Inspection Reports for The Waters of Syracuse Skilled Nursing Facility
500 E PICKWICK DR, SYRACUSE, IN, 46567
Back to Facility ProfileInspection Report Summary
The most recent inspection on February 25, 2025, found the facility in compliance with relevant federal and state regulations and noted no deficiencies. Earlier inspections showed a pattern of deficiencies primarily related to comprehensive care planning, catheter use, infection control, and some life safety code issues involving exit doors and hazardous storage. Complaint investigations conducted during this period were consistently unsubstantiated, with no deficiencies cited related to the allegations. Prior reports also identified issues with medication management, resident dignity, and environmental sanitation, but no fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility appears to have made improvements over time, with the most recent inspections showing resolution of previously cited deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
274% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
47 residents
Based on a February 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
Paper Compliance to the Post Survey Revisit completed on 2/25/2025 to the Recertification and State Licensure Survey completed on January 10, 2025.
Findings
The Waters of Syracuse 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: 47
Deficiencies: 0
Date: Feb 24, 2025
Visit Reason
This visit was for the investigation of complaints IN00453975 and IN00452867, conducted in conjunction with a Post Survey Revisit to the Recertification and State Licensure Survey completed on 2025-01-10.
Complaint Details
Complaint IN00453975 and Complaint IN00452867 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in complaints IN00453975 and IN00452867 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Report Facts
Census: 47
Census Bed Type - SNF/NF: 2
Census Bed Type - NF: 45
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 18
Inspection Report
Re-Inspection
Census: 47
Deficiencies: 3
Date: Feb 24, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2025-01-10, conducted in conjunction with the Investigation of Complaints IN00453975 and IN00452867.
Complaint Details
This visit was conducted in conjunction with the Investigation of Complaints IN00453975 and IN00452867.
Findings
The facility was found deficient in implementing comprehensive care plans for residents, appropriate catheter use, and infection prevention and control practices. Specific failures included missing care plans for cognitive loss and pressure ulcer risk, inappropriate indwelling catheter use, and failure to use proper PPE for residents on enhanced barrier precautions.
Deficiencies (3)
Failed to implement a comprehensive plan of care for 2 of 5 residents reviewed for comprehensive care plans.
Failed to ensure an incontinent resident remained free from an indwelling urinary catheter for 1 of 3 residents reviewed for urinary catheters.
Failed to ensure infection control practices were carried out appropriately for residents on enhanced barrier precautions for 1 of 3 residents reviewed.
Report Facts
Census: 47
Residents reviewed for comprehensive care plans: 5
Residents reviewed for urinary catheters: 3
Residents reviewed for infection control: 3
Survey dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeff Brinkman | Administrator | Signed the report and involved in oversight |
Inspection Report
Life Safety
Census: 48
Capacity: 66
Deficiencies: 0
Date: Feb 10, 2025
Visit Reason
A 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 Waters of Syracuse Skilled Nursing Facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and applicable NFPA codes. The facility is a one-story, fully sprinklered Type V construction with a fire alarm system and smoke detectors. The facility had no deficiencies noted.
Report Facts
Certified beds: 66
Medicare and Medicaid dually certified beds: 60
Medicare only certified beds: 6
Census: 48
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 17
Date: Jan 10, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of two complaints (IN00446524 and IN00450345).
Complaint Details
Complaint IN00446524 and IN00450345 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including resident dignity related to urinary catheter care, Medicaid/Medicare coverage notices, PASARR screening timeliness, baseline and comprehensive care plans, fall risk interventions, catheter use, nutrition and hydration documentation, respiratory equipment storage, pain management monitoring, dialysis pre/post assessments, medication adjustments based on lab results, psychotropic medication use limits, food sanitation, and infection control practices for residents on enhanced barrier precautions.
Deficiencies (17)
Failed to provide dignity cover for urinary catheter drainage bag for Resident 34.
Failed to ensure SNF-ABN form was provided following end of Medicare skilled services for Residents 9 and 14.
