Inspection Reports for Waters of Wabash Skilled Nursing Facility West
1720 ALBER ST, IN, 46992
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 3, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mix of compliance and deficiencies, with issues primarily involving emergency preparedness, life safety code requirements, resident care including assistance with eating, infection control, and visitation rights. Complaint investigations were mostly unsubstantiated, though some substantiated cases involved visitation restrictions, failure to report resident mistreatment, and kitchen sanitation concerns. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement in emergency preparedness and life safety compliance following earlier citations, though resident care and documentation issues appeared intermittently over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
100% occupied
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 25
Capacity: 25
Deficiencies: 0
Feb 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00451237.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00451237 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 25
Total Capacity: 25
Medicaid Census: 19
Other Payor Census: 6
Inspection Report
Complaint Investigation
Census: 25
Capacity: 25
Deficiencies: 0
Jan 10, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00448295 and IN00448504.
Findings
No deficiencies related to the allegations in complaints IN00448295 and IN00448504 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding these complaints.
Complaint Details
Investigation of Complaints IN00448295 and IN00448504 found no deficiencies related to the allegations.
Report Facts
Census: 25
Total Capacity: 25
Medicaid Census: 19
Other Payor Census: 6
Inspection Report
Re-Inspection
Census: 30
Capacity: 44
Deficiencies: 0
Oct 22, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/29/24.
Findings
At this PSR survey, Waters of Wabash Skilled Nursing Facility West was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility was fully sprinklered with a fire alarm system and smoke detection, except for two detached sheds that were not sprinklered.
Report Facts
Facility capacity: 44
Census: 30
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 26, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure, including Investigation of Complaint IN00434626 completed on July 18, 2024.
Findings
Waters of Wabash Skilled Nursing Facility West was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the Recertification and State Licensure survey and Investigation of Complaint IN00434626.
Complaint Details
Investigation of Complaint IN00434626 was included in the review; no deficiencies were found.
Inspection Report
Life Safety
Census: 24
Capacity: 44
Deficiencies: 4
Aug 29, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 08/29/2024 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found in substantial compliance with Emergency Preparedness requirements but failed to document staff knowledge of the Emergency Preparedness Program. Life Safety Code deficiencies included failure to ensure a self-closing and latching door on a hazardous storage room, unsealed drywall gaps in a mechanical room with fuel-fired equipment, and lack of signage on the liquid oxygen transfilling room indicating when transfilling is occurring.
Severity Breakdown
SS=C: 1
SS=E: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to conduct and document annual training demonstrating staff knowledge of the Emergency Preparedness Program. | SS=C |
| Corridor door to hazardous storage room containing combustible storage and greater than 50 square feet did not have a self-closing device that latched when air conditioner was running. | SS=E |
| Mechanical room with fuel-fired furnace had unsealed drywall patch with gaps. | SS=E |
| Liquid oxygen storage/transfer room door lacked signage indicating when oxygen transfilling is occurring. | SS=E |
Report Facts
Facility capacity: 44
Census: 24
Number of hazardous rooms affected: 2
Number of residents potentially affected by hazardous room deficiencies: 15
Number of residents potentially affected by oxygen transfilling room deficiency: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiri Burks | Administrator | Named in relation to Emergency Preparedness training and Life Safety Code findings |
| Maintenance Director | Interviewed regarding Emergency Preparedness training and Life Safety Code deficiencies | |
| Maintenance Supervisor/designee | Responsible for corrective actions and education related to Emergency Preparedness and Life Safety Code deficiencies |
Inspection Report
Annual Inspection
Census: 24
Capacity: 24
Deficiencies: 5
Jul 18, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00434626.
Findings
The facility was found deficient in providing adequate assistance with eating for dependent residents, posting nurse staffing information properly, ensuring food was palatable and served at appropriate temperatures, providing nourishing snacks at bedtime, and implementing enhanced barrier precautions for infection control.
Complaint Details
Complaint IN00434626 was investigated and deficiencies related to the allegations were cited at F677 regarding ADL care provided for dependent residents.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide assistance with eating for 1 of 1 reviewed dependent resident (Resident B). | SS=D |
| Failed to post nurse staffing information in a clear, readable format and in a prominent, accessible location. | SS=D |
| Failed to provide food that was attractive, palatable, and at a safe and appetizing temperature for multiple residents (Residents 5, 15, 18, and 21). | SS=D |
| Failed to provide a nourishing snack at bedtime when there was more than 14 hours between the evening meal and breakfast the next day, potentially affecting all residents. | SS=D |
| Failed to implement Enhanced Barrier Precautions (EBP) for 1 of 5 residents reviewed for EBP (Resident 21), including lack of proper PPE use and signage. | SS=D |
Report Facts
Survey dates: July 15, 16, 17, and 18, 2024
Resident census: 24
Licensed capacity: 24
Medicare census: 3
Medicaid census: 17
Other payor census: 4
Meals consumed by Resident B: 88
Meals eaten 0-25%: 30
Meals eaten 26-50%: 18
Meals eaten 51-75%: 30
Meals eaten >76%: 9
Meals refused: 1
Meal times: Breakfast 7:30 a.m., Lunch 12:00 p.m., Dinner 5:00 p.m.
