F0561

D

Failure to Honor Cognitively Intact Residents’ Right to Free Movement and Outdoor Access

Wabash, Indiana Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The facility failed to honor residents' rights to self-determination and freedom of movement by restricting cognitively intact residents from independently accessing other areas of the building and the outdoors. During a Resident Council group interview, three residents living on the third floor reported they were prohibited from going to the first floor or the outdoor patio without staff supervision. Barriers included an elevator that required a keypad code, which was not shared with residents, and a locked exterior door to the patio. These restrictions prevented them from visiting common areas such as the first-floor aquarium, the lobby, and the outdoor seating area at will; one resident reported being prevented from going to the lobby to collect cups for coffee the previous evening. All three residents expressed a desire for independent access to facility amenities and the outdoors and stated the facility felt like a prison.

Record review showed that each of the three residents was assessed as cognitively intact and without hallucinations, delusions, or behavioral issues. One resident had diagnoses of anxiety, depression, and vitamin D deficiency, and her MDS indicated it was very important for her to go outside for fresh air when weather permitted. Another resident had anxiety, vitamin D deficiency, and psoriatic arthritis, was able to transfer independently in her wheelchair, and her MDS also indicated it was very important for her to go outside for fresh air when weather permitted. The third resident had type 2 diabetes, insomnia, heart failure, chronic pain, and Parkinson's disease, was able to transfer independently in his wheelchair, and his MDS likewise documented that it was very important for him to go outside for fresh air when weather permitted.

Care plans for all three residents documented that they enjoyed going outside in good weather and were to participate in activities of their choice, with assistance or reminders as needed. However, the March activities calendar for the third floor contained no scheduled outdoor activities. The AD stated that residents could go outside only when weather permitted and when a staff member was available to accompany them, and that some residents would be fine to go outside unsupervised but corporate required supervision. The DON confirmed that third-floor residents were not given the elevator code because some residents on that floor were elopement risks, that the outside patio door was locked due to a past elopement, and that aides did not have time to take residents downstairs or outside, so they were to contact the AD to do so. The Administrator acknowledged there was no policy for keeping the third floor secured, that residents were not allowed to have the elevator code, that residents had to be supervised to go outside, and that there was no policy for residents going outside, despite a facility Resident Rights policy stating residents must be able to exercise their rights without interference, coercion, discrimination, or reprisal.