Failed to ensure PASARR screening was completed timely for Resident B.
Failed to ensure baseline care plans were initiated with goals and interventions for Residents B and 247.
Failed to complete comprehensive care plans for Residents 18, 20, and 32.
Failed to ensure care plan meetings were held timely for Residents 27, 30, and 38.
Failed to develop and implement fall risk interventions for Residents 27 and 247, resulting in a fall with hospitalization for Resident 247.
Failed to ensure incontinent resident (Resident 34) remained free from indwelling urinary catheter without proper diagnosis and evaluation.
Failed to document nutritional supplement intake percentages, initiate dietitian recommendations timely, and serve appropriate diet for dialysis resident (Residents 1, 27, and 20).
Failed to properly store oxygen therapy and C-PAP equipment for Residents 18 and 20.
Failed to monitor effectiveness of pain medication for Resident 1.
Failed to complete pre/post dialysis assessments for Resident 20.
Failed to adjust vitamin D medication dose based on elevated lab results for Resident 32.
Failed to limit use of PRN psychotropic medication Xanax to 14 days for Resident 20.
Failed to ensure nutritive value and flavor were maintained for pureed diets.
Failed to ensure food was stored, prepared and served under sanitary conditions including unsealed and undated items, expired foods, and dirty utensils in the kitchen.
Failed to ensure infection control practices were carried out appropriately for residents on enhanced barrier precautions (Residents 30, 247, and 27).
Report Facts
Census: 44
Medicare residents: 5
Medicaid residents: 28
Other payor residents: 11
Deficiency count: 16
Vitamin D level: 120
Weight loss percentage: 13.1
Xanax PRN days exceeded: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Failed to wear gown for Enhanced Barrier Precautions and did not document pain medication effectiveness | |
| CNA 3 | Failed to wear PPE for Enhanced Barrier Precautions and handled leaking catheter drainage bag without proper PPE | |
| CNA 2 | Failed to wear PPE for Enhanced Barrier Precautions and handled leaking catheter drainage bag without proper PPE | |
| Dietary Manager | Observed food preparation and storage deficiencies, provided policies and in-service training | |
| DON | Director of Nursing | Provided policies, conducted in-services, and responsible for monitoring corrective actions |
| Nurse Practitioner | Provided clinical assessment and medication management for Resident 34 and Resident 32 |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Apr 17, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00429559 and IN00430990 at the Waters of Syracuse Skilled Nursing Facility.
Complaint Details
Investigation of complaints IN00429559 and IN00430990 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00429559 and IN00430990 were cited. The facility was found to be in compliance with relevant federal and state regulations.
Report Facts
Census Bed Type: 32
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 20
Census Payor Type - Other: 11
Inspection Report
Re-Inspection
Census: 39
Capacity: 66
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/05/24 by the Indiana Department of Health.
Findings
The Waters of Syracuse Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable NFPA codes. The facility is fully sprinklered with a fire alarm system and smoke detection, except for an unsprinklered garage used for storage.
Report Facts
Certified beds: 66
Census: 39
Inspection Report
Life Safety
Census: 39
Capacity: 66
Deficiencies: 4
Date: Mar 5, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements. Deficiencies included impeded exit discharge doors, uneven exit discharge walkways, unprotected hazardous storage areas, and improper smoking area enforcement.
Deficiencies (4)
Failed to maintain 1 of 8 exit discharge doors free of impediments to full instant use in case of emergency; door required excessive force to open.
Failed to ensure 4 of 8 exit discharges had an unobstructed level walking surface; walkways were uneven with holes, dips, bumps, and vegetation growth.
Failed to protect 1 of 1 storage rooms with large amounts of combustible storage and greater than 50 square feet as a hazardous area; corridor door was not self-closing.
Failed to enforce smoking policies; cigarette butts were improperly disposed in non-combustible containers with self-closing lids missing or absent.
