Inspection Reports for The Waters of Rockport Skilled Nursing Facility
815 W WASHINGTON ST, IN, 47635
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 27, 2025, identified a deficiency related to bedroom size requirements, with a continuing waiver approved for this issue. Earlier inspections showed a pattern of deficiencies in resident care, medication management, and life safety code compliance, including issues with emergency preparedness, staffing documentation, and food temperature. Several complaint investigations were substantiated, notably involving pressure ulcer prevention, medication delivery failures, and safe discharge planning, though many complaints were unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with regulatory compliance, particularly in safety and care documentation, with some improvements noted in life safety and emergency preparedness over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
16.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
293% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 32
Capacity: 32
Deficiencies: 1
Jun 27, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 5/23/25.
Findings
The Waters of Rockport Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey. A continuing annual waiver was approved for the deficiency related to bedroom size requirements.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Bedrooms did not meet the requirement of at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms. | SS=E |
Report Facts
Census: 32
Total Capacity: 32
Medicare Census: 2
Medicaid Census: 19
Other Payor Census: 11
Inspection Report
Life Safety
Census: 34
Capacity: 60
Deficiencies: 17
Jun 17, 2025
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with several emergency preparedness and life safety requirements including failure to exercise the emergency generator monthly at required load, lack of proper generator annunciator placement, inadequate maintenance of battery operated smoke alarms, malfunctioning hazardous area doors, incomplete kitchen exhaust system inspections, fire alarm system deficiencies, sprinkler system maintenance issues, smoke barrier door malfunctions, incomplete fire drill documentation, improper use of power strips, lack of annual inspection of oxygen room fire door, incomplete testing of patient care related electrical equipment, unsecured oxygen cylinders, and inadequate mechanical ventilation in the oxygen storage room.
Severity Breakdown
SS=F: 10
SS=E: 5
SS=C: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to exercise emergency generator monthly at required load and lack of annual load bank test. | SS=F |
| Emergency generator annunciator panel not located at a regularly staffed nurses station. | SS=F |
| Failed to conduct preventative maintenance for battery operated smoke alarms according to manufacturer's instructions (weekly testing required, only monthly done). | SS=F |
| Hazardous area door (Laundry room) did not close completely and latch automatically. | SS=E |
| Kitchen exhaust system inspections not conducted semiannually as required. | SS=C |
| Fire alarm system not maintained properly; heat detector hanging loosely from ceiling. | SS=E |
| Sprinkler head covered with grease and dust; sprinkler gauges not replaced or tested within 5 years; damaged ceiling in sprinklered smoke compartment. | SS=F |
| Two sets of smoke/fire barrier doors did not close completely to form smoke resistant barrier. | SS=F |
| Fire drills lacked documentation of transmission of fire alarm signal to monitoring company for 8 of 12 drills. | SS=F |
| Failed to conduct annual inspection and testing of oxygen room fire door assembly. | SS=E |
| Incomplete documentation for annual testing of non-hospital grade electrical receptacles in resident rooms. | SS=F |
| Emergency generator annunciator panel not located at a regularly staffed nurses station (repeat of earlier deficiency). | SS=F |
| Failed to exercise emergency generator monthly at required load and lack of annual load bank test (repeat of earlier deficiency). | SS=F |
| Power strips used as substitute for fixed wiring in resident rooms. | SS=E |
| Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE). | SS=F |
| Oxygen cylinders not properly secured from falling in oxygen storage/transfilling room. | SS=E |
| Oxygen storage/transfilling room exhaust fan covered with dirt/dust and not properly maintained. | SS=E |
Report Facts
Certified beds: 60
Census: 34
Fire drill reports missing transmission documentation: 8
Resident rooms with power strip use: 2
Sprinkler gauges past due: 4
Oxygen cylinders unsecured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Walker | Administrator | Named in multiple findings and exit conferences |
| Maintenance Director | Interviewed and acknowledged multiple deficiencies including generator load testing, smoke alarm testing, door malfunctions, and oxygen cylinder storage |
Inspection Report
Annual Inspection
Census: 30
Capacity: 30
Deficiencies: 8
May 23, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 19 to May 23, 2025.
