Inspection Reports for
Waters of Wabash Skilled Nursing Facility West

This citation relates to Intake 2633792. The complaint was substantiated based on interviews and record review indicating failure to promote resident dignity and safety during transportation.

The facility failed to promote resident dignity for Resident F during transportation in a shower chair, resulting in a fall and injury due to a shower chair wheel detaching. Staff transported residents in shower chairs down hallways despite policies indicating this should not occur unless a mechanical lift was required.

The facility failed to ensure staff performed hand hygiene during all observed medication administration events. Three separate observations showed Qualified Medication Aides did not cleanse their hands before administering medications to residents.

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.

The Federal tag relates to Complaint IN00434626. The complaint involved failure to provide adequate assistance with eating and supervision during meals for Resident B.

The facility failed to provide timely and adequate assistance with eating for Resident B, who required supervision and prompting during meals. Resident B was frequently left unattended in the dining room while eating, resulting in minimal food intake and potential risk of harm.

Complaint IN00434626 triggered the inspection. The complaint involved concerns about resident care, staffing information posting, food quality, snack availability, and infection control practices. The complaint was substantiated based on observations, interviews, and record reviews.

The facility was found deficient in providing adequate assistance with eating, posting nurse staffing information accessibly, ensuring food palatability and appropriate snack availability, and implementing Enhanced Barrier Precautions for infection control.

Complaint IN00434626 was investigated and deficiencies related to the allegations were cited at F677 regarding ADL care provided for dependent residents.

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.

This visit relates to Complaint IN00424644 concerning visitation rights and restrictions due to bedbug concerns.

The facility failed to allow one of Resident B's visitors to enter the building due to concerns about bedbug infestation. Visits were restricted to outdoor only despite cold weather, and bedbugs were still found in the facility after the visitor was restricted.

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.

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.

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.

The complaint investigation involved allegations of failure to report resident-to-resident abuse, failure to follow heart failure protocols regarding weight gain notification, and failure to prevent falls through adequate supervision and individualized care planning. The abuse allegation was determined unsubstantiated after investigation, but reporting failure was noted. The weight gain notification failures and fall prevention deficiencies were substantiated.

The facility failed to timely report resident-to-resident abuse for one incident, failed to notify physicians of significant daily weight gains for two residents with heart failure, and failed to provide adequate supervision and individualized fall prevention interventions for a resident with a history of falls.

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.

This Federal Tag relates to Complaint IN00399395.

The facility failed to ensure that staff reported suspicions of abuse or mistreatment of a resident to the Administrator. Multiple employees acknowledged hearing inappropriate language used by a staff member but did not report it as required by facility policy.

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).

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 IN00398423 was substantiated with related deficiencies cited at F812 regarding kitchen sanitation.

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.