Waters Of Wabash Skilled Nursing Facility East The
Inspection history, citations, penalties and survey trends for this long-term care facility in Wabash, Indiana.
- Location
- 1900 N Alber St, Wabash, Indiana 46992
- CMS Provider Number
- 155006
- Inspections on file
- 34
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Waters Of Wabash Skilled Nursing Facility East The during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities (including DM with neuropathy, PVD, CKD, CHF, and malnutrition), and documented risk for pressure ulcers had physician orders and care plan interventions for bilateral heel elevation, use of moon boots, skin protectants, and pressure-reducing devices. Surveyors repeatedly observed the resident in bed on an air mattress with a foot cradle in place but with both feet resting directly on the mattress, covered by blankets, and without moon boots or pillows offloading the heels. Staff interviews showed they believed wound prevention included moon boots, a foot cradle, air mattress, and repositioning, but CNAs relied on printed task sheets that only referenced a “foot buddy” and did not list heel offloading or moon boots. The care plan had been revised for new arterial/ischemic toe ulcers, yet the resident’s wound prevention interventions were not consistently implemented or accurately reflected on CNA documentation tools.
QMAs performed and documented wound care outside their legal scope of practice for a resident with a recurrent left great toe wound involving partial and full thickness loss. The MAR contained orders to cleanse and paint the toe with povidone iodine and leave it open to air on day and evening shifts, and multiple QMAs documented completing these treatments over several months. In interviews, QMAs stated they understood they were only allowed to apply creams and powders and not to treat stage 1 or open wounds, and one QMA admitted signing for treatments she did not perform while another stated she signed after watching a nurse perform the care. The DON believed QMAs could complete the toe treatment because it was open to air, but the state QMA scope of practice limited QMAs to minor skin conditions (including stage I decubitus) and prohibited them from administering treatments for advanced skin conditions such as stage II–IV decubitus ulcers or documenting medications not personally administered.
A resident with dementia, osteoporosis, and high dependence on staff for ADLs was subjected to verbally abusive and rough care by a CNA during toileting and hygiene assistance. While the resident resisted by clamping her legs, the CNA was reported to have pulled forcefully on the resident’s arm and stated, “we can do this the easy way or the hard way,” and to have told the resident to open her “da** legs.” Another CNA present reported feeling uncomfortable with the rude language and rough handling, and an RN was informed that the CNA had cursed and raised her voice toward the resident. The facility’s own incident report documented that the CNA was rude and used the phrase “open your da** legs,” which met the facility’s definition of verbal abuse.
A resident with dementia and major depressive disorder was involved in an incident where a CNA allegedly became aggressive after being scratched by the resident. The event was observed by a dietary manager and reported to the DON, but the Administrator did not report the allegation to the State Agency as required, citing lack of evidence and interpersonal conflicts among staff. The facility did not collect written witness statements or follow its abuse reporting policy, resulting in a deficiency for failure to report suspected abuse.
A facility failed to properly investigate and report an allegation of staff-to-resident abuse involving a resident with dementia. The incident, witnessed by a dietary manager, was not thoroughly documented or reported to the state as required by facility policy. The administrator did not collect written statements from all involved staff and did not separate the alleged perpetrator from resident contact during the investigation.
The facility employed a Dietary Manager who lacked the required certification and had not received any training since being hired. Leadership was aware of the lack of qualifications, and facility policy requiring a qualified Food Service Director was not followed, potentially affecting all residents receiving meals.
Surveyors observed unsanitary conditions in the kitchen, including improper storage of food and chemicals, unclean equipment and surfaces, and staff failing to follow safe food handling practices. These deficiencies had the potential to affect all residents receiving food from the kitchen.
Multiple residents and their representatives reported that meals were frequently cold, lacked flavor, appeared unappetizing, and were served in inconsistent and often insufficient portions. Observations confirmed issues with food temperature, presentation, and portion sizes, while grievances and council minutes documented ongoing dissatisfaction with meal quality and adequacy. Staff interviews and facility records acknowledged these concerns, indicating a systemic failure to meet standards for palatable and properly served meals.
