 9, 2024

  Based on observation, record review, and resident, staff and physician interviews, the facility failed to ensure Resident #4 was safely secured in the transportation van. During transport on 11/15/24 Resident #4 reported to the driver, Transporter #1, he felt like he was sliding out of his wheelchair. Transporter #1 had arrived at the resident's doctor's office and came to a complete stop at the front entrance to the appointment location at the time the resident reported this to him. Transporter #1 got into the back of the van and removed the seatbelt securement system. Resident #4 continued to slide down from wheelchair and onto the floor of the van with Transporter #1's assistance. […]

• Immediate jeopardy, isolatedF689Apr 28, 2022

  Based on record review, observation, and staff, family, and police interviews, the facility failed to prevent a severely cognitively impaired resident (Resident #2) with known wandering and exit seeking behaviors from exiting the facility unsupervised. Nurse #1 failed to look for the resident when a wanderguard (a bracelet device that alarms within several feet of doors) was found in the laundry room during the day shift on 2/23/22 which allowed Resident #2 to leave the facility through the front doors on 2/24/22 without the doors alarming and without staff's knowledge. The resident walked approximately 0.2 miles away from the facility when he was observed by a police officer during a routine patrol in the area at approximately 2:30 AM. […]

• Actual harm, isolatedF600Mar 21, 2025

  Based on observation, record reviews, and interviews with Police Officer, staff, Resident, Psychiatric Nurse Practitioner, and Physician, the facility failed to protect a Resident's right to be free from staff to resident abuse perpetrated by Nurse Aide (NA) #3 while giving care to a resident with a history of being combative. On 03/08/2025 during morning rounds, Medication Aide #2 observed Resident #9 in his bed with scratches on the left side of his forehead, side of face, nose and left eye redness (bruising). This affected 1 of 4 Residents reviewed for abuse (Resident #9). The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses including cerebral infarct (stroke). […]

• No harm, potential for more than minimal, widespreadF843Apr 28, 2022

  Based on record review and staff interviews, the facility failed to have a transfer agreement in place for transferring residents to the local hospital for evaluation and treatment, which had the potential to effect 63 of 63 residents who resided in the facility. The findings included: Review of the facility contracts with local entities revealed that the transfer agreement with the local hospital was not executed. During an interview on 4/28/22 at 3:30 PM, the Administrator indicated residents and family were able to choose which hospital they attended. They did not have a transfer agreement with these hospitals. She revealed she had contacted the hospital and they stated they were required to treat anyone coming in under federal law.