Waters Of Wabash Skilled Nursing Facility West

Based on interview and record review, the facility failed to promote resident dignity during transportation following a shower in the shower room for 1 of 3 residents reviewed for dignity. (Resident F) Findings include:Resident F's clinical record was reviewed on 10/15/25 at 9:55 a.m. Diagnoses included stroke affecting right non dominant side, mild intellectual disability, weakness, unsteadiness on feet, and cognitive communication deficit. An 8/11/25, admission, Minimum Data Set (MDS) assessment indicated she used a walker and wheelchair. She had upper extremity impairment on one side of her body. She was substantial/ maximal staff assistance for showering, upper and lower body dressing, toileting hygiene and tub/shower transfer.A progress note, on 8/6/25 at 10:40 p.m., indicated Resident F had fallen forward from the shower chair while coming out of the shower. The right front wheel fell off the shower chair causing Resident F to fall forward. Resident F hit her head on the floor causing a laceration above her right eye. Resident F did not lose consciousness and remained alert.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure staff performed hand hygiene during 3 of 3 medication administration observations. (Resident 13, Resident 3, and Resident 12)Findings include:During a medication administration observation on 8/6/25 at 11:09 a.m., Qualified Medication Aide (QMA) 4 removed one medication for Resident 13 from the [NAME] Hall medication cart. Prior to removing the medication, the QMA did not perform hand hygiene. She popped one pill from a blister pack into a medication cup and poured water into a plastic drinking cup. QMA 3 entered Resident 13's room and administered the medication. The QMA did not perform hand hygiene during the observation.During a medication administration observation on 8/6/25 at 11:13 a.m., QMA 4 removed one medication for Resident 3 from the [NAME] Hall medication cart. Prior to removing the medication, the QMA did not perform hand hygiene. She popped one pill from a blister pack into a medication cup and poured water into a plastic drinking cup. QMA 4 entered Resident 3's room, administered the medication, then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide assistance with eating for 1 of 1 reviewed for ADLs. (Resident B) Finding includes: During a dining observation, beginning on 7/16/24 at 11:57 a.m., Resident B had not eaten any of her lunch as of 12:41 p.m. Her eyes were closed, and she had a utensil in her hand. At 12:45 p.m., QMA 6 picked up the resident's spoon and offered the resident green beans. During an interview following the observation, QMA 6 indicated Resident B was able to feed herself, but had insomnia and fell asleep frequently during the day and required reminders to eat. QMA 6 first prompted her to eat at 12:45 p.m. During an observation, on 7/17/24 at 8:41 a.m., four residents were in the dining room. No staff were present. Resident B was talking incoherently and fidgeting with her glasses. She had eaten a few bites of eggs. Housekeeper 4 entered the dining room at 8:46 a.m. and indicated that at least one nursing staff was required to be in the dining room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure staff information was posted in a prominent place, was readily accessible to residents and visitors, and was in a clear and readable format. Findings include: On 7/15/24, at 11:32 a.m., staffing information was not readily available at the nurses station towards the front doors of the facility. No information was available on the walls at the front of the facility. The front of the building was the main entrance into the facility. On 7/15/24, at 11:41, during an interview with the Administrator (Adm), she indicated the staff posting was on the wall outside of the Director of Nursing's (DON) door. The DON's office was located in the west hall of the facility, past the nurses desk, through a doorway, and on the left side of the hallway. On 7/16/24, at 12:05 p.m., nurse staffing was posted outside the DON's door. There were two plastic sleeves that contained two 8.5 x 11 sheets of paper with staffing information. The two documents were positioned on their sides. In order to view the documents, they had to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide food that was attractive and palatable. (Residents 5, 15, 18, and 21) Findings include: During an interview on 7/15/24 at 11:08 a.m., Resident 18 indicated she was not feeling well. She thought her blood glucose might be low. She had not eaten any breakfast that morning because she .could not face another peanut butter and jelly sandwich She described the food as awful. She complained repeatedly to the administrator and other staff about the palatability of the food. She finally resorted to eating peanut butter and jelly sandwiches because that was the only thing she could tolerate. Carbohydrates were too many and there was not enough protein provided. The food was not properly seasoned and not appealing in appearance. During an interview on 7/18/24 at 10:42 a.m., Resident 5 indicated the food palatability varied. Sometimes the food was not bad, but other times it was not edible. It all depended on who was working in the kitchen. During an interview on 7/15/24 at 11:23 a.m., Resident 21 indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a nourishing snack at bedtime when there was more than fourteen (14) hours between the evening meal and breakfast the next day. This had the potential to affect twenty four (24) out of twenty four (24) residents. (Residents 3, 16, 15, 18, 21, and 22) Findings include: During a resident council meeting on 7/17/24 at 3:04 p.m., Resident 15 indicated the facility used to provide snacks in the evening. Eventually, the snacks provided were only oatmeal pies. The