Inspection Reports for
The Waters of Sullivan Nursing Facility
505 W WOLFE ST, SULLIVAN, IN, 47882
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
57% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 5, 2025
Visit Reason
The inspection was conducted in response to complaints regarding a gnat infestation and inadequate nursing staff coverage affecting resident care and facility environment.
Complaint Details
The investigation was triggered by complaints about a persistent gnat infestation and inadequate nursing staff coverage affecting resident care and safety. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to control a gnat infestation affecting multiple residents and areas, and did not ensure sufficient nursing staff to cover resident care while managing laundry services. The Administrator also failed to manage resources effectively, impacting quality of life and safety.
Deficiencies (3)
F 0584: The facility failed to control a gnat infestation in multiple areas, affecting 48 residents. Residents reported gnats in their rooms and food, and one resident developed maggots between toes.
F 0725: The facility failed to provide enough nursing staff to meet resident needs while covering laundry services since the end of October. Staff reported increased workload and delayed call light responses.
F 0835: The Administrator failed to manage the facility effectively, ignoring pest infestation, staffing shortages, and unsafe environmental conditions. Resident safety was compromised by unresolved maintenance issues.
Report Facts
Residents affected: 48
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident E | Resident | Reported gnat infestation and injury from door frame |
| Resident G | Resident | Reported gnats in food and beverages |
| Resident H | Resident | Reported gnats in room and stress on staff |
| Resident J | Resident | Reported gnats and maggot development between toes |
| Administrator | Facility Administrator | Failed to manage pest control, staffing, and facility safety |
| Director of Nursing | Director of Nursing | Provided skin integrity report and interviewed about staffing |
| CNA 2 | Certified Nursing Assistant | Reported gnat infestation and staffing issues |
| CNA 3 | Certified Nursing Assistant | Reported gnat infestation |
| CNA 4 | Certified Nursing Assistant | Reported gnat infestation and laundry duties affecting care |
| CNA 6 | Certified Nursing Assistant | Reported gnat infestation and laundry duties affecting care |
| CNA 7 | Certified Nursing Assistant | Reported gnat infestation and laundry duties affecting care |
| LPN 8 | Licensed Practical Nurse | Reported gnat infestation and laundry duties affecting care |
Inspection Report
Routine
Deficiencies: 15
Date: Aug 1, 2025
Visit Reason
Routine inspection of Waters of Sullivan Nursing Facility to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including call light accessibility, resident council grievance response, notification of resident representative for isolation precautions, timely treatment of urinary tract infections, proper respiratory equipment storage, dialysis care accuracy, nurse staffing postings, behavioral health monitoring, medication labeling, food palatability, and food safety practices.
Deficiencies (15)
F 0558: The facility failed to ensure a resident's call light was kept within reach for 1 of 24 residents reviewed.
F 0565: The facility failed to ensure prompt response regarding resident council grievances for 3 of 3 resident council meetings reviewed.
F 0580: The facility failed to ensure a resident's representative was notified of a new isolation order for 1 of 4 resident representative interviews.
F 0582: The facility failed to ensure Advance Beneficiary Notice (ABN) forms were provided for 2 of 3 residents reviewed for beneficiary notices.
F 0609: The facility failed to ensure staff immediately reported an abuse allegation to the Administrator for 1 of 1 reportable incidents reviewed.
F 0641: The facility failed to ensure a Minimum Data Set (MDS) assessment was coded correctly for 1 of 19 residents reviewed.
F 0657: The facility failed to ensure residents were invited to quarterly care plan meetings for 2 of 3 residents and failed to ensure care plans were consistent with advanced directives for 1 of 19 residents.
F 0690: The facility failed to ensure timely treatment of urinary tract infections for 2 of 2 residents reviewed.
F 0695: The facility failed to ensure proper storage of respiratory equipment for 2 of 3 residents reviewed.
F 0698: The facility failed to ensure a resident's dialysis access site was accurately assessed for 1 of 1 resident reviewed.
F 0732: The facility failed to post required nurse staffing information for Saturday, Sunday, and Monday during 1 of 5 observations.
F 0740: The facility failed to ensure behavior monitoring was completed for 1 of 5 residents reviewed for unnecessary medications.
F 0761: The facility failed to ensure medication was labeled properly for 1 of 2 medication storage rooms reviewed.
F 0804: The facility failed to provide meals that were palatable during 2 of 2 mealtime observations.