Findings
The facility was found deficient in multiple areas including chemical restraint use, accuracy of assessments, fall prevention and supervision, staffing posting, dementia care, dietary staff certification, medication and treatment documentation, and room size compliance. Several residents experienced adverse outcomes such as falls with injury and ineffective medication management.
Severity Breakdown
SS=D: 3
SS=G: 1
SS=C: 1
SS=E: 3
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure a resident's medication regimen was free from chemical restraints, resulting in increased confusion and ineffective anxiety control for Resident 28. | SS=D |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for 3 residents related to PASRR screening, antibiotic use, and UTI diagnoses. | SS=D |
| Failed to ensure adequate supervision and fall prevention interventions for a high-risk resident with dementia, resulting in multiple falls and fractures. | SS=G |
| Failed to post nurse staffing sheets for the correct day for 5 consecutive days during the survey. | SS=C |
| Failed to provide appropriate treatment and services to maintain highest practicable well-being for a resident with dementia, resulting in increased restlessness and falls. | SS=D |
| Dietary manager was not certified in food service at the time of survey. | SS=E |
| Failed to ensure accurate documentation on Medication Administration Records (MAR) and Treatment Administration Records (TAR) for 4 residents; multiple medication doses and treatments were left blank. | SS=E |
| Failed to provide at least 80 square feet per resident in double occupancy rooms and 100 square feet in single occupancy rooms in 14 resident rooms. | SS=E |
Report Facts
Survey dates: 5
Census: 30
Total capacity: 30
Number of falls: 10
Room size: 77.32
Room size: 90.52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Walker | Health Facility Administrator (HFA) | Signed the inspection report |
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 1
Feb 3, 2025
Visit Reason
This visit was for the investigation of complaints IN00452313, IN00452187, and IN00451981. The investigation focused on allegations related to pressure ulcer prevention and care.
Findings
The facility failed to ensure services were provided to prevent the development of pressure ulcers for one resident reviewed. Specifically, Resident D's care plan lacked timely interventions to prevent pressure ulcers after being assessed at moderate risk, and documentation of routine turning and repositioning was missing prior to 1/27/25. The facility policy and staff interviews confirmed the requirement for timely care plan updates and repositioning.
Complaint Details
Complaint IN00452313 was substantiated with federal/state deficiencies cited at F686 related to pressure ulcer prevention. Complaints IN00452187 and IN00451981 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure services were provided to prevent the development of pressure ulcers for Resident D, including lack of timely care plan interventions and documentation of turning/repositioning. | SS=D |
Report Facts
Residents present: 38
Total licensed capacity: 38
Medicare residents: 5
Medicaid residents: 23
Other payor residents: 10
Pressure ulcer measurements: 5
Pressure ulcer measurements: 4.2
Pressure ulcer measurements: 6
Pressure ulcer measurements: 4.9
Pressure ulcer measurements: 4.3
Pressure ulcer measurements: 11
Pressure ulcer measurements: 9.5
Pressure ulcer measurements: 4.5
Pressure ulcer measurements: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Walker | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing (DON) | Interviewed regarding care plan updates and pressure ulcer prevention policies | |
| LPN 4 | Interviewed regarding CNA documentation of turning and repositioning |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 3, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00452313.
Findings
The Waters of Rockport Skilled Nursing was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Complaint Details
Investigation of Complaint IN00452313; the facility was found to be in compliance.
Inspection Report
Complaint Investigation
Census: 37
Capacity: 37
Deficiencies: 1
Jan 23, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00451695 and IN00451740. Complaint IN00451695 had no deficiencies related to the allegations, while complaint IN00451740 resulted in federal/state deficiencies related to food temperature.
Findings
The facility failed to ensure residents received food at safe and appetizing temperatures, with observed meal trays testing below safe temperature standards. Resident interviews and grievances indicated ongoing issues with food temperature and quality.