night before the meeting, there were no snacks available at all. Resident 21 indicated the facility sometimes provided goldfish, oatmeal pies, or a sandwich. If the facility would run out of snacks, the residents did not get an evening snack. Resident 15 indicated residents would sometimes ask a kitchen staff member to hold food items for them. The staff member would do so. All residents present at the council meeting indicated snacks were not offered in the evenings. They could get snacks only when they asked for them and often, no snacks were…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 5 residents reviewed for EBP (Resident 21) Findings include: Resident 21's clinical record was reviewed on 7/16/24 at 3:25 p.m. Diagnoses for the resident included, but were not limited to, type 2 diabetes mellitus with diabetic neuropathy, morbid (severe) obesity due to excess calories, and non-pressure chronic ulcer of other part of left foot with unspecified severity. Current physician orders included, but were not limited to: 6/7/24 - An external ointment, mupirocin 2%, was to be applied to the left great toe topically every day and night shift. The wound was to be covered with dry, sterile gauze. 5/14/24 - A weight bearing as tolerated (WBAT) surgical shoe to be worn on the left foot. 5/6/24 - Monitor the left great toe each shift for signs and symptoms of infection, dressing placement, and surrounding tissue until healed. 2/8/24 - Notify the physician of any foul-smelling odor, red streaking up the leg, discolored drainage, and watch for infection,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on, record review, and interview, the facility failed to accommodate visitation rights for 1 of 3 residents reviewed for resident rights. (Resident B) Finding includes: During an interview, on 2/1/24 at 11:18 a.m., Resident B indicated she wasn't allowed to have a friend enter the building for visitation. Outside visitation with her friend was allowed. Inside visitation was not permitted until documentation was provided to the facility of bedbug infestation treatment at his place of residence. Her friend was unable to afford treatment. During an interview, on 2/1/24 at 12:00 p.m., LPN 10 indicated the facility had limitations with one of Resident B's visitors. During an interview, on 2/1/24 at 12:17 p.m., the Administrator indicated that one specific visitor of Resident B was found to have brought bedbugs into the facility. They had the restricted visits to outside only. On 2/1/23 at 12:35 p.m., a facility document of a conversation between the resident and the Administrator, dated 11/6/23, was provided by the Administrator. The document indicated the Administrator spoke with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report resident-to-resident abuse for 1 of 2 resident altercations reviewed for State Agency reporting (Resident 6 and Resident 17). Findings include: During an interview on 7/27/23 at 10:15 a.m., Resident 6 indicated her previous roommate (Resident 17) and she argued periodically. The last time they argued, it became physical. Resident 6 was in bed when Resident 17 came over to her bed, grabbed Resident 6's face, and said Don't you ignore me. Resident 6's clinical record was reviewed on 7/27/23 at 1:27 p.m. Her diagnoses included multiple sclerosis, generalized anxiety disorder, bipolar disorder, major depressive disorder, and delusional disorder. Her medications included aripiprazole (antipsychotic) 2.5 mg (milligrams) daily and sertraline (antidepressant) 75 mg daily. A quarterly Minimum Data Set (MDS) assessment, dated 6/14/23, indicated the resident was cognitively intact. She was totally dependent on the assistance of two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to report weight gains of 2 lbs (pounds) or greater for heart failure protocol, as ordered by the physician, for 2 of 5 residents reviewed for unnecessary medications (Resident 5 and 16). Findings include: 1. During a random observation, on 7/26/23 at 10:12 a.m., Resident 16 was was sitting in a recliner with feet elevated, her eyes were closed, connected to oxygen via nasal cannula, and was opened-mouth breathing. During an interview, on 7/26/23 at 1:17 p.m., Resident 16 indicated she retained fluids, had trouble breathing for last couple of weeks, had started on oxygen the day prior, and had also had an X-ray taken. Her clinical record was reviewed on 7/28/23 at 1:27 p.m. Diagnoses included combined systolic and diastolic congestive heart failure, chronic atrial fibrillation, and shortness of breath. Current physician orders included the following; a. Heart failure: daily weight-after voiding and before breakfast and medications with same clothes every day. Notify physician of 2 lb gain in one day and 4 lb…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility to failed to provide adequate supervision for a resident with a history of falls and failed to develop and implement person-centered, individualized interventions to reduce the risk of falls, for 1 of 4 residents reviewed for accidents (Resident 23). Findings include: Resident 23's clinical record was reviewed on 7/28/23 at 3:07 p.m. He had admitted to the facility on [DATE] and transferred to an acute hospital on 6/24/23. Diagnoses included pathological hip fracture, weakness, unsteadiness on feet, abnormalities of gait and mobility, and dementia. Physician orders included the following: a. Monitor incision to left hip each shift for signs/symptoms of infection or worsening, dressing placement, and surrounding tissue until healed, the order date was 6/1/23. b. Weight bearing as tolerated to left hip/leg, the order date was 6/1/23. c. Oxycodone (opioid)-acetaminophen 7.5-325 mg (milligram), one tablet every eight hours as needed for chronic pain, the order date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.