Time between dinner and breakfast: 14.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kiri Burks | Administrator | Signed report and involved in staffing posting location decisions |
| QMA 6 | Observed assisting Resident B with eating and interviewed about feeding assistance | |
| Dining Staff 3 | Interviewed regarding Resident B being left unattended in dining room | |
| Housekeeper 4 | Reported nursing staff requirements in dining room | |
| Director of Nursing | DON | Provided policies, education, and interviews related to deficiencies |
| Administrator | Interviewed about food complaints and snack availability | |
| CNA 5 | Interviewed about snack availability and resident requests | |
| Wound care nurse | Observed providing wound care to Resident 21 | |
| Corporate nurse consultant | Interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00424644 completed on February 1, 2024.
Findings
The Waters of Wabash Skilled Nursing Facility West was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Paper compliance review of Complaint IN00424644 completed on February 1, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 25
Capacity: 25
Deficiencies: 1
Feb 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00424644 regarding allegations related to visitation rights at the facility.
Findings
The facility failed to accommodate visitation rights for 1 of 3 residents reviewed (Resident B), restricting a visitor's access due to bedbug infestation concerns at the visitor's residence, limiting visits to outside only despite the resident's preference for inside visitation.
Complaint Details
Complaint IN00424644 was substantiated with federal/state deficiencies cited related to visitation rights. The visitor was restricted from entering the facility until providing documentation of bedbug treatment at his residence. The resident expressed feelings of discrimination against her friend.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to accommodate visitation rights for Resident B by restricting a visitor's access due to bedbug infestation concerns. | SS=D |
Report Facts
Census: 25
Total Capacity: 25
Medicare Census: 2
Medicaid Census: 13
Other Payor Census: 9
Bedbug Treatment Dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Wright | Administrator | Named in relation to visitation restriction and plan of correction |
| LPN 10 | Interviewed regarding visitation limitations | |
| Social Services designee | Interviewed regarding visitor restrictions | |
| DON | Interviewed regarding visitor restrictions | |
| CNA 11 | Interviewed regarding visitation requirements | |
| QMA 12 | Interviewed regarding visitor restrictions |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 23
Deficiencies: 0
Nov 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419319.
Findings
No deficiencies related to the allegations in Complaint IN00419319 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00419319 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 23
Total Capacity: 23
Medicaid Census: 17
Other Payor Census: 6
Inspection Report
Follow-Up
Census: 22
Capacity: 44
Deficiencies: 0
Sep 28, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 08/29/23.
Findings
The Waters of Wabash Skilled Nursing Facility West was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 14, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey completed on August 1, 2023.
Findings
The Waters Skilled Nursing Facility of Wabash West was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 19
Capacity: 44
Deficiencies: 10
Aug 29, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements due to failure to conduct required emergency plan exercises twice per year. Life safety deficiencies included failure to test emergency lighting monthly and annually, missing exit signage in the kitchen, hazardous area door without self-closing device, expired fuel-fired water heater inspection certificates, exposed wiring in attic, corridor door impeded from closing, missing monthly fire extinguisher inspections, missing fire drills on all shifts quarterly, and use of a non-compliant power strip in the therapy room.
Severity Breakdown
SS=F: 3
SS=E: 4
SS=D: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to ensure 4 of 4 battery backup emergency lights were tested monthly for 30 seconds and annually for 90 minutes. | SS=F |
| Failed to install exit signage in 1 of 2 kitchen exits; storage room exit door was not obvious as an exit and had no exit sign. | SS=E |
| Storage room with combustible storage lacked self-closing door. | SS=E |
| Failed to have current inspection certificates for 2 fuel fired water heaters. | SS=E |
| Exposed wiring in attic due to missing junction box cover. | SS=E |
| Corridor door to resident room 12 would not close fully due to bed obstruction. | SS=D |
| Failed to inspect 2 of 12 portable fire extinguishers monthly; missing July 2023 inspection documentation. | SS=E |
| Failed to conduct fire drills on each shift for 1 of 4 quarters; missing documentation for fourth quarter first shift drill. | SS=F |
| Power strip in therapy room did not meet UL 1363 standards. | SS=D |
Report Facts
Facility capacity: 44
Census: 19
Number of battery backup emergency lights: 4
Number of portable fire extinguishers: 12
Number of fuel fired water heaters: 2
Number of corridor doors inspected: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Tech | Interviewed regarding emergency preparedness exercises, emergency lighting, fire extinguisher inspections, and other findings | |
| Maintenance Supervisor/designee | Conducted corrective actions including testing, inspections, and repairs; involved in monitoring compliance | |
| Administrator | Reviewed findings and corrective actions; responsible for oversight and monitoring compliance |
Inspection Report
Annual Inspection
Census: 21
Capacity: 21
Deficiencies: 3
Aug 1, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from July 26 to August 1, 2023.