Two residents were observed eating meals while seated in wheelchairs that were too low for the dining tables, causing difficulty in reaching food and drinks and requiring awkward postures. Both residents, who were cognitively intact and required some assistance with eating, experienced undignified dining conditions over multiple meals. Staff did not recognize the issue, and care plans included interventions to ensure proper positioning, but these were not effectively implemented.
The facility did not provide required Skilled Nursing Facility Advance Beneficiary Notices of Non-coverage (SNF ABN) to two residents who remained after their Medicare Part A skilled services ended. The Business Office Manager reported informing residents of private pay amounts but had never issued an ABN form, and clinical records lacked documentation of the required notice.
Two residents were found using wheelchairs that remained visibly soiled with food particles, stains, and unidentified substances over several days, despite a facility policy and cleaning schedule requiring regular deep cleaning. Staff interviews revealed inconsistent understanding of cleaning responsibilities, and the ADON confirmed the wheelchairs should have been cleaned as scheduled.
A resident with a history of repeated falls and severe cognitive impairment experienced multiple falls, but the care plan was not consistently updated with new interventions after each incident. Observations showed that some fall prevention measures, such as non-skid strips and reminder signage, were not properly implemented. Staff interviews confirmed that care plan updates and interventions were not always carried out as required.
A resident with severe cognitive impairment and multiple comorbidities was repeatedly observed lying in bed without the ordered moon boots to offload pressure from the heels, despite care plans and physician orders requiring their use. Staff interviews and documentation review confirmed that the intervention was not consistently implemented, and there was no record of resident refusal. The resident had a stage 3 pressure injury on the heel and additional skin breakdown, indicating a failure to follow prescribed pressure ulcer prevention measures.
A resident with a history of syncope, repeated falls, and a recent seizure did not have proper seizure precautions in place, as only one bed rail was partially padded and staff were unclear on correct procedures. The facility's policy lacked guidance on side rail padding, and maintenance staff were unfamiliar with installation requirements.
A resident with an arterial foot wound and multiple comorbidities did not have required enhanced barrier precautions implemented, including missing door signage and disposal bins for PPE, despite physician orders and care plans. Staff were unaware of the resident's EBP status due to lack of signage and documentation, resulting in noncompliance with facility policy.
A facility failed to maintain infection control practices during catheter care for a resident requiring Enhanced Barrier Precautions. A CNA did not wear a gown as required, despite EBP signage on the resident's door. The ADON confirmed the need for protective gear, as outlined in the facility's policy.
The facility failed to provide palatable food to 23 residents, with issues such as dry and cold meat, mushy vegetables, and inadequate grievance responses. Observations showed staff struggling to cut tough brisket, and residents reported inedible meals. The facility's policy lacked specific guidelines for meat preparation.
A CNA was observed handling bread with bare hands during meal service for 23 residents, violating the facility's infection control policy that prohibits bare hand contact with ready-to-eat foods. The CNA admitted to the oversight, acknowledging that gloves should have been used.
Failure to Implement and Update Wound Prevention Interventions for High-Risk Resident
Penalty
Summary
Surveyors identified a failure to implement ordered wound prevention interventions and to update the care plan for a resident with multiple comorbidities and high risk for skin breakdown. On several observations during the same day, the resident was seen lying on his back on an air mattress with his head elevated, with a foot cradle at the end of the bed, but his feet were directly on the mattress. At various times, his blankets covered one or both feet, and he wore a nonskid sock on the right foot, rather than having his heels elevated or protected as ordered. The foot cradle was in place only to keep blankets off the feet, and there was no evidence that pillows or moon boots were being used to offload the heels while he was in bed. Record review showed the resident had significant diagnoses including permanent atrial fibrillation, pulmonary fibrosis, type II DM with neuropathy, CHF, CKD, PVD, malnutrition, post-polio syndrome, and chronic pain. Physician orders included bilateral heel elevation off the bed with pillows every shift, Aquaphor to bilateral legs/feet twice daily, Pro-heal twice daily, and encouragement of moon boots at all times except for bathing and care. Additional orders were in place for daily wound care to multiple toes on the right foot. The MDS and Braden Scale documented that he was severely cognitively impaired, dependent for mobility and ADLs, at risk for pressure ulcers, and using pressure-reducing devices. A nurse’s note documented new areas on the toes discovered by a CNA during a shower, with wound measurements and treatment initiated. The resident’s care plan for increased risk of impaired skin integrity, revised earlier, included offloading heels at all times in bed, frequent repositioning, good pericare, barrier cream, and use of a pressure-reducing mattress. Later care plans were added for arterial/ischemic ulcers of the right great toe, right second toe distal, and right third toe proximal, with interventions such as daily foot inspection, keeping feet clean and dry, and wound observation and documentation. However, interviews with staff revealed that wound prevention interventions were understood to include moon boots, foot cradle, air mattress, and repositioning, but the resident was observed without heels offloaded and without moon boots in use. The DON stated the resident sometimes refused moon boots and that care plans were in the process of being updated. The ADON indicated CNAs followed printed CNA sheets rather than the electronic care plan, and the CNA sheets for this resident listed a “foot buddy to end of bed” but did not include heel offloading or moon boots, demonstrating that the resident’s wound prevention interventions were not fully implemented or reflected on the CNA task sheets.