Complaint Details
Complaint IN00451695 was not substantiated with deficiencies. Complaint IN00451740 was substantiated with deficiencies related to food temperature.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents received food at safe and appetizing temperatures. | SS=E |
Report Facts
Census: 37
Total Capacity: 37
Meal tray temperature: 89
Meal tray temperature: 76.3
Medicare census: 4
Medicaid census: 22
Other payor census: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Walker | HFA | Facility representative signing the report |
| Administrator | Interviewed regarding food temperature expectations and policy | |
| Dietary Manager | Responsible for conducting daily tray temperature audits as part of corrective action |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 23, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00451740 survey completed on January 23, 2025.
Findings
The Waters of Rockport Skilled Nursing was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00451740; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 38
Capacity: 38
Deficiencies: 1
Jan 9, 2025
Visit Reason
This visit was for the investigation of complaint IN00450691 regarding federal and state deficiencies related to pharmaceutical services and medication delivery.
Findings
The facility failed to ensure adequate pharmaceutical services were available, resulting in multiple residents missing prescribed routine medications due to the contracted pharmacy's failure to deliver medications during a winter storm and state of emergency.
Complaint Details
Complaint IN00450691 was substantiated with federal and state deficiencies cited at F0755 related to medication delivery failures causing residents to miss prescribed medications.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 4 of 4 residents reviewed. | SS=E |
Report Facts
Residents reviewed for pharmacy services: 4
Census: 38
Total licensed capacity: 38
Medicare residents: 4
Medicaid residents: 21
Other payor residents: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andrew Grubb | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 6 | Registered Nurse | Interviewed regarding pharmacy delivery issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 9, 2025
Visit Reason
Paper compliance review to the Investigation of Complaint IN00450691 survey completed on January 9, 2025.
Findings
The Waters of Rockport Skilled Nursing was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00450691; paper compliance review found the facility in compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 17, 2024
Visit Reason
Paper compliance review to the Post Survey Revisit (PSR) to the Recertification and State Licensure survey completed on May 30, 2024.
Findings
The Waters of Rockport Skilled Nursing was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the PSR to the Recertification and State Licensure survey.
Inspection Report
Follow-Up
Census: 30
Capacity: 60
Deficiencies: 0
Jun 13, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 04/29/2024.
Findings
At this Post Survey Revisit, the Waters of Rockport Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Report Facts
Certified beds: 60
Census: 30
Inspection Report
Complaint Investigation
Census: 34
Capacity: 34
Deficiencies: 0
May 30, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00434728 and was conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on April 5, 2024.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00434728 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 34
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 20
Census Payor Type Other: 12
Inspection Report
Re-Inspection
Census: 34
Capacity: 34
Deficiencies: 2
May 29, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 5, 2024, conducted in conjunction with the Investigation of Complaint IN00434728.
Findings
The facility was found deficient for using nurse aides who had not completed CNA training and competency evaluation within 4 months of hire, and for failing to maintain safe and secure storage of medications with proper labeling and dating. The facility failed to implement systemic plans of correction to prevent recurrence of these deficiencies.
Complaint Details
Investigation of Complaint IN00434728 was conducted in conjunction with the Post Survey Revisit.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure staff completed CNA training and evaluation within 4 months of hire for 4 nurse aides who were performing CNA duties without certification. | SS=E |
| Facility failed to maintain safe and secure storage of medications; medications were not labeled and lacked open dates on multiple medication carts. | SS=E |
Report Facts
Census: 34
Total Capacity: 34
Number of nurse aides not certified within 4 months: 4
Dates of survey: 2024-05-29 to 2024-05-30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Walker | Administrator | Interviewed regarding CNA training documentation and facility plans |
| NA 18 | Nurse Aide | Found working without CNA certification, interviewed about job duties |
| NA 19 | Nurse Aide | Found working without CNA certification |
| NA 20 | Nurse Aide | Found working without CNA certification |
| NA 21 | Nurse Aide | Found working without CNA certification, interviewed about job duties |
| Business Office Manager | BOM | Provided nursing schedules and employee records |
| QMA 13 | Qualified Medication Aide | Interviewed regarding medication labeling and storage |
| RN 15 | Registered Nurse | Interviewed regarding medication labeling and storage |
| Director of Nursing | DON | Provided plan of correction and policy information |
Inspection Report
Annual Inspection
Census: 31
Capacity: 60
Deficiencies: 3
Apr 29, 2024
Visit Reason
An annual Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with several Life Safety Code requirements including emergency power system maintenance, corridor door integrity, and improper use of power strips and multi-plug adapters. The facility failed to document an annual fuel quality test for the diesel generator and had a med room door held open with a hole in it. Power strips and multi-plug adapters were found in use as substitutes for fixed wiring in smoke compartments.
