Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Warsaw Meadows during CMS and state inspections, most recent first.
A resident with dementia and other conditions was allegedly subjected to verbal abuse by a CNA, who reportedly used profanity during care. The incident was not reported to the Administrator or proper authorities until several days after it occurred, contrary to facility policy requiring immediate reporting of abuse allegations.
A resident with a known history of behavioral issues physically assaulted another resident, causing extensive bruising and emotional trauma, and later verbally abused a second resident, resulting in fear and mental anguish. Staff failed to follow care plan interventions or implement timely supervision, and documentation of required monitoring was lacking.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
A resident at risk for skin breakdown developed multiple pressure ulcers due to inadequate interventions and monitoring. Despite being assessed as at moderate risk, the resident's care plan was not effectively implemented, leading to the development of stage 3 and stage 2 pressure ulcers. The facility failed to adhere to physician orders for wound care and incontinence management, contributing to the worsening of the resident's condition.
A resident with Alzheimer's and other psychiatric disorders repeatedly exhibited aggressive behaviors towards other residents, causing harm. Despite being placed on one-on-one supervision and discharged to a psychiatric hospital twice, the facility failed to implement new interventions to prevent further incidents. The Director of Nursing admitted that no new measures were added, violating the facility's abuse prevention policy.
The facility failed to store food under sanitary conditions in the main kitchen, affecting all residents who received food from this kitchen. Surveyors observed unlabeled and undated food items, including frozen meat patties, beverages, bread products, and juice pitchers. The Dietary Manager confirmed that all food and beverages should be labeled with the name and date, as per the facility's policy.
The facility failed to create comprehensive, person-centered care plans for residents with specific needs, including delusions, hallucinations, and hospice care. Despite being prescribed medications for their conditions, the clinical records for these residents lacked appropriate care plans. The Director of Nursing confirmed these omissions, which were contrary to the facility's policy requiring such care plans.
A resident with multiple health conditions, including diabetes and chronic kidney disease, did not receive a baseline or routine care plan meeting since admission. The resident reported not having access to test results until discharge. The Social Service Director confirmed the lack of scheduled meetings and undocumented interactions, contrary to the facility's policy requiring comprehensive, person-centered care plans.
The facility failed to provide adequate ADL care for three residents, including insufficient showering opportunities and personal hygiene assistance. A resident reported receiving only two showers in over a month, with inconvenient timing leading to refusals. Another resident missed scheduled showers, and a third was observed with poor hygiene despite needing total assistance. The DON was unaware of these issues, and documentation practices were inadequate.
A resident with cerebral palsy and other conditions did not receive an individualized activities program as outlined in their care plan. Observations showed the resident often without entertainment, despite preferences for TV and music. The facility's policy requires programs to meet individual needs, but interviews confirmed the resident's activities were not provided, leading to a deficiency.
A resident with a urostomy was repeatedly observed with an uncovered drainage bag, despite facility policy requiring it to be covered for dignity. Staff interviews confirmed the expectation for coverage, yet the deficiency persisted over several days.
The facility failed to properly label and store respiratory equipment for three residents, leading to deficiencies in respiratory care. A resident received oxygen therapy with undated tubing and without humidification, contrary to physician orders. Two other residents had improperly stored and undated respiratory equipment, despite having specific physician orders for oxygen therapy. The facility's policy required respiratory equipment to be stored in plastic bags and dated, which was not followed.
The facility failed to ensure narcotics were counted and documented every shift for one of the narcotic count log books. An observation revealed that the narcotic log book for Freedom cart 1 lacked signatures, indicating a missed narcotic count. QMA 2 confirmed that the log sheets should have been signed every shift. The facility's policy requires nursing staff to count controlled medications at the end of each shift, with both the incoming and outgoing nurses participating in the count.
The facility failed to properly store and label medications on two medication carts. Observations revealed improperly stored eye drops, unlabeled Colace and Antacid tablets, loose pills, and wound cleanser stored with medications. Staff acknowledged the errors, and facility policies on medication storage and labeling were provided.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to implement its abuse reporting policy by not reporting an allegation of verbal abuse in a timely manner for one resident. Resident B, who had multiple diagnoses including dementia, anxiety, depression, and cognitive communication deficit, was allegedly subjected to verbal abuse by a CNA who reportedly told the resident to "shut the f--- up" while assisting with toileting. The incident occurred on 12/6/25, but was not reported to the appropriate authorities or the Administrator until 12/10/25. CNA 3, who witnessed the event, initially reported it only to the Weekend Manager and did not escalate the allegation to the Unit Manager or Administrator as required by facility policy. Interviews revealed that the Weekend Manager was not made aware of the abuse allegation at the time it occurred, and the Administrator was not informed until four days later. The facility's abuse policy requires immediate reporting of abuse allegations, but this protocol was not followed. The delay in reporting was confirmed through staff interviews and record review, indicating a breakdown in communication and adherence to established procedures for reporting suspected abuse.