Report Facts
Certified beds: 66
Census: 39
Exit discharge doors inspected: 8
Exit discharge doors deficient: 1
Exit discharge walkways inspected: 8
Exit discharge walkways deficient: 4
Storage rooms inspected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Anna Foster | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Environmental Supervisor | Interviewed and observed during exit door and walkway inspections | |
| Maintenance Director | Interviewed and involved in exit door and walkway inspections and smoking policy enforcement | |
| Administrator | Participated in exit conference and corrective action discussions | |
| Maintenance Supervisor/designee | Performed repairs and inspections related to deficiencies |
Inspection Report
Annual Inspection
Census: 35
Capacity: 35
Deficiencies: 9
Date: Feb 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 5 to 9, 2024.
Findings
The facility was found deficient in multiple areas including failure to timely provide Notice of Medicare Non-Coverage, incomplete care plans, inadequate individualized activity programs, improper use of splints, lack of respiratory orders and equipment storage, medication errors related to Coumadin therapy, improper medication storage and labeling, failure to sanitize blood glucose monitors, and incomplete employee job documentation.
Deficiencies (9)
Failure to ensure a change in Notice of Medicare Non-Coverage form was provided timely for 1 of 3 residents reviewed.
Failure to implement and revise comprehensive care plans for 2 of 15 residents reviewed.
Failure to provide individualized activity programs for 2 of 3 residents reviewed.
Failure to ensure a splint to prevent contracture progression was applied for 1 of 1 resident reviewed.
Failure to ensure residents had respiratory orders, tubing changes and equipment properly stored for 2 of 7 residents reviewed.
Failure to ensure residents were free from significant medication errors related to not following a Physician's Order for Coumadin therapy for 1 of 5 residents reviewed.
Failure to document open date of Tubersol and keep lorazepam liquid stored and locked properly in the Pyxis system.
Failure to sanitize a community use blood glucose monitor after use, risking transmission of infection to residents.
Failure to maintain current and accurate personnel records including job description and job specific orientation for 1 of 5 new employees reviewed.
Report Facts
Census: 35
Total Capacity: 35
Residents reviewed for beneficiary notices: 3
Residents reviewed for care plans: 15
Residents reviewed for activities: 3
Residents reviewed for respiratory care: 7
Residents reviewed for medication errors: 5
Residents reviewed for medication storage: 1
Residents affected by blood glucose monitor sanitation: 4
New employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Dunnuck | Director of Nursing | Named in relation to multiple findings including respiratory care, medication errors, and corrective actions |
| RN 10 | Registered Nurse | New employee lacking job description and job specific orientation documentation |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding respiratory equipment and lab draws |
| RN 3 | Registered Nurse | Observed during medication pass and blood glucose monitoring |
| Employee 7 | Occupational Therapist | Provided documentation and interview regarding splint use |
| Employee 11 | Activity Assistant | Interviewed regarding activity participation and resident engagement |
| CNA 6 | Certified Nursing Assistant | Interviewed regarding resident care and splint usage |
| Business Office Manager | Interviewed regarding Notice of Medicare Non-Coverage and employee records |
Inspection Report
Renewal
Deficiencies: 0
Date: Feb 9, 2024
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
The Waters of Syracuse Skilled Nursing Facility 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 Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 40
Capacity: 40
Deficiencies: 0
Date: Nov 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418932.
Complaint Details
Complaint IN00418932 was investigated and found to have no deficiencies related to the allegation.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 7
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Date: Jul 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411962.
Complaint Details
Investigation of Complaint IN00411962 found no deficiencies related to the allegations; the complaint was not substantiated.
Findings
No deficiencies related to the allegations in Complaint IN00411962 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 19
Other payor census: 9
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Apr 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399824.
Complaint Details
Complaint IN00399824 was investigated and found to have no related deficiencies.