Severity Breakdown
SS=C: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure an annual fuel quality test was performed for the diesel powered generator. | SS=C |
| Med room door was held wide open with a container and had a 1/4 inch hole, failing to resist smoke passage. | SS=E |
| Power strips and multi-plug adapters were used as substitutes for fixed wiring in smoke compartments. | SS=E |
Report Facts
Certified beds: 60
Census: 31
Deficiency completion date: May 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Walker | Maintenance Supervisor | Named in relation to findings about emergency power system maintenance and med room door issues |
Inspection Report
Annual Inspection
Census: 33
Capacity: 33
Deficiencies: 16
Apr 5, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted April 1-5, 2024.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, bed hold policy documentation, accuracy of Minimum Data Set (MDS) assessments, comprehensive care plans, nurse aide training and certification, nurse staffing postings, sufficient staff knowledge of Narcan administration, pharmacy record accuracy, medication storage and disposal, food safety and sanitation, infection prevention and control, immunization consents and documentation, and resident room size compliance.
Severity Breakdown
SS=D: 7
SS=E: 5
SS=C: 1
SS=F: 1
: 1
Deficiencies (16)
| Description | Severity |
|---|---|
| Failed to ensure residents self-administering medications were assessed for capability, had physician orders and care plans. | SS=D |
| Failed to provide bed hold policy documentation to residents or representatives upon hospitalization for 8 of 9 residents reviewed. | SS=E |
| Failed to ensure accurate Minimum Data Set (MDS) assessments for hospice services, pneumonia, septicemia, and hypoglycemic medication use. | SS=D |
| Failed to develop comprehensive care plans for residents on anticoagulants, diuretics, antidepressants, risk of opioid overdose, and hospice services. | SS=D |
| Failed to ensure Certified Nursing Aides completed training and competency evaluation within 4 months of hire; lacked documentation and supplies for CNA training program. | SS=E |
| Failed to post nurse staffing data in a prominent, accessible location daily for residents and visitors. | SS=C |
| Failed to ensure staff had knowledge and training on Narcan administration; Narcan was not available for use despite orders. | SS=D |
| Failed to maintain complete and accurate clinical records for medications prescribed by outside physicians and lacked documentation of medication destruction. | SS=D |
| Failed to ensure drug regimen was free from unnecessary drugs due to multiple providers prescribing narcotic pain medications without coordination. | SS=E |
| Failed to ensure proper storage and disposal of medications; observed unlabeled medication, expired medications, medications of discharged residents, and unlocked medication carts. | SS=D |
| Failed to store, prepare, and serve food in accordance with professional standards; food items were unlabeled, open to air, expired, and staff failed to follow hygiene and food handling protocols. | SS=E |
| Failed to implement infection control practices to prevent and contain COVID-19; improper PPE use, failure to notify physician of abnormal vital signs, and failure to isolate COVID positive resident. | SS=D |
| Failed to employ a qualified Infection Preventionist; the full-time Director of Nursing was also performing IP duties without documented hours or certification. | SS=F |
| Failed to ensure residents were informed of benefits, offered, and documented consents or refusals for influenza and pneumococcal vaccines. | SS=E |
| Failed to ensure residents were informed of benefits, offered, and documented consents or refusals for COVID-19 vaccines. | SS=E |
| Failed to provide at least 80 square feet per resident in multiple occupancy rooms and 100 square feet in single occupancy rooms in 14 of 43 resident rooms. | — |
Report Facts
Residents reviewed: 33
Residents with bed hold policy missing: 8
Residents with room size below minimum: 14
Medication carts unlocked: 2
Expired medication found: 1
Medication quantity: 67
Medication quantity: 45
Medication quantity: 3
Medication quantity: 28
Medication quantity: 4
Room size: 154.65
Room size: 77.32
Room size: 90.52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Natalie Walker | Administrator/Director of Nursing | Named in plan of correction and interviews related to multiple findings |
| RN 3 | Registered Nurse | Interviewed about medication destruction and orders |
| RN 5 | Registered Nurse | Interviewed about Narcan availability and infection control |
| DON | Director of Nursing | Named as Infection Preventionist and involved in multiple corrective actions |
| ADON | Assistant Director of Nursing | Named as Infection Preventionist after certification |
| Nurse Aide 45 | Nurse Aide | Interviewed about CNA training and certification |
| Dietary Manager | Dietary Manager | Named in relation to dietary deficiencies and training |
| QMA 37 | Qualified Medication Aide | Observed locking medication cart |
| LPN 7 | Licensed Practical Nurse | Observed locking medication cart |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Jan 10, 2024
Visit Reason
This visit was conducted for the investigation of two complaints, IN00421681 and IN00420159.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00421681 and Complaint IN00420159 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 31
Medicare Census: 3
Medicaid Census: 20
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Apr 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404418.