Failure to Prevent Resident-to-Resident Abuse and Emotional Distress
Penalty
Summary
The facility failed to prevent both physical and emotional abuse among residents, specifically involving two residents who were subject to abuse by another resident with a known history of behavioral issues. One resident, who had diagnoses including schizophrenia, alcohol abuse, and major depressive disorder, had a care plan in place due to a history of striking out at staff and peers. Despite this, staff did not follow the planned interventions, such as removing the resident from situations at the first signs of agitation and providing a safe space. This failure led to an incident where the resident physically assaulted another resident, resulting in extensive bruising to multiple areas of her body, including her forearm, elbow, breast, palm, wrist, fingers, and shoulders. The assaulted resident, who had a history of PTSD and other psychiatric diagnoses, experienced significant emotional trauma, including fear, crying, shaking, and symptoms that triggered her PTSD. Following the initial physical altercation, the same resident verbally abused and threatened another resident, causing her to experience mental anguish and fear. This resident, who was cognitively intact but had physical disabilities, reported feeling unsafe, kept a grabber stick under her pillow for protection, and expressed distrust in the facility. Staff interviews confirmed that the resident who committed the abuse had a pattern of angry outbursts and altercations, and that staff were aware of his behavioral history. However, one-to-one supervision and other preventative interventions were not implemented until after the second incident of abuse occurred. Documentation and communication lapses were also evident. The DON was not informed of the full extent of the altercations or the interventions that were (or were not) implemented. The executive director was aware of the incidents but could not produce documentation of one-to-one supervision. Staff interviews revealed concerns about the resident's behavior and the adequacy of supervision, but these concerns were not acted upon in a timely manner. The facility's own abuse policy required supervision and intervention for residents with behavioral needs, but these measures were not effectively carried out, resulting in physical harm and emotional distress to two residents.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate interventions to prevent the development of pressure ulcers for a resident identified as being at risk. The resident, who had a history of peripheral vascular disease, diabetes mellitus type 2, heart failure, and lymphedema, was assessed to be at moderate risk for skin breakdown. Despite this, the resident developed multiple pressure ulcers, including a stage 3 ulcer on the left gluteal area, a stage 2 ulcer near the coccyx, and an unstageable wound on the left ischial area. The facility's care plan included interventions such as a pressure relief mattress and assistance with turning and repositioning, but these were not effectively implemented. The resident's pressure ulcers were not adequately monitored or treated according to physician orders. The resident reported that dressings were not changed routinely, and the prescribed treatment cream was not applied as ordered. Additionally, the resident's incontinence care was insufficient, with reports of infrequent brief changes leading to contamination of the wounds with stool. This lack of adherence to the treatment plan and inadequate incontinence management likely contributed to the worsening of the resident's pressure ulcers. Observations revealed that the resident did not have a low air loss mattress in place, contrary to the care plan, and there was no documentation of the resident refusing this intervention. Interviews with staff indicated a reliance on shower sheets for skin assessments, which were not consistently documented or available. The facility's policy on skin and wound management was not followed, as ongoing monitoring and preventative interventions were not effectively implemented for the resident at risk for skin compromise.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement effective interventions to prevent physical and verbal resident-to-resident abuse, resulting in harm to three residents. Resident B, diagnosed with Alzheimer's disease, psychotic disorder with delusions, depression, and dementia with agitation, exhibited physically abusive behaviors towards other residents. On multiple occasions, Resident B made physical contact with other residents, including incidents where he grabbed a resident's walker, causing her to fall, and hit another resident with a photo album. Despite these incidents, the facility did not add new interventions to prevent further occurrences. Resident B's aggressive behaviors were documented in several notes, indicating a pattern of physical and verbal aggression. The facility's records show that Resident B was placed on one-on-one supervision and was discharged to a psychiatric hospital twice, but these measures did not prevent further incidents upon his return. The facility's failure to identify triggers and implement additional interventions contributed to the recurrence of abuse. The Director of Nursing acknowledged that no new interventions were added for Resident B following the altercations. The facility's abuse policy, which mandates processes for screening, training, prevention, identification, and protection against abuse, was not effectively implemented in this case. This deficiency highlights the facility's inability to protect residents from abuse by other residents, as required by their policy.