QMAs Performed and Documented Wound Care Outside Scope of Practice
Penalty
Summary
Surveyors identified a deficiency in which Qualified Medication Aides (QMAs) performed and/or documented wound treatments outside their legal scope of practice for a resident with a left great toe wound. Resident D had multiple diagnoses, including chronic systolic heart failure, chronic pain syndrome, venous thrombosis history, malnutrition, atherosclerosis of the lower extremities, and restless legs syndrome. A NP wound note from late December documented that an earlier toe wound had resolved but a new wound on the left great toe had developed, initially suspected as an arterial ulcer and later classified as trauma-related. The wound was described as full thickness loss, dry, without drainage, and measured 0.8 cm x 1.2 cm x 0.1 cm. The January MAR ordered cleansing of the left great toe with povidone iodine and leaving it open to air on the day shift, with monitoring for infection or worsening, and QMA 5 documented completion of this treatment on two dates. In late January, nursing documentation indicated the resident’s left toe wound had reopened, was bleeding, and was wrapped with gauze, though the resident would not allow measurement. A February NP wound note recorded that the left great toe wound had reopened with partial thickness loss and measured 0.7 cm x 1.0 cm x 0.1 cm. The February MAR contained orders to cleanse the left great toe with povidone iodine and leave it open to air every day and evening shift, later specifying to cleanse and paint with povidone iodine and leave open to air, with monitoring for signs of infection or worsening. QMAs 5, 7, and 9 documented on multiple dates in February that they completed these wound treatments. A subsequent NP wound note in late February described the wound as stable, scabbed, with partial thickness loss and measuring 0.6 cm x 0.7 cm x 0.1 cm. In March, the MAR continued the order to cleanse and paint the left great toe with povidone iodine and leave it open to air every day and evening shift, with monitoring instructions, and QMAs 5, 7, and 9 again documented completion of these treatments on multiple dates. During interviews, QMA 5 stated that QMAs were allowed to apply creams and powders but not to treat any stage 1 or higher wounds, and acknowledged it was possible she signed for Resident D’s wound treatments even though the wound had worsened and QMAs had stopped doing the treatment. QMA 9 stated QMAs could apply creams and powders but not treat stage 1 or open wounds, and reported that she watched a nurse complete Resident D’s wound treatment but signed it off in the MAR herself, believing she could apply povidone iodine to a wound. QMA 7 similarly indicated QMAs were not allowed to complete treatments above a stage 1 or on open wounds and said she had not completed the resident’s wound treatments because he had a “crater” on his toe. The DON, however, indicated QMAs could not complete wound treatments above stage 2, wounds with bandages, or invasive treatments, but believed QMAs could complete this resident’s wound treatment because the toe was left open to air. The state QMA scope of practice obtained from IDOH specified that QMAs may apply topical medications only to minor skin conditions, including stage one decubitus ulcers, and may not administer treatments involving advanced skin conditions such as stage II–IV decubitus ulcers, and also may only document medications they personally administered, not those given by another person or not administered at all.
