Inspection Reports for
Waters of Wabash Skilled Nursing Facility East the

The complaint involved an anonymous allegation of verbal and physical abuse by CNA 2 towards Resident E on 11/3/25. The Dietary Manager witnessed the incident and reported it to the Director of Nursing and Administrator. The Administrator conducted an investigation but found no evidence to substantiate the claim and did not report the allegation to the State Agency as required. The facility policy for abuse prevention and investigation was not properly followed.

The facility failed to timely report the suspected abuse allegation to the State Agency and failed to properly investigate the allegation or implement the facility's abuse prevention policy. The Administrator did not report the incident, and the investigation found no substantiated evidence of abuse despite conflicting witness statements.

The facility was found not in compliance with emergency preparedness requirements, fire safety codes, and maintenance of essential electrical systems. Deficiencies included failure to track staff and residents during emergencies, malfunctioning generator annunciator panel, obstructed corridor egress, uneven exit discharge surfaces, missing self-closing devices on hazardous area doors, lack of approved kitchen hood appliance placement method, incomplete fire alarm system maintenance, inadequate fire watch plan, corridor door not latching properly, missing annual fire door inspections, lack of ground fault circuit interrupter protection in wet locations, incomplete fire drill documentation, and incomplete testing of patient care related electrical equipment.

The facility was found deficient in multiple areas including resident dignity during dining, notification of Medicare non-coverage, cleanliness of wheelchairs, care plan updates after falls, pressure ulcer prevention, seizure precautions, dietary staff qualifications, meal palatability, food storage and sanitation, and infection prevention practices related to enhanced barrier precautions.

The facility was found deficient in multiple areas including failure to provide dignified dining experiences, lack of notification for Medicare non-coverage, unclean wheelchairs, incomplete care plans after resident falls, inadequate pressure ulcer care, failure to implement seizure precautions, unqualified dietary manager, poor food quality and safety, unsanitary kitchen conditions, inadequate quality assurance program implementation, and failure to implement enhanced barrier precautions for infection control.

Complaint IN00452389 was substantiated with federal/state deficiencies cited at F880 related to infection prevention and control. Complaint IN00454338 had no deficiencies related to the allegations.

The facility failed to maintain appropriate infection control practices during urinary catheter care for one resident requiring Enhanced Barrier Precautions. Specifically, a CNA failed to don a gown before catheter care despite signage and policy requirements.

This citation relates to Complaint IN00452389.

The facility failed to maintain appropriate infection control practices during urinary catheter care for one resident requiring Enhanced Barrier Precautions. Specifically, a staff member did not don a gown as required before catheter care.

The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to ensure smoke barrier walls were constructed to required standards. The deficiency involved penetrations sealed with joint compound instead of firestop systems meeting ASTM E 814. The facility implemented corrective actions and a plan to prevent recurrence.

The facility was found not in compliance with several emergency preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, policies and procedures, communication plan, training program, and arrangements with other facilities. Life safety deficiencies included a collapsed ceiling smoke barrier, obstructed sprinkler heads, propped open kitchen door, corridor door not latching, improper storage of liquid oxygen in resident room, and incomplete fire watch and fire safety plans. Corrective actions and monitoring plans were implemented.

Complaint IN00439229 was investigated with no deficiencies related to the allegations cited.

No deficiencies related to the complaint allegations were cited. However, the facility failed to report a resident suicide attempt to the Indiana State Department of Health for one resident. Immediate corrective actions and staff education were implemented, and ongoing monitoring was planned.

This citation relates to Complaint IN00427042.

The facility failed to provide palatable food to 23 residents, with issues including dry and cold meat and unappetizing side dishes. Additionally, infection control practices were not maintained during meal service, as staff handled bread with bare hands contrary to facility policy.

Complaint IN00427042 was substantiated with federal/state deficiencies cited at F804 (food palatability) and F880 (infection control).

The facility failed to provide palatable food to 23 residents, with issues including dry, cold, and hard meat, and mushy vegetables. Additionally, infection control practices were not maintained during meal service, as staff handled ready-to-eat food without gloves.

This citation relates to Complaint IN00422953.

The facility failed to assess residents for safe self-administration of medications, supervise a resident during nebulizer treatment, administer medications according to physician orders, and securely store topical medications. Multiple residents were affected by these deficiencies, all with minimal harm or potential for harm.

Complaint IN00422953 was investigated with federal/state deficiencies cited at F554, F695, F726, and F761.

The facility failed to ensure residents were assessed for ability to self-administer medications, failed to supervise a resident during nebulizer treatment, failed to administer medications per physician's orders for narcotics, and failed to store topical medications securely.

The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including failure to conduct required emergency plan exercises, maintain smoke barrier door latching hardware, test emergency lighting, maintain battery-operated smoke alarms, seal smoke barrier penetrations, maintain fuel-fired water heater inspections, and conduct required generator load testing.

The facility was found deficient in several areas including failure to ensure adequate supervision to prevent falls, failure to notify physicians of significant weight loss for residents, failure to implement physician-ordered enhanced barrier precautions for infection control, and failure to ensure employees completed required dementia training and two-step tuberculin skin testing.

The facility failed to ensure adequate supervision and individualized interventions to prevent falls for one resident, failed to notify physicians of significant weight loss for two residents, and failed to implement physician-ordered enhanced barrier precautions for three residents.