Inspection Reports for Waters of Columbia City Skilled Nursing Facility
640 W ELLSWORTH ST, IN, 46725
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 3, 2025, was a complaint investigation in which no deficiencies were cited. Earlier inspections showed a pattern of deficiencies primarily related to emergency preparedness and life safety code compliance, including failure to update emergency plans, conduct required drills, and maintain fire safety equipment. Prior reports also noted issues with resident care aspects such as infection control, privacy, and staffing, as well as a medication error in early 2024 that resulted in immediate jeopardy and the death of a resident; this serious finding was addressed with corrective actions and no enforcement actions like fines or license suspensions were listed in the available reports. Most complaint investigations were unsubstantiated, and the facility demonstrated compliance in follow-up revisits. The inspection history indicates some improvement in emergency preparedness and life safety compliance in the most recent surveys compared to earlier findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
33 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Jun 3, 2025
Visit Reason
This visit was for the investigation of complaints IN00458537 and IN00458734.
Findings
No deficiencies related to the allegations in complaints IN00458537 and IN00458734 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00458537 - No deficiencies related to the allegations are cited. Complaint IN00458734 - No deficiencies related to the allegations are cited.
Report Facts
Census: 33
Medicare census: 5
Medicaid census: 17
Other payor census: 11
Inspection Report
Re-Inspection
Census: 31
Capacity: 84
Deficiencies: 0
Jan 16, 2025
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 11/20/2024.
Findings
At this PSR survey, Waters of Columbia City Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility was fully sprinklered except for a shed providing facility services which was not sprinklered.
Inspection Report
Routine
Census: 26
Capacity: 84
Deficiencies: 13
Nov 20, 2024
Visit Reason
Routine Emergency Preparedness and Life Safety Code inspection 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 not in compliance with Emergency Preparedness requirements including failure to annually review and update the Emergency Preparedness Plan, maintain a documented all-hazards risk assessment, update policies and procedures, provide subsistence needs agreements, maintain communication plans, conduct training and testing, and maintain Life Safety Code compliance including hazardous area door closures, sprinkler maintenance, fire extinguisher operability, electrical outlet safety, and proper use of extension cords and power strips.
Severity Breakdown
SS=C: 6
SS=F: 3
SS=E: 5
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to review and update the Emergency Preparedness Plan at least annually. | SS=C |
| Failed to maintain an Emergency Preparedness Plan based on a documented facility and community-based risk assessment utilizing an all-hazards approach. | SS=F |
| Failed to review and update Emergency Preparedness Plan Policies and Procedures at least annually. | SS=C |
| Failed to ensure emergency preparedness policies include subsistence needs for staff and residents including emergency fuel agreements. | SS=F |
| Failed to ensure emergency preparedness policies include development and annual review of arrangements with other LTC facilities and providers. | SS=F |
| Failed to review and update the Emergency Preparedness Plan Communication plan at least annually. | SS=C |
| Failed to review and update the Emergency Preparedness Plan Training program at least annually. | SS=C |
| Failed to conduct annual training demonstrating staff knowledge of the Emergency Preparedness Program. | SS=C |
| Failed to ensure storerooms greater than 50 square feet used for storage of large amounts of combustibles were protected as hazardous areas with self-closing doors. | SS=E |
| Failed to ensure sprinklers in the kitchen cooking room were free of corrosion. | SS=E |
| Failed to ensure electrical outlet in satellite kitchen contained a cover plate and was protected from damage. | SS=E |
| Failed to ensure K-class portable fire extinguisher was repaired or replaced when pressure gauge was not in operable range. | SS=E |
| Failed to ensure extension cords and power strips were not used as a substitute for fixed wiring in patient care areas. | SS=E |
Report Facts
Facility capacity: 84
Census: 26
Number of storerooms greater than 50 sq ft: 6
Number of sprinklers with corrosion: 2
Number of electrical outlets missing cover plates: 1
Number of K-class fire extinguishers with pressure gauge issues: 1
Number of extension cords and power strips improperly used: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Barnes | Administrator | Named as facility administrator signing the report and involved in corrective actions. |
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 0
Oct 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445853.
Findings
No Federal or State deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations regarding the complaint.
Complaint Details
Complaint IN00445853 was investigated and found to have no substantiated Federal or State deficiencies related to the allegations.
Report Facts
Medicare census: 2
Medicaid census: 15
Other payor census: 10
Inspection Report
Annual Inspection
Census: 27
Capacity: 27
Deficiencies: 5
Oct 21, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on October 16, 17, 18, and 21, 2024.
Findings
The facility was found deficient in maintaining safe and comfortable temperatures in resident areas, ensuring personal hygiene of fingernails, safe storage of treatment supplies, safe and sanitary food storage, and proper infection prevention and control practices including hand hygiene and cleaning of blood glucose monitors.
Severity Breakdown
SS=E: 2
SS=D: 2
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure safe and comfortable temperatures between 71 and 81 degrees in resident areas for 4 of 27 residents. | SS=E |
| Failed to ensure personal hygiene of fingernails for 1 of 6 residents reviewed (Resident 22). | SS=D |
| Failed to ensure safe storage of treatment supplies for 1 of 27 residents reviewed (Resident 11). | SS=D |
| Failed to ensure safe and sanitary food storage practices for facility prepared leftovers. | SS=F |
| Failed to ensure hand hygiene was correctly performed and blood glucose monitors were properly cleaned during care for 4 of 8 residents reviewed (Residents 11, 13, 14, and 128). | SS=E |
Report Facts
Residents affected by temperature deficiency: 4
Residents reviewed for fingernail hygiene: 6
Residents reviewed for treatment supply storage: 27
Residents reviewed for infection control: 8
Temperature readings below 71 degrees: Multiple temperature logs showed readings as low as 61 degrees in resident rooms.
Leftover food storage dates: Leftovers dated from 10/9/24 to 10/13/24 were found, some without dates.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Barnes | Administrator | Interviewed regarding temperature issues and corrective actions. |
| Maintenance 3 | Provided information about HVAC system and temperature monitoring. | |
| DON (Director of Nursing) | Director of Nursing | Provided information on personal hygiene, infection control policies, and corrective actions. |
| LPN 6 | Licensed Practical Nurse | Observed during medication pass and infection control deficiencies. |
| QMA 2 | Qualified Medicine Aide | Reported improper storage of treatment supplies. |
| Cook 7 | Provided information about leftover food storage. | |
| CDM 8 | Certified Dietary Manager in training | Provided information about leftover food storage and dating. |
| NP 5 | Nurse Practitioner | Observed during wound care with improper hand hygiene. |
| CNA 4 | Certified Nurse Aide | Observed during wound care. |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 21, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey was conducted.
Findings
The Waters of Columbia City Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Oct 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00443476 and IN00443957.
Findings
No deficiencies related to the allegations in complaints IN00443476 and IN00443957 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00443476 and IN00443957 found no deficiencies related to the allegations.
Report Facts
Census: 26
Medicare residents: 2
Medicaid residents: 15
Other residents: 9
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 0
Aug 27, 2024
Visit Reason
This visit was for the investigation of Complaint IN00440779.
Findings
No deficiencies related to the 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 IN00440779 - No deficiencies related to the allegations are cited.
Report Facts
Census: 28
Total Capacity: 28
Medicare Census: 2
Medicaid Census: 15
Other Payor Census: 11
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Jul 31, 2024
Visit Reason
This visit was conducted for the investigation of four complaints: IN00437996, IN00438039, IN00438052, and IN00438721.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00437996, IN00438039, IN00438052, and IN00438721 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 32