F 0812: The facility failed to ensure a male cook with a full beard wore a beard restraint and failed to ensure the dish machine reached proper rinse temperature; also failed to ensure proper handling of ice during food service.
Report Facts
Residents affected: 24
Resident council meetings reviewed: 3
Resident representative interviews: 4
Residents reviewed for beneficiary notices: 3
Reportable incidents reviewed: 1
Resident MDS assessments reviewed: 19
Residents reviewed for care plan meetings: 3
Residents reviewed for UTI treatment: 2
Residents reviewed for respiratory care: 3
Residents reviewed for dialysis care: 1
Staff posting observations: 5
Residents reviewed for unnecessary medications: 5
Medication storage rooms reviewed: 2
Mealtime observations: 2
Kitchen observations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 16 | LPN | Named in call light accessibility and drink cart handling |
| Director of Nursing | DON | Named in multiple findings including call light, isolation notification, UTI treatment, respiratory care, staffing posting, behavior monitoring, medication labeling, food safety |
| Administrator | Administrator | Named in grievance response, abuse reporting, kitchen concerns, food safety |
| Business Office Manager | BOM | Named in beneficiary notice findings |
| Licensed Practical Nurse 17 | LPN | Named in respiratory equipment storage and dialysis care |
| Licensed Practical Nurse 7 | LPN | Named in respiratory equipment storage and behavior monitoring |
| Regional Director of Operations | RDO | Named in kitchen and food palatability findings |
| Hospice Registered Nurse 8 | RN | Named in behavior monitoring |
| Hospice Aide 9 | Hospice Aide | Named in behavior monitoring |
| Hospice Aide 10 | Hospice Aide | Named in behavior monitoring |
| Certified Nurse Aide 11 | CNA | Named in behavior monitoring and meal service |
| Certified Nurse Aide 12 | CNA | Named in behavior monitoring |
| Licensed Practical Nurse 14 | LPN | Named in medication labeling |
| Dietary Manager | Dietary Manager | Named in kitchen observations and food safety |
| Cook with beard | Cook | Named in food safety for not wearing beard restraint |
| Activity Aide 15 | Activity Aide | Named in food safety for ice handling |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00449803 and IN00452651 completed on February 28, 2025.
Complaint Details
The visit was related to investigations of complaints IN00449803 and IN00452651; compliance was found.
Findings
Waters of Sullivan was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the investigations.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 28, 2025
Visit Reason
The inspection was conducted in response to complaints regarding pharmaceutical services and dietary services at the nursing facility.
Complaint Details
This citation relates to complaint IN00449803 for medication issues and complaint IN00452651 for food temperature issues.
Findings
The facility failed to ensure timely administration of medications for one resident and failed to serve food at a safe and appetizing temperature for three residents. Medication availability issues and improper food temperature control were noted.
Deficiencies (2)
F 0755: The facility failed to ensure medications were obtained and administered in a timely manner for one resident. Several scheduled medications were not administered due to unavailability in the Emergency Drug Kit and lack of documentation.
F 0804: The facility failed to ensure food was served at a safe and appetizing temperature for three residents. Food was observed to be below the required 130 degrees Fahrenheit and was often cold when served.
Report Facts
Medication doses not administered: 3
Food temperature: 107.3
Food temperature: 117.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication administration and Emergency Drug Kit restocking. | |
| Dietary Manager | Observed and interviewed regarding food temperature and meal service. |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Date: Feb 26, 2025
Visit Reason
This visit was for the investigation of complaints IN00449803, IN00452651, IN00454291, and IN00447096.
Complaint Details
Complaint IN00449803 had federal/state deficiencies cited at F755 related to medication administration. Complaint IN00452651 had federal/state deficiencies cited at F804 related to dietary services. Complaints IN00454291 and IN00447096 had no deficiencies related to the allegations.
Findings
The facility was found deficient in pharmaceutical services related to timely medication administration for one resident and in dietary services related to serving food at safe and appetizing temperatures for three residents. Two complaints had deficiencies cited, while two complaints had no deficiencies related to the allegations.
Deficiencies (2)
Failed to ensure medications were obtained and administered in a timely manner for one resident.
Failed to ensure food was served at a safe and appetizing temperature for three residents.
Report Facts
Census: 53
SNF beds: 9
SNF/NF beds: 44
Medicare residents: 10
Medicaid residents: 30
Other payor residents: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sally Robertson | Administrator | Signed the report and is named as the facility administrator. |
| Director of Nursing | Interviewed regarding medication administration and pharmacy policies; name not provided. | |
| Dietary Manager | Interviewed and observed regarding food temperature and dietary services; name not provided. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446662 and IN00446735.