Findings
The facility was found deficient in reporting alleged resident-to-resident abuse, failure to report weight gains for heart failure protocol for two residents, and inadequate supervision and individualized interventions to prevent falls for one resident. Corrective actions and plans of correction were provided with a compliance date of August 20, 2023.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to report resident-to-resident abuse for 1 of 2 resident altercations reviewed. | SS=D |
| Failed to report weight gains of 2 lbs or greater for heart failure protocol for 2 of 5 residents reviewed for unnecessary medications. | SS=D |
| Failed to provide adequate supervision and individualized interventions to reduce risk of falls for 1 of 4 residents reviewed for accidents. | SS=D |
Report Facts
Census: 21
Total Capacity: 21
Survey Dates: July 26, 27, 28, 31, and August 1, 2023
Deficiencies cited: 3
Resident 16 weight gains: 2.6
Resident 5 weight gains: 2.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Katherine Wright | Administrator | Signed report and involved in interviews and corrective action plans |
| LPN 51 | Licensed Practical Nurse | Nurse on duty during resident-to-resident altercation |
| LPN 5 | Licensed Practical Nurse | Provided information about daily weight documentation |
| DON | Director of Nursing | Provided interviews and information about physician notifications and policies |
| Nurse Consultant | Provided information about heart failure protocol |
Inspection Report
Complaint Investigation
Census: 22
Capacity: 22
Deficiencies: 0
Jun 20, 2023
Visit Reason
The visit was conducted for the investigation of Complaint IN00408500.
Findings
No deficiencies related to the allegations in Complaint IN00408500 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00408500 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 22
Total Capacity: 22
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 12
Census Payor Type - Other: 6
Inspection Report
Complaint Investigation
Deficiencies: 0
May 11, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00399395 completed on April 5, 2023.
Findings
Waters of Wabash Skilled Nursing Facility West was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Paper compliance to the Investigation of Complaint IN00399395 completed on April 5, 2023.
Inspection Report
Complaint Investigation
Census: 22
Capacity: 22
Deficiencies: 1
Apr 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00405235 and IN00399395. Complaint IN00405235 had no deficiencies related to the allegations, while Complaint IN00399395 resulted in federal/state deficiencies related to abuse/neglect policies.
Findings
The facility failed to ensure that staff reported suspicions of resident mistreatment involving inappropriate language and refusal to meet resident needs by a staff member. Interviews revealed that multiple employees were aware of the incidents but did not report them to the Administrator. The facility provided inservices on abuse prevention and implemented a QAPI action plan to monitor compliance.
Complaint Details
Complaint IN00405235 - No deficiencies related to the allegations are cited. Complaint IN00399395 - Federal/State deficiencies related to the allegations are cited at F607. The facility failed to ensure staff reported suspicions of resident mistreatment involving inappropriate language and refusal to meet resident needs by a staff member (CNA 4).
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff reported suspicions of resident mistreatment involving inappropriate language and refusal to meet resident needs. | SS=D |
Report Facts
Census: 22
Total Capacity: 22
Medicare Residents: 2
Medicaid Residents: 12
Other Residents: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Foster | Administrator | Facility Administrator who indicated staff should report all suspicions of abuse or mistreatment immediately |
| Employee 1 | Reported being told about inappropriate language used by CNA 4 but did not report to Administrator | |
| Employee 2 | Heard CNA 4 use inappropriate language and did not report to Administrator | |
| Employee 3 | Was told CNA 4 made inappropriate remarks and did not report to Administrator | |
| CNA 4 | Certified Nursing Assistant | Alleged to have used inappropriate language and refused to meet resident needs; denied allegations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 24, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00398423 completed on January 4, 2023.
Findings
The Waters of Wabash West Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00398423 completed on January 4, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 18
Capacity: 18
Deficiencies: 1
Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398423, which was substantiated with federal and state deficiencies cited related to the allegations.
Findings
The facility failed to maintain the kitchen in a hygienic and sanitary manner, with observations of grime, debris, and food residue on the stove, shelves, appliances, and floors. The Dietary Manager confirmed cleaning schedules were in place but deficiencies were noted. Corrective actions included cleaning all affected areas, discarding outdated food, repairing a refrigerator leak, and staff reeducation on kitchen sanitation.
Complaint Details
Complaint IN00398423 was substantiated with related deficiencies cited at F812 regarding kitchen sanitation.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility kitchen was not maintained in a hygienic and sanitary manner, including grime and debris on stove burners, shelves, appliances, and floors. | SS=F |
Report Facts
Residents present: 18
Residents at risk: 17
Residents not affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Isaac Lenon | Administrator | Named as facility Administrator and involved in staff reeducation regarding kitchen sanitation |
| Dietary Manager | Interviewed regarding cleaning schedules and kitchen conditions, name not provided |
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