Inspection Reports for
The Waters of Fort Wayne Skilled Nursing Facility

The complaint investigation was triggered by allegations that Resident C did not receive Coumadin as ordered, resulting in fluctuating lab results, and concerns about falls and injury assessments for Resident H. The investigation found substantiated issues with medication administration, fall prevention, injury assessment, and documentation.

The facility failed to ensure proper administration and monitoring of anticoagulant therapy for one resident, failed to adequately assess injuries and prevent falls for another resident, and failed to maintain complete and accurate documentation related to falls, hospice services, and anticoagulant therapy for two residents.

The facility was found deficient in ensuring proper grooming for residents, maintaining resident weight, labeling medications with opened dates, and maintaining complete temperature logs for food storage and preparation areas. Several residents had unmet care needs related to facial hair grooming and weight maintenance. Medication carts had unlabeled or improperly labeled medications. Food temperature logs were incomplete or missing for refrigerators, freezers, and the dishwasher.

The facility was found in compliance with Emergency Preparedness Requirements and in substantial compliance with Life Safety Code requirements. One deficiency was cited related to failure to maintain the automatic sprinkler system antifreeze concentration according to NFPA standards, which was corrected with a plan of correction.

The facility was found not in compliance with emergency preparedness requirements including failure to conduct required emergency plan exercises and failure to maintain emergency power system testing. Life safety deficiencies included dead-end corridors exceeding 30 feet, missing exit signage, fire suppression system issues, interior wall finish flame spread documentation missing, sprinkler system antifreeze testing below required levels, unsecured portable fire extinguishers, resident room doors not fully smoke resistant or latching, penetrations in smoke barriers not properly sealed, missing electrical outlet cover plates and lack of GFCI protection, incomplete fire door inspections, incomplete electrical receptacle testing documentation, failure to exercise diesel generator annually, and improper use of power strips and extension cords.

The facility failed to follow physician orders for weight monitoring for 2 of 16 residents reviewed, resulting in missed or undocumented weights and lack of physician notification for significant weight changes. Additionally, the facility failed to monitor side effects of antipsychotic medication for 1 of 5 residents reviewed.

Complaint IN00440344 and Complaint IN00440916 were investigated with no deficiencies related to the allegations cited.

The facility was found deficient in following physician orders regarding weight monitoring for 2 of 16 residents reviewed and failed to monitor side effects of antipsychotic medication for 1 of 5 residents reviewed. No deficiencies were cited related to the complaints investigated.

This inspection relates to Complaint IN00431619 regarding fall follow-up and Complaint IN00432307 regarding trauma-informed care and resident modesty.

The facility failed to properly assess and follow up on acute changes in condition for a resident after two falls, resulting in injuries and hospitalization. Additionally, the facility failed to provide trauma-informed care for another resident, neglecting to respect her need for modesty and privacy during care.

This investigation was triggered by complaints IN00431619, IN00432307, and IN00432367. Deficiencies related to complaints IN00431619 and IN00432307 were substantiated with citations at F689 and F699 respectively. Complaint IN00432367 was not substantiated with deficiencies.

The facility failed to ensure proper identification, assessment, and follow-up for acute changes in condition following two falls for one resident (Resident B). Additionally, the facility failed to provide trauma-informed care by identifying triggers and initiating resident-specific approaches for another resident (Resident C).

This citation is related to complaint numbers IN00425818 and IN00426133. The complaints were substantiated as staff were found to have verbally abused Resident B.

The facility failed to ensure residents were free from abuse, specifically verbal abuse by staff toward Resident B. Two staff members were found to have spoken inappropriately to Resident B and were terminated following the investigation.

The investigation was triggered by complaints IN00425818 and IN00426133. Both complaints were substantiated with federal/state deficiencies cited at F600 related to abuse allegations.

The facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed (Resident B). Investigations confirmed inappropriate verbal abuse by staff members, resulting in termination of involved employees and implementation of corrective actions including staff education and ongoing monitoring.

Complaint IN00417508 related to inadequate dementia care, failure to implement individualized interventions, and insufficient management of aggressive behaviors and psychosocial needs.

The facility failed to develop and implement individualized care plans and activities for dementia residents, resulting in inadequate management of behaviors, insufficient non-pharmacological interventions, and incidents of physical altercations and injuries among residents. Staffing shortages and lack of structured dementia programming were also noted.

Complaint IN00417508 was substantiated with federal and state deficiencies cited at F744 related to inadequate dementia care and failure to prevent resident-to-resident altercations.

The facility failed to develop and implement individualized interventions for dementia care to support psychosocial well-being and address aggressive behaviors for two residents. Observations, interviews, and record reviews revealed inadequate activity programming, insufficient non-pharmacological interventions, multiple incidents of resident-to-resident altercations, and extensive bruising without proper documentation or care plan updates.

The facility was found not in compliance with emergency preparedness training requirements, battery backup emergency lighting testing, access to electrical power panels, and oxygen storage room signage. Deficiencies included failure to conduct annual emergency preparedness training, failure to test emergency lighting monthly and annually, blocked access to electrical panels, and missing caution signage on the oxygen storage room.

The facility was found deficient in communicating resident code status accurately, maintaining kitchen sanitation for residents, and having a formal QAPI process. Deficiencies were noted in documentation of code status changes, kitchen cleanliness, and quality assurance policies.

The facility was found deficient in ensuring timely communication of residents' code status changes, maintaining kitchen sanitation and food safety standards, and implementing an effective Quality Assurance Performance Improvement (QAPI) program. Deficiencies were noted in code status documentation for one resident, unsanitary kitchen conditions affecting all residents, and failure to have a fully effective QAPI process for all residents.

Complaint IN00392499 was substantiated. The complaint involved failure to implement fall interventions and update care plans for residents at risk of falls.

The facility failed to implement fall interventions and update care plans to prevent further falls for 2 of 3 residents reviewed (Resident U and Resident V). Multiple falls occurred without proper fall investigation, root cause analysis, or care plan updates. The facility policy requires fall investigations, root cause analysis, and care plan updates, but these were not consistently followed.

The facility was found to have deficiencies related to failure to identify and maintain code status for residents, incomplete transfer and discharge documentation, failure to monitor side effects of psychotropic medications, and incomplete quality assurance efforts regarding advance directives.