Complaint Details
Complaint IN00446662 and Complaint IN00446735 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00446662 and IN00446735 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF: 2
Census Bed Type - SNF/NF: 46
Total Census: 48
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 19
Total Census Payor: 48
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 0
Date: Sep 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441722 at The Waters Of Sullivan Nursing Facility.
Complaint Details
Investigation of Complaint IN00441722 found no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type Total: 55
Census Payor Type Total: 55
Medicare Census: 3
Medicaid Census: 30
Other Payor Census: 22
SNF/NF Beds: 50
SNF Beds: 5
Inspection Report
Re-Inspection
Census: 55
Capacity: 93
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/02/24 was performed to verify compliance with applicable regulations.
Findings
The Waters of Sullivan Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm systems and smoke detectors.
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00439476.
Complaint Details
Complaint IN00439476 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are 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.
Report Facts
Census Bed Type: 54
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 29
Census Payor Type - Other: 22
Inspection Report
Life Safety
Census: 52
Capacity: 93
Deficiencies: 1
Date: Jul 2, 2024
Visit Reason
The Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code to assess compliance with fire safety requirements.
Findings
The facility was found not in compliance due to failure to ensure that the corridor door to a hazardous area (storage room of combustible supplies) was provided with a self-closing device that would cause the door to automatically close and latch. This deficiency could affect 10 residents and staff in the vicinity of room 35.
Deficiencies (1)
The corridor door to resident room 35, used for storage of combustible supplies, was not provided with a self-closing device and failed to automatically close and latch into the door frame.
Report Facts
Certified beds: 93
Census: 52
Residents and staff potentially affected: 10
Cardboard boxes of supplies: 24
Room dimensions: Approximately 16 feet by 14 feet
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karl Eck | RDO | Laboratory Director or Provider/Supplier Representative who signed the report |
| Maintenance Director | Interviewed regarding the deficient corridor door | |
| Administrator | Reviewed findings at exit conference and involved in corrective action | |
| Maintenance Supervisor/designee | Installed self-closing device and responsible for ongoing maintenance |
Inspection Report
Routine
Deficiencies: 8
Date: Jun 21, 2024
Visit Reason
Routine inspection of Waters of Sullivan Nursing Facility to assess compliance with healthcare regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly care plan meetings, failure to notify physicians of resident condition changes, inadequate supervision during medication administration, improper respiratory equipment storage, lack of physician documentation for medication decisions, incomplete lab testing, food safety violations, and poor infection prevention practices.
Deficiencies (8)
F 0657: The facility failed to ensure quarterly care plan meetings were conducted for 2 of 24 residents reviewed (Residents 19 and 30).
F 0684: The facility failed to notify a physician of a resident's change in condition related to edema for 1 of 1 resident reviewed (Resident 46).
F 0689: The facility failed to ensure a resident was supervised while administering medications for 1 of 1 resident reviewed (Resident 104).
F 0695: The facility failed to store respiratory equipment in a plastic bag and lacked a physician order for CPAP settings for 1 of 1 resident reviewed (Resident 22).
F 0757: The facility failed to ensure physician documentation to justify declination of a pharmacy recommendation for 1 of 5 residents reviewed (Resident 8).
F 0773: The facility failed to ensure physician ordered lab tests were completed for 1 of 5 residents reviewed (Resident 42).
F 0812: The facility failed to discard expired food, maintain temperature logs, monitor sanitizer levels, label and date food items without manufacturer expiration dates, and store food at least six inches from the floor in 1 of 2 kitchen observations.
F 0880: The facility failed to maintain infection prevention measures during meal service, medication administration, and hand hygiene for staff in multiple observations.
Report Facts
Weight measurements: 143.6
Weight measurements: 130.8
Weight measurements: 126.8
Weight measurements: 121.8
Weight measurements: 113.3
Weight measurements: 118
Weight measurements: 117
Sanitizer concentration: 400
Sanitizer concentration: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Noted leaving resident unattended during medication administration |
| Physical Therapist 19 | Physical Therapist | Interviewed regarding resident edema observation |
| Certified Nurse's Assistant 20 | CNA | Noted resident swelling and elevation of legs |
| LPN 21 | Licensed Practical Nurse | Observed CPAP equipment storage and lack of physician order for settings |
| Regional Nurse Consultant | Provided multiple policy documents and interviews regarding deficiencies | |
| Dietary Director | Interviewed regarding food safety and sanitation policies | |
| Dietary Assistant 13 | Tested sanitizer solution concentration during kitchen inspection | |
| CNA 7 | Certified Nurse Assistant | Observed failing to sanitize hands during meal service and ice handling |
| LPN 7 | Licensed Practical Nurse | Observed failing to wash hands between residents during blood sugar testing |
| LPN 8 | Licensed Practical Nurse | Observed performing blood sugar test |
Inspection Report
Annual Inspection
Census: 50
Capacity: 50
Deficiencies: 9
Date: Jun 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from June 17 to June 21, 2024.