Failure to Protect a Dependent Resident From Verbal and Rough Care During ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and potential physical abuse during the provision of care. Resident C, who had dementia, osteoporosis, and significant dependence on staff for ADLs including toileting, dressing, and bed mobility, required assistance and redirection as needed. During an episode of care, CNA 4 reported that CNA 3 approached Resident C and began pulling on the resident’s arm in a forceful manner. While Resident C was clamping her legs shut, CNA 3 told the resident to open her “da** legs” and stated, “we can do this the easy way or the hard way.” According to CNA 4, Resident C did not become combative until CNA 3 began roughly yanking on the resident’s arm. CNA 3 acknowledged to the Administrator that she used the phrase “we can do this the easy way or the hard way,” claiming it was said under her breath and that she did not intend harm, and she recalled telling the resident to open her legs but denied using a curse word or pulling the resident’s arm forcefully. CNA 4’s statement indicated that CNA 3 used rude language and had been rough with Resident C, and that CNA 3 firmly grasped the resident’s arm while the resident was combative. RN 5 reported that CNA 4 came to her after the care episode, stating that CNA 3 had cursed and raised her voice toward the resident, which made CNA 4 uncomfortable. The facility’s self-reported incident to the state indicated that CNA 3 was rude to the resident and told the resident to open her “da** legs.” The facility’s abuse policy defined verbal abuse as the use of disparaging or derogatory language within a resident’s hearing, regardless of the resident’s ability to comprehend, and the documented conduct of CNA 3 met this definition.
Failure to Report Alleged Staff-to-Resident Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the State Agency as required. The incident involved a resident with diagnoses of dementia and major depressive disorder, who was severely cognitively impaired and required behavioral monitoring. During a lunch service, a dietary manager observed a CNA become aggressive with the resident after the resident scratched the CNA's hand while both reached for a drink. The CNA reportedly grabbed the resident's wrists and loudly told the resident not to scratch her. The dietary manager reported the incident to the DON and later inquired if her written statement was needed, but was told by the Administrator that it was not necessary. The Administrator, who was ill at the time of the incident, indicated that he did not believe the event was reportable and did not submit a report to the State Agency. He conducted an internal investigation, which included interviews with the involved CNA and other staff, but found no evidence to substantiate the allegation. The Administrator also noted interpersonal conflicts between the dietary manager and the CNA, which influenced his perception of the credibility of the report. The DON confirmed that she had notified the Administrator of the allegation and that no written statements were collected from the witnesses at the time. Facility policy required that all allegations or suspicions of abuse be immediately reported to the Administrator and the State Agency, and that written statements from witnesses be collected within 24 hours. Despite these requirements, the facility did not report the incident to the State Agency, did not collect written statements from all involved parties, and did not document the incident in accordance with policy. The failure to report the allegation and follow established procedures resulted in noncompliance with regulatory requirements for abuse reporting.
Failure to Investigate and Report Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of staff-to-resident abuse and did not implement its abuse prevention policy following an incident involving a resident with dementia and major depressive disorder. An anonymous allegation was received by the state regarding a staff member becoming aggressive with a resident during lunch. The Dietary Manager (DM) reported witnessing a certified nursing assistant (CNA) grab the resident's wrists and speak loudly after the resident scratched the CNA. The DM attempted to report the incident to the Director of Nursing (DON) and the Administrator, but the Administrator later indicated there were no findings and did not request a written statement from the DM. Interviews revealed inconsistencies in the facility's response to the allegation. The Administrator stated he was unaware of any abuse reports or grievances in the relevant period and did not consider the incident reportable. He also questioned the reliability of the DM as a witness due to prior conflicts between the DM and the CNA. The DON recalled the DM reporting the incident and attempting to check security cameras, but did not recall collecting written statements from involved staff. The facility's own policy required immediate reporting, separation of the alleged perpetrator, documentation, and notification to the state, none of which were fully followed. The resident involved was severely cognitively impaired and required cues for eating. Clinical records indicated behavioral symptoms related to dementia, but no physical or verbal aggression was documented during the assessment period. The facility's documentation of the incident was created over a month after the event and did not include timely written statements from all witnesses. The facility did not ensure that all required investigative steps were taken or that residents were protected according to policy following the allegation.