Failure to Store Food Under Sanitary Conditions
Penalty
Summary
The facility failed to store food under sanitary conditions in the main kitchen, which had the potential to affect all 69 residents who received food from this kitchen. During an initial tour, surveyors observed several issues: two opened bags of frozen meat patties in the double-door freezer were unlabeled and undated; a tray of beverages in the double-door cooler was unlabeled, with only one cup bearing a date; multiple bread products in the dry pantry, including hot dog buns, hamburger buns, and English muffins, were without labels or dates; and two pitchers of juice in the walk-in fridge were also without dates or labels. The Dietary Manager confirmed that all food and beverages should have labels with the name of the item and dates. The facility's policy, provided by the Executive Director, stated that all food should be dated at the time of receipt and inventoried using the first-in, first-out method, with unserved leftovers labeled, dated, and stored for no more than three days.
Deficiencies in Person-Centered Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for several residents, leading to deficiencies in meeting their specific needs. Resident 36, diagnosed with psychotic disorder with delusions, depression, dementia with agitation, and anxiety, was receiving antipsychotic and antidepressant medications. However, the clinical record lacked a person-centered care plan addressing the resident's delusions. The Director of Nursing acknowledged the absence of such a care plan during an interview. Similarly, Resident E, who had diagnoses including dementia, depression, and psychotic disorder, was noted to have delusions according to an Admission Minimum Data Set assessment. Despite being prescribed Depakote for delusions, the resident's clinical record did not include a person-centered care plan for this condition. The Director of Nursing confirmed the omission of the necessary care plan during an interview. Resident 55, with diagnoses of malnutrition, bipolar disorder, visual hallucinations, and depression, was receiving antipsychotic medication for visual hallucinations. However, the clinical record lacked a person-centered care plan for hallucinations. Additionally, Resident 16, who was receiving hospice care for end-stage cerebral atherosclerosis, had a care plan that was not person-centered, as confirmed by the Director of Nursing. The facility's policy required comprehensive, person-centered care plans, but these were not implemented for the residents in question.
Failure to Conduct Care Plan Meetings for a Resident
Penalty
Summary
The facility failed to provide a baseline care plan meeting and routine care plan meeting for a resident, identified as Resident 53, who was reviewed for care planning. During an interview, the resident reported that he had not been allowed to access his test results until discharge and had not participated in any care plan meetings since his admission. A review of the resident's electronic medical record confirmed the absence of documentation regarding a baseline or routine care plan meeting. The resident's diagnoses included alcohol abuse, diabetes mellitus type 2, idiopathic acute pancreatitis, cannabis use, iron deficiency anemia, and chronic kidney disease. The Social Service Director acknowledged that the resident had likely not had a baseline care plan meeting and that no meeting had been scheduled since admission. Despite frequent visits to the Social Service Director's office, these interactions were not documented. The facility's policy requires a comprehensive, person-centered care plan to be developed and implemented for each resident, involving the interdisciplinary team and the resident or their representative.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care for three residents, as observed and documented in the report. Resident 53 reported receiving only two showers in the past month and a half, with showers being offered at inconvenient times between 11 P.M. and 3 A.M., which he refused. The resident's care plan indicated a need for assistance with bathing due to various health conditions, but there was no documentation of his shower time preferences. The Director of Nursing (DON) was unaware of the issue and noted that refusals were documented, but accepted showers were not. Resident 9 also experienced inadequate showering opportunities, reporting missed showers on scheduled days. The resident's care plan required assistance with ADLs due to multiple health issues, including dementia and schizophrenia. The documentation showed sporadic shower occurrences and several refusals, but the resident was not care planned for refusals. The DON acknowledged the resident's tendency to refuse showers but did not have a system in place to document accepted showers. Resident 1 was observed with poor personal hygiene, including long, dirty fingernails, unkempt facial hair, and greasy hair. The resident required total assistance for ADLs due to severe cognitive impairment and multiple health conditions. Despite being dependent on staff for personal hygiene, the resident's care needs were not met, as confirmed by RN 14, who was unaware of the resident's shower schedule. The DON confirmed that the resident should have scheduled showers and grooming assistance, but these were not provided as per the facility's policy.