Findings
The facility was found deficient in multiple areas including failure to conduct quarterly care plan meetings for some residents, failure to notify physicians of changes in condition, inadequate supervision during medication administration, improper storage and documentation of respiratory equipment, lack of physician documentation for declination of pharmacy recommendations, incomplete lab testing per physician orders, food safety violations, and inadequate infection control practices.
Deficiencies (9)
Failed to ensure care plan meetings were conducted quarterly for 2 of 24 residents reviewed.
Failed to ensure physician was notified of a resident's change in condition related to edema.
Failed to ensure a resident was supervised while administering medications.
Failed to ensure respiratory equipment was stored in a plastic bag and obtain physician order for CPAP settings.
Failed to ensure physician documentation to justify declination of pharmacy recommendation for unnecessary medication.
Failed to ensure physician ordered lab tests had been completed.
Failed to discard expired food items, maintain temperature logs, monitor sanitizer concentration, label and date food items without manufacturer expiration dates, and store food at least six inches from the floor.
Failed to maintain infection prevention measures during meal service, medication administration, and hand hygiene.
Failed to complete second step TB skin test for 5 of 10 employees reviewed.
Report Facts
Survey dates: 5
Census: 50
Total capacity: 50
Residents reviewed for care plan meetings: 24
Residents with missing quarterly care plan meetings: 2
Residents reviewed for medication supervision: 1
Residents reviewed for respiratory care: 1
Residents reviewed for unnecessary medications: 5
Residents reviewed for lab testing: 5
Employees reviewed for TB testing: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sally Robertson | Administrator | Signed the report |
| Kay Eastham | Activity Assistant | Named in infection control hand hygiene in meal service |
| LPN 4 | Noted leaving medications unattended in Resident 104's room | |
| LPN 7 | Failed to wash hands between residents during blood sugar checks | |
| CNA 7 | Failed to sanitize hands after touching hair and ear during meal service | |
| LPN 21 | Noted unbagged CPAP equipment and lack of physician order for CPAP settings | |
| Cook 11 | Observed during kitchen inspection | |
| Dietary Director | Interviewed regarding food safety policies and practices | |
| Regional Nurse Consultant | Provided multiple policy documents and interviews |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 21, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure Survey.
Findings
Waters of Sullivan Nursing Facility was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 0
Date: Apr 29, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429172 at The Waters of Sullivan Nursing Facility.
Complaint Details
Complaint IN00429172 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00429172 were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census: 46
Census Bed Type - SNF: 6
Census Bed Type - SNF/NF: 40
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Census: 43
Capacity: 43
Deficiencies: 0
Date: Dec 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420456.
Complaint Details
Complaint IN00420456 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 43
Total Capacity: 43
Census Bed Type: 38
Census Bed Type: 5
Census Payor Type: 1
Census Payor Type: 18
Census Payor Type: 24
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413453 at The Waters of Sullivan Nursing Facility.
Complaint Details
Investigation of Complaint IN00413453 found no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census Bed Type - SNF: 6
Census Bed Type - SNF/NF: 42
Total Census: 48
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 21
Inspection Report
Re-Inspection
Census: 45
Capacity: 93
Deficiencies: 0
Date: Jun 29, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/31/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The Waters of Sullivan Nursing Facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 45
Capacity: 93
Deficiencies: 3
Date: May 31, 2023
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to failure to perform an annual fuel quality test for the diesel generator and failure to maintain written records of weekly generator inspections for 2 of 52 weeks. Additionally, a power strip was improperly used to power a high current draw refrigerator, which was corrected during the survey.
Deficiencies (3)
Failure to ensure an annual fuel quality test was performed for the diesel-powered generator.
Failure to maintain written records of weekly inspections for the generator for 2 of 52 weeks.
Use of a power strip as a substitute for fixed wiring to power a high current draw refrigerator.