Findings
No deficiencies related to the allegations of Complaint IN00404418 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00404418 found no deficiencies related to the allegations.
Report Facts
Census: 35
Medicare residents: 5
Medicaid residents: 22
Other payor residents: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 31, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00401785 survey completed on March 1, 2023.
Findings
The Waters of Rockport Skilled Nursing was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the Investigation of Complaint IN00401785 survey.
Complaint Details
Investigation of Complaint IN00401785; complaint corrected.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Mar 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00401785 and IN00401796. Complaint IN00401785 was substantiated with related deficiencies cited, while complaint IN00401796 was substantiated with no deficiencies cited.
Findings
The facility failed to ensure a resident (Resident B) had a safe and complete discharge. Resident B was discharged without proper preparation, orientation, or notification to caregivers at the discharge location, resulting in unsafe conditions. The discharge was facility-initiated due to lack of payor source, and the resident was left at a friend's house without adequate support or knowledge of the situation. The facility implemented corrective actions including audits, staff education, and monitoring to prevent recurrence.
Complaint Details
Complaint IN00401785 was substantiated with federal/state deficiencies cited at F624. Complaint IN00401796 was substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. | SS=D |
Report Facts
Census: 32
SNF/NF beds: 29
SNF beds: 3
Medicare residents: 7
Medicaid residents: 18
Other payor residents: 7
Inspection Report
Life Safety
Census: 32
Capacity: 60
Deficiencies: 0
Feb 23, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/18/23 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Waters of Rockport Skilled Nursing Facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered except for two detached wood framed structures used for storage.
Inspection Report
Life Safety
Census: 39
Capacity: 60
Deficiencies: 5
Jan 18, 2023
Visit Reason
The facility underwent an Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey identified deficiencies including incorrect exit door codes posted, failure to inspect the kitchen exhaust system semiannually, lack of fire department connection signage, dropped or missing sprinkler escutcheon rings, and unsecured electrical panels in corridors.
Severity Breakdown
SS=F: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through 9 of 9 exits was readily accessible; incorrect codes posted on exit door keypads. | SS=F |
| Failed to ensure 1 of 1 kitchen exhaust systems was inspected semiannually as required by NFPA 96. | SS=E |
| Failed to ensure 1 of 1 fire department connection had proper signage for easy identification. | SS=E |
| Failed to ensure the ceiling in 2 of 7 sprinklered smoke compartments was maintained to allow sprinkler heads to function to their full capability (missing or dropped sprinkler escutcheon rings and unsealed ceiling penetrations). | SS=E |
| Failed to ensure 6 of 6 electrical panels observed in facility corridors were secured from non-authorized personnel. | SS=F |
Report Facts
Certified beds: 60
Census: 39
Exit doors with incorrect codes: 9
Kitchen exhaust systems inspected: 0
Electrical panels unsecured: 6
Sprinklered smoke compartments with ceiling issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Barnett | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Supervisor | Named in relation to findings about exit door codes, kitchen exhaust system, fire department connection signage, sprinkler escutcheon rings, and electrical panel security | |
| Administrator | Named in relation to review of findings and corrective actions |
Inspection Report
Annual Inspection
Census: 34
Capacity: 34
Deficiencies: 10
Jan 9, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey. This visit included the Investigation of Complaint IN00397988, which was unsubstantiated due to lack of evidence.
