Inspection Reports for
The Waters of Dunkirk Skilled Nursing Facility

The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies were identified in emergency lighting documentation, sprinkler system maintenance, corridor door latching, electrical receptacle grounding, fire damper inspection, fire drill documentation, emergency generator testing, automatic transfer switch indicators, and patient care related electrical equipment maintenance.

The facility was cited for deficiencies including failure to post survey results at an accessible height, failure to notify resident representatives in writing of transfer/discharge appeal rights, failure to follow menus and resident preferences, poor palatability of meals, and inadequate sanitation and food storage practices in the kitchen.

Complaint IN00448842 was substantiated with federal/state deficiencies cited at F689 related to the allegations of improper physical transfers causing injury.

The facility failed to identify the number of staff needed for physical transfers and to ensure transfers were provided consistently for a resident requiring extensive assistance, resulting in a fracture to the resident's right ankle. The investigation included review of clinical records, interviews, and observations confirming inconsistent transfer practices and lack of staff awareness.

The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included issues with exit door locking, hazardous area enclosure, unsecured electrical panels, improper use of power strips, and lack of mechanical ventilation in the oxygen storage room.

Complaint IN00409625 was substantiated with federal and state deficiencies cited at F726 and F835 related to medication administration by unqualified personnel.

The facility failed to ensure residents received medications, including insulin injections, from qualified nursing personnel. An unlicensed nursing student administered medications to five residents during a job shadowing activity without proper authorization or facility policy, potentially affecting all 41 residents.

Complaint IN00406798 was substantiated with federal/state deficiencies cited at F684 related to quality of care and failure to properly assess and document bruising on Resident B.

The facility failed to assess and document bruising of unknown origin on a resident's hand (Resident B) during a respite stay. The bruising was noted but not properly documented or investigated, and the resident was discharged with a significant bruise and fracture. The facility implemented corrective actions including staff education and increased skin assessments.

The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including exit door accessibility, fire alarm system maintenance, fuel-fired water heater inspections, ground fault circuit interrupter functionality, smoking policy enforcement, fire door inspections, kitchen serving door operation, and power strip usage.

The facility was found deficient for failing to develop and implement interventions to reduce the risk of falls for one resident, resulting in a fall with fracture requiring hospitalization. The facility requested a desk review due to the low scope and severity and only one deficiency cited.

Complaint IN00397976 was substantiated with federal/state deficiencies cited at F802, F803, and F812.

The facility failed to ensure dietary employees were competently trained in food storage, safe food temperatures, and completion of dietary duties; menus were not approved by a Registered Dietitian and lacked proper guidance for diet types; and food was not prepared, stored, and served under safe and sanitary conditions, potentially impacting all 40 residents.