Report Facts
Certified beds: 93
Census: 45
Weeks missing generator inspection records: 2
Generator weekly inspections required: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding generator maintenance and power strip usage | |
| Executive Director | Present at exit conference reviewing findings | |
| Maintenance Supervisor | Conducted weekly generator inspections and corrective actions | |
| Administrator | Inserviced staff and monitored compliance with corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 12, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations and to identify deficiencies in care and facility operations.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of resident transfers, failure to revise care plans timely, improper catheter care, inadequate respiratory care, lack of behavioral health care planning, and failure to address pharmacy recommendations for psychotropic medications.
Deficiencies (6)
F 0623: The facility failed to notify the Office of the State Long-Term Care Ombudsman of the hospital transfer and discharge for 1 of 3 residents reviewed.
F 0657: The facility failed to revise the care plan to reflect removal of a floor mat used as a fall intervention for 1 of 12 residents reviewed.
F 0690: The facility failed to prevent a suprapubic urinary catheter drainage bag from contacting the floor for 1 of 2 residents reviewed.
F 0695: The facility failed to ensure a resident's oxygen concentrator machine was turned on, tubing was dated, and tubing was not outdated for 1 of 1 resident reviewed for respiratory care.
F 0740: The facility failed to monitor side effects and develop a care plan for the use of antipsychotic medication for 1 of 5 residents reviewed.
F 0758: The facility failed to ensure pharmacy recommendations for psychotropic medications were addressed by a physician and implemented for 2 of 5 residents reviewed.
Report Facts
Residents reviewed for care plans: 12
Residents reviewed for hospitalization notification: 3
Residents reviewed for urinary catheter/urinary tract infection: 2
Residents reviewed for respiratory care: 1
Residents reviewed for unnecessary medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided policy documents and interviews related to deficiencies in care plans, catheter care, respiratory care, and pharmacy recommendations. |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding failure to notify Ombudsman and lack of care plan for antipsychotic medication. |
| Unit Manager 19 | Unit Manager | Provided facility policy on care plans. |
| LPN 4 | Licensed Practical Nurse | Interviewed about removal of floor mat used as fall intervention. |
| CNA 9 | Certified Nursing Assistant | Interviewed about removal of floor mat used as fall intervention. |
| Regional Nurse Consultant | Regional Nurse Consultant | Provided policy on indwelling urinary catheterization. |
Inspection Report
Renewal
Census: 41
Capacity: 41
Deficiencies: 7
Date: May 12, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from May 8 to May 12, 2023.
Findings
The facility was found deficient in multiple areas including failure to notify the Ombudsman of hospital transfers, failure to revise care plans timely, improper catheter bag placement, improper oxygen therapy management, lack of monitoring and care planning for antipsychotic medication use, failure to address pharmacy recommendations timely, and incomplete employee personnel records.
Deficiencies (7)
Failed to notify the Office of the State Long-Term Care Ombudsman of hospital transfer for 1 of 3 residents reviewed.
Failed to revise care plan for 1 of 12 residents reviewed for care plans.
Failed to ensure urinary catheter drainage bag was prevented from contact with the floor for 1 of 2 residents reviewed.
Failed to ensure a resident's supplemental oxygen concentrator machine was turned on and oxygen tubing was dated and properly placed for 1 of 1 resident reviewed.
Failed to monitor side effects/behaviors and develop a care plan for the use of antipsychotic medication for 1 of 5 residents reviewed.
Failed to ensure pharmacy recommendations were addressed by a physician and implemented for 2 of 5 residents reviewed for unnecessary psychotropic medications.
Failed to ensure employee records included all required documentation for 5 of 10 employee records reviewed.
Report Facts
Census: 41
Total Capacity: 41
Deficiencies cited: 7
Inspection Report
Renewal
Deficiencies: 0
Date: May 12, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on May 12, 2023.
Findings
Waters of Sullivan was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Date: Nov 14, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00394233.
Complaint Details
Complaint IN00394233 was investigated and found unsubstantiated due to lack of evidence.
Findings
The complaint IN00394233 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 42
Census Bed Type - SNF: 4
Census Bed Type - SNF/NF: 38
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 18
Inspection Report
Re-Inspection
Census: 50
Capacity: 50
Deficiencies: 0
Date: Aug 8, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00380202 completed on June 30, 2022.
Complaint Details
Complaint IN00380202 - Corrected.
Findings
Miller's Merry Manor 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 Investigation of Complaint IN00380202. The complaint was corrected.
Report Facts
Census Bed Type: 50
Census Payor Type: 50
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