Unqualified Dietary Manager Employed Without Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications and completed the necessary education to serve in that role. The Dietary Manager, who was hired in December 2024, reported during an interview that she did not possess certification qualifying her to act as Dietary Manager and had not received any training at the time of hire or since. Both the Administrator and the Regional Director of Operations confirmed their awareness that the Dietary Manager was not certified and had been employed in the position since December 2024. Facility policy requires the employment of a qualified Food Service Director per regulatory requirements, but this standard was not met, potentially impacting all 56 residents who received meals from the facility kitchen.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store and prepare food under safe and sanitary conditions, as evidenced by multiple observations in the kitchen. Surveyors observed an open container of brown sugar with a scoop handle inside the sugar, a microwave with dried food splatters, and upper cabinets with visible food splatters. Discarded kitchen gloves and empty coffee packets were found on the countertop, and the floor beneath was covered with corn flakes. The toaster had crumbs on both the spill tray and countertop, with scissors lying among the crumbs and an uncovered container of melted butter on top. The refrigerator had sticky fingerprints on the exterior and contained a roast beef in a zip lock bag that was past its date. Utensil drawers contained crumbs, a brown substance, and torn paper, and an open bag of panko breadcrumbs was stored improperly under a counter. In the dry storage area, chemicals such as bleach and floor cleaner were stored on the floor beneath electrical panels. Additionally, a kitchen staff member was observed improperly emptying a can of green beans, allowing the lid to repeatedly touch the food, which the Dietary Manager acknowledged was incorrect and attributed to lack of training. The chemicals in the dry storage area remained improperly stored during subsequent observations. Facility policies required clean, sanitary, and safe food storage and preparation, as well as proper cleaning schedules and staff training, but these were not followed, resulting in unsanitary conditions that had the potential to affect all residents receiving food from the kitchen.
Failure to Provide Palatable, Attractive, and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at a safe and appetizing temperature for 17 of 31 residents reviewed. Multiple residents and their representatives reported that the food was consistently cold, lacked flavor, was unappetizing in appearance, and was sometimes served in insufficient portions. Specific complaints included hard rolls, unidentifiable or flavorless soups, watered-down drinks, and inconsistent portion sizes. Observations confirmed that food items such as meatloaf appeared grayish and unappealing, mashed potatoes and gravy lacked flavor, and pudding portions varied between residents. Residents also reported receiving meals late, with some meals missing items listed on the menu or being substituted with less desirable options due to shortages. Grievances and resident council minutes further documented ongoing dissatisfaction with the quality, temperature, and quantity of food served. Residents described meals as poorly cooked, insufficient to satisfy hunger, and sometimes inedible, with examples such as undercooked French fries, very small portions of pizza, and missing condiments like butter or sour cream. Several residents indicated they relied on snacks or food brought in by family members to supplement their meals due to the inadequacy of the facility's food service. The issues were persistent, with complaints spanning several months and being raised repeatedly in resident council meetings and formal grievances. Staff interviews and facility records acknowledged the residents' dissatisfaction, with staff noting inconsistent food temperatures, portion sizes, and presentation. The facility's own policy required that food be prepared, held, and served in a manner that maintains its nutritive value and palatability, but observations and resident feedback indicated this standard was not consistently met. The deficiency was evident through direct resident interviews, observations of meal service, review of grievances, and resident council minutes, all pointing to a systemic failure to provide meals that met residents' expectations for palatability, temperature, and adequacy.
Failure to Provide Dignified Dining Experience Due to Improper Table and Wheelchair Positioning
Penalty
Summary
Surveyors observed that two residents were not provided with a dignified dining experience during multiple meal services in the main dining room. Both residents were seated in wheelchairs that were significantly lower than the dining tables, resulting in their chins being at or below the tabletop. This positioning made it difficult for them to eat and required them to reach upward for their food and drinks. One resident was seen eating while hunched over and leaning to the right, and both had to lift their cups from below the table to drink. Staff interviews revealed that CNAs did not perceive the table height as a problem and were unsure if the tables could be adjusted. Neither resident had complained about the table height, and the ADON had not previously considered the issue. The clinical records for both residents indicated they were cognitively intact and required setup or clean-up assistance with eating. One resident had diagnoses including dementia, osteoarthritis, and heart failure, while the other had altered mental status, dysphagia, epilepsy, and adult failure to thrive. Care plans for both residents included supervision and assistance during meals, with interventions to ensure they were close enough to the table to reach food and drink properly. Facility policy stated that residents' needs and preferences should be honored as much as possible, considering their health status and safety.