Findings
The facility was cited for multiple deficiencies including failure to develop baseline and comprehensive care plans timely, failure to revise care plans after changes in condition, failure to provide respiratory care consistent with orders, failure to post accurate nurse staffing data, failure to limit PRN psychotropic medication orders to 14 days, failure to provide food at safe and appetizing temperatures, failure to maintain a safe and sanitary environment, and failure to designate a qualified infection preventionist.
Complaint Details
Complaint IN00397988 was investigated and found to be unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 4
SS=E: 4
SS=C: 1
SS=F: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Baseline care plans were not initiated within 48 hours of admission for 1 of 2 residents reviewed. | SS=D |
| Facility failed to develop comprehensive care plans for 3 of 4 residents reviewed. | SS=D |
| Facility failed to revise care plans timely and hold care plan conferences timely for 6 of 7 residents reviewed. | SS=E |
| Facility failed to provide respiratory care consistent with professional standards and orders for 3 of 3 residents reviewed. | SS=D |
| Facility failed to post accurate nurse staffing data daily for 5 of 5 days reviewed. | SS=C |
| Facility failed to ensure residents were free from unnecessary psychotropic medications; PRN anti-anxiety medication was ordered beyond 14 days without review. | SS=D |
| Facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 trays tested. | SS=E |
| Facility failed to designate a qualified infection preventionist with specialized training or certification for 3 of 5 days of survey. | SS=F |
| Facility failed to provide resident rooms measuring at least 80 square feet per resident in multiple occupancy rooms and 100 square feet in single rooms for 14 rooms. | SS=E |
| Facility failed to maintain a safe, functional, sanitary, and comfortable environment; issues included loose bathroom flooring, slow draining sink, peeling paint, chipped paint, and nails/screws protruding in resident areas and hallways. | SS=E |
Report Facts
Survey dates: January 3, 4, 5, 6, 9, 2023
Census: 34
Medicare census: 7
Medicaid census: 21
Other payor census: 6
PRN psychotropic medication duration limit: 14
Food temperatures: 114.3
Food temperatures: 103.3
Food temperatures: 111.8
Food temperatures: 113.3
Food temperatures: 16.3
Food temperatures: 58.8
Food temperatures: 47.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Barnett | Administrator | Signed the report and involved in plan of correction |
| Regional MDS Consultant | Conducted audits and in-services related to care plans | |
| Director of Nursing | DON | Interviewed regarding care plans, respiratory care, and medication orders |
| Assistant Director of Nursing | ADON | Interviewed regarding care plans, respiratory care, and medication orders |
| Certified Nursing Aide 4 | CNA | Interviewed regarding resident care |
| Licensed Practical Nurse 5 | LPN | Interviewed regarding resident care and CPAP machine |
| Certified Nurses Aide 7 | CNA | Interviewed regarding resident care and CPAP machine |
| Registered Nurse 10 | RN | Interviewed regarding resident care and CPAP machine |
| Kitchen Manager | Interviewed regarding food temperatures | |
| Kitchen Staff 12 | Interviewed regarding food temperatures | |
| Maintenance Supervisor | Interviewed regarding facility maintenance and repairs |
Inspection Report
Renewal
Deficiencies: 0
Jan 9, 2023
Visit Reason
Paper compliance review to the Recertification and State licensure survey completed on January 9, 2023.
Findings
The Waters of Rockport Skilled Nursing was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State licensure survey.
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Nov 10, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00385857.
Findings
Complaint IN00385857 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00385857 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
Census: 33
Census Bed Type: 32
Census Bed Type: 1
Census Payor Type: 6
Census Payor Type: 20
Census Payor Type: 7
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