Failure to Implement Individualized Activities Program
Penalty
Summary
The facility failed to implement an individualized activities program for a resident, leading to a deficiency. Observations over several days revealed that the resident was often found in his room, either in bed or in a chair, without any form of entertainment such as television or music, despite being awake. The resident's care plan, dated June 4, 2024, emphasized the importance of engaging in activities like watching favorite TV shows, listening to music, and having access to books and newspapers. However, these preferences were not consistently met, as evidenced by the lack of stimulation observed during the survey. The resident's medical history includes cerebral palsy, epilepsy, intellectual disabilities, and other conditions, which necessitate a tailored approach to activities. The facility's policy on activity recreation programs, dated March 2015, mandates that programs should meet individual resident needs and reflect their schedules and choices. Interviews with the Activity Director and the Director of Nursing confirmed that the resident's television should have been on to allow him to watch his favorite shows, and staff should have monitored for overstimulation. Despite these requirements, the resident did not receive the activities he enjoyed, resulting in a failure to adhere to the care plan and facility policy.
Failure to Cover Urostomy Drainage Bag with Dignity Bag
Penalty
Summary
The facility failed to ensure that a resident's urostomy drainage bag was covered with a dignity bag, as observed on multiple occasions. Resident 264, who has a medical history including spina bifida, depression, paraplegia, morbid obesity, obstructive sleep apnea, stoma of the urinary tract, and colostomy status, was observed on several dates with an uncovered urostomy drainage bag. These observations occurred on 8/7/2024, 8/8/2024, 8/12/2024, and 8/13/2024, indicating a consistent failure to maintain the resident's dignity by not covering the drainage bag. Interviews with facility staff, including a Qualified Medication Aide (QMA) and the Assistant Director of Nursing (ADON), confirmed that the urostomy bag should have been covered with a dignity bag. The facility's policy on indwelling urinary catheter care, provided by the Director of Nursing (DON), emphasized the importance of keeping the drainage bag hidden under clothing to help the patient feel more comfortable. Despite this policy, the facility did not adhere to these guidelines, resulting in the deficiency.
Improper Labeling and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper labeling and storage of respiratory equipment and provide necessary respiratory services according to physician orders for three residents. Resident 30 was observed receiving oxygen therapy with undated tubing and without humidification, despite physician orders requiring these elements. The resident, who had multiple diagnoses including COPD and chronic respiratory failure, refused humidification due to discomfort, but the tubing was still required to be dated. The Director of Nursing confirmed that the oxygen tubing should have been dated, as per the facility's policy. Resident 215's respiratory equipment, including a nebulizer and oxygen nasal cannula, was improperly stored and undated. The resident, diagnosed with systemic lupus, COPD, and heart failure, had physician orders for continuous oxygen therapy and nebulizer treatments. Similarly, Resident 46's oxygen nasal cannula was found undated and improperly stored. This resident had emphysema and COPD, with orders for oxygen therapy as needed. The facility's policy required respiratory equipment to be stored in plastic bags and dated, which was not adhered to in these cases.
Failure to Document Narcotic Counts
Penalty
Summary
The facility failed to ensure that narcotics were counted and documented every shift for one of the four narcotic count log books reviewed, specifically for the Freedom cart 1. During a medication storage observation of the Freedom hall medication cart, it was noted that the narcotic log book lacked signatures on 8/3/2024, indicating that a narcotic count was not completed. In an interview, QMA 2 confirmed that the narcotic log sheets should have been signed every shift. The Director of Nursing provided the facility's policy on controlled substances, which stated that nursing staff must count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty making the count together.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications on two medication carts, leading to deficiencies in medication management. During an observation of medication storage on Freedom hall med cart 1, a box of Xalanta eye drops was improperly stored with injectable medications. Additionally, a bottle of Colace pills and an opened bottle of Antacid tablets lacked resident identifiers or labels. The Qualified Medication Aide (QMA) acknowledged that the medications should have been labeled and stored correctly. On Freedom hall medication cart 2, three loose pills were found in two drawers, and a bottle of Derma Klenze wound cleanser was stored with liquid medications. Furthermore, two opened and undated bottles of lax granules and an opened package of Ipratropium Bromide ampules lacked resident identifiers. The Licensed Practical Nurse (LPN) confirmed that there should be no loose pills, medications should be labeled, and wound cleansers should not be stored with medications. The facility's policies on medication storage and labeling were provided by the Director of Nursing, indicating the requirements for labeling and storage of medications.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Warsaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paddock Springs | 0.3 mi | — | 4 | 0 |
| Miller's Merry Manor | 1.1 mi | — | 0 | 0 |
| Mason Health Care Center | 1.8 mi | — | 11 | 0 |
| Grace Village Health Care Facility | 2.8 mi | — | 0 | 0 |
| Waters Of Syracuse Skilled Nursing Facility, The | 13.9 mi | — | 0 | 0 |
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