Failure to Provide Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide required notification of Medicare non-coverage to two residents who remained in the facility after their Medicare Part A skilled services ended. For both residents, the clinical records did not contain a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) after their last covered day under Medicare Part A. During an interview, the Business Office Manager stated that she informed residents or their representatives of private pay amounts but had never provided an ABN form to any resident. The facility's current policy referenced providing a detailed explanation of non-coverage, but there was no evidence that the required SNF ABN was issued to the affected residents.
Failure to Maintain Clean Wheelchairs for Two Residents
Penalty
Summary
The facility failed to provide clean and sanitary wheelchairs for two residents, as evidenced by multiple observations over several days. One resident's wheelchair was repeatedly found with smeared dark and reddish-brown substances, as well as honey-colored streaks on the outer panels. Despite a cleaning schedule indicating that deep cleaning should occur every Wednesday night, the wheelchair remained visibly soiled during several observations. Staff interviews revealed inconsistent understanding of cleaning responsibilities, with some indicating that third shift CNAs were responsible for deep cleaning, while others stated it was the responsibility of all staff members. Another resident's wheelchair was observed to have a nickel-sized dark brown substance on the right arm pad, a buildup of food particles and stains on the left side of the seat, and additional unidentifiable streaks and crumbs on various parts of the wheelchair. These conditions persisted over several days, despite the facility's policy requiring durable medical equipment to be clean and in good repair. The Assistant Director of Nursing confirmed that the wheelchairs should have been cleaned according to the schedule, but the deficiencies remained unaddressed at the time of the observations.
Failure to Update Care Plan and Implement Fall Precautions After Multiple Falls
Penalty
Summary
The facility failed to implement fall precautions and update care plan interventions following multiple falls for a resident with significant risk factors. The resident had diagnoses including syncope, repeated falls, chronic kidney disease, and severe cognitive impairment. Despite a history of falls and specific care plan interventions in place, the care plan was not consistently updated with new interventions after each fall event, as required by facility policy and regulatory standards. Several incidents were documented where the resident experienced falls, including being found on the floor in another resident's room, in front of her wheelchair, and by her bed. After some of these falls, such as those on 12/21/25, 4/13/25, and 5/19/25, there was no evidence that new interventions were added to the care plan. In one instance, a new intervention (pommel cushion) was added after a fall, but this was not consistently done after subsequent incidents. Staff interviews confirmed that new interventions should be implemented after each fall, but this was not always carried out. Observations also revealed that some existing interventions were not properly implemented, such as the use of non-skid strips and signage to remind the resident to ask for assistance. The non-skid strips were smaller than intended, and the required signage was missing from the resident's room. Staff interviews corroborated these findings, indicating a lack of adherence to the care plan and facility policy regarding fall prevention and care plan updates.
Failure to Consistently Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement prescribed interventions to prevent and promote the healing of a pressure injury for one resident. Multiple observations over several days showed that the resident, who was severely cognitively impaired and dependent on staff for mobility and care, was repeatedly found lying on his back in bed without his ordered moon boots, which are designed to offload pressure from the heels. Despite physician orders and care plan interventions specifying the use of moon boots while in bed and the need to float the resident's heels, staff did not consistently apply these devices. The moon boots were frequently observed on a chair or chest of drawers rather than on the resident, and his heels were not floated as required. Interviews with staff confirmed that the resident was supposed to have the moon boots on while in bed, and that this was a standing order signed off every shift. However, there was no documentation of the resident refusing the intervention, and staff acknowledged that the boots were not always applied. The resident's representative also reported that the resident was not repositioned for extended periods and that the moon boots were only used about half the time. The resident had a history of pressure injuries, including a stage 3 pressure injury on the left heel that developed after admission, as well as sores on his back and buttocks. Clinical record review indicated ongoing wound care treatments and preventative interventions, including the use of a pressure-relieving mattress, hydrophilic wound dressings, and regular wound assessments. Despite these measures, the lack of consistent application of the moon boots and failure to float the heels as ordered contributed to the deficiency. Facility policy required the use of specialty boots or floating heels for residents at high risk for skin breakdown, but this was not consistently followed for this resident.