Findings
No deficiencies related to the allegations in Complaint IN00399824 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 39
Medicare residents: 2
Medicaid residents: 28
Other residents: 9
Inspection Report
Re-Inspection
Census: 33
Capacity: 66
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 01/18/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
The Waters of Syracuse Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety Code, and Health Care Facilities Code. The facility is fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Certified beds: 66
Census: 33
Inspection Report
Annual Inspection
Census: 33
Capacity: 66
Deficiencies: 4
Date: Jan 18, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations on January 18, 2023.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements. Deficiencies included impeded resident hall exit door requiring excessive force to open, exit doors with locked access codes not posted, outdated battery-operated smoke alarms in resident rooms, and improper use of power strips for high current draw equipment.
Deficiencies (4)
Resident hall exit discharge door #7 required excessive force to open, not free of impediments to full instant use in case of emergency.
Means of egress through 3 of 3 resident hall exit doors were not readily accessible as exit door access codes were not posted.
Battery operated smoke alarms in 34 resident rooms were not replaced according to manufacturer's instructions and were older than 10 years.
Power strips were used as a substitute for fixed wiring to provide power to high current draw equipment in multiple areas.
Report Facts
Certified beds: 66
Census: 33
Resident hall exit doors with access codes not posted: 3
Battery operated smoke alarms: 34
Power strips improperly used: 3
Residents potentially affected by exit door impediment: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | Administrator | Named in relation to findings and plan of correction. |
| Maintenance Director | Involved in observations and interviews related to deficiencies. | |
| Maintenance Supervisor/Designee | Responsible for corrective actions and inspections. |
Inspection Report
Annual Inspection
Census: 33
Capacity: 33
Deficiencies: 10
Date: Jan 3, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from December 27, 2022 through January 3, 2023.
Findings
The facility was found deficient in multiple areas including timely transmission of discharge assessments, baseline and comprehensive care planning, provision of ADL care, following physician orders for pressure ulcer prevention, registered nurse coverage, psychotropic medication monitoring, medication storage, and environmental maintenance.
Deficiencies (10)
Failed to ensure a Discharge MDS Assessment was transmitted timely for 1 of 1 assessments reviewed.
Failed to develop a baseline careplan for psychotropic medications for 1 of 17 residents reviewed.
Failed to develop person-centered care plans for 3 of 17 residents reviewed.
Failed to ensure showers were provided timely and failed to provide personal hygiene needs for 2 of 3 residents reviewed for ADL.
Failed to follow Physician's Orders for applying bilateral heel protectors for 1 of 17 residents reviewed.
Failed to assess a resident's skin to prevent pressure ulcers for 1 of 2 residents reviewed for pressure ulcers.
Failed to provide 8 consecutive hours of registered nurse coverage for 1 out of 7 days.
Failed to monitor for side effects of antidepressant medication, failed to have appropriate diagnoses for antipsychotic medication use, and failed to complete gradual dose reduction for psychotropic medications for 3 of 5 residents reviewed.
Failed to ensure unused/refused medications were removed and destroyed from medication carts and failed to ensure medication and treatment carts were locked when unattended.
Failed to maintain a clean, safe, functional and sanitary environment in 5 resident rooms with issues including black marks, gouges, broken fixtures, peeling paint, and missing plaster.
Report Facts
Survey dates: 5
Residents present: 33
Licensed capacity: 33
Deficiency counts: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolyn Davidson | Administrator | Named in relation to plan of correction and facility administration contact |
| RN 6 | Interviewed regarding discharge assessment and psychotropic medication monitoring | |
| RN 5 | Interviewed regarding discharge assessment | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding baseline care plan, ADL care, and RN coverage |
| Director of Nursing | Director of Nursing | Interviewed regarding pressure ulcer wounds and skin assessments |
| Scheduler 8 | Interviewed regarding RN scheduling | |
| QMA 3 | Interviewed regarding pressure ulcer care and medication cart locking | |
| RN 6 | Interviewed regarding medication cart practices | |
| LPN 2 | Observed locking treatment cart and interviewed about cart locking |
Inspection Report
Renewal
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
The inspection was conducted as a Paper Compliance Review to the Recertification and State Licensure Survey.
Findings
The Waters of Syracuse was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the Paper Compliance Review to the Recertification and State Licensure Survey.
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