Failure to Implement Seizure Precautions for Resident
Penalty
Summary
The facility failed to implement appropriate seizure precautions for a resident with a history of syncope, repeated falls, and a recent seizure episode. The resident, who was severely cognitively impaired and required significant assistance with activities of daily living, experienced an unwitnessed fall and a witnessed seizure within the same day. Medical orders and care plans specified the use of two, one-half padded side rails as a seizure precaution, and interventions included ensuring proper body alignment and padding of side rails as needed. Upon observation, only one side rail was partially padded with a pool noodle, leaving parts of the rail exposed, while the other rail was not padded at all. Interviews with staff revealed uncertainty regarding the correct application of padding for seizure precautions, and the Director of Nursing confirmed that maintenance staff were unfamiliar with the installation of side rail pads due to the infrequent use of seizure precautions in the facility. The facility's policy on seizure precautions did not provide instructions for side rail pad application.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to consistently implement its policy for enhanced barrier precautions (EBP) for a resident with a wound requiring such precautions. Multiple observations over several days showed that the resident, who had an arterial wound on his right foot and was under orders for EBP, did not have the required signage for transmission-based precautions on his door. Additionally, the necessary bins for disposal of personal protective equipment (PPE), trash, and laundry were not present in the resident's room until after the deficiency was identified. Staff interviews revealed that certified nursing assistants (CNAs) relied on door signage and assignment sheets to identify residents on EBP, but the resident in question was not listed or marked appropriately, leading to confusion about his precaution status. The resident had significant medical conditions, including chronic diastolic heart failure, peripheral vascular disease, multiple myeloma, and a protein calorie deficit, and required substantial staff assistance for daily activities. Despite care plans and physician orders indicating the need for EBP due to his wound, the infection preventionist had not placed the required signage, and staff were unaware of the resident's EBP status. The facility's policy, revised in December 2022, required proper signage and receptacles for EBP, but these measures were not implemented as ordered for this resident.
Infection Control Lapse During Catheter Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices during urinary catheter care for a resident who required Enhanced Barrier Precautions (EBP). During an observation, a Certified Nursing Assistant (CNA) performed hand hygiene with soap and water before donning gloves but failed to wear a gown before starting the catheter care for the resident. The resident had EBP signage displayed on the door, indicating the need for additional protective measures during care. Interviews conducted during the observation revealed that the CNA acknowledged the failure to don a gown before providing catheter care. The Assistant Director of Nursing (ADON) confirmed that staff members were required to wear a gown, gloves, goggles, and a mask before performing catheter care on residents requiring EBP. The facility's EBP sign and catheter care policy outlined the necessary infection prevention and control techniques, which were not adhered to in this instance.
Deficiency in Food Quality and Palatability
Penalty
Summary
The facility failed to provide palatable food to 23 residents in the main dining room during meal service. Observations and interviews revealed that residents experienced issues with the quality and temperature of the food. Resident 19 reported that the meat was dry and there were delays in service. Resident 12 mentioned that the meat was hard and the food was often cold when served in her room. During meal observations, a CNA struggled to cut brisket with a butter knife, indicating the meat's toughness. Resident 16 found her meal inedible and requested a salad instead. A test tray confirmed that the brisket was dry and the green beans were mushy and flavorless. The facility's grievance binder showed previous complaints about the food quality, including grievances from Resident 47 about cold meat and Resident 16 about dry meat and other food issues. The responses to these grievances were inadequate, as they did not fully address the concerns. The Regional Nurse Consultant acknowledged the difficulty in providing perfectly cooked food daily. The facility's policy on general preparation and cooking practices did not specifically address meat preparation or ensuring palatable food, contributing to the deficiency.
Infection Control Breach During Meal Service
Penalty
Summary
The facility failed to adhere to infection control practices during meal service for 23 residents in the main dining room. During a meal observation, a CNA was seen handling bread with bare hands on two separate occasions, contrary to the facility's policy that prohibits bare hand contact with ready-to-eat foods. This incident was confirmed during an interview with the CNA, who acknowledged that gloves should have been used when handling the bread. The facility's policy on meal service, provided by the Administrator, clearly states that there should be no bare hand contact with ready-to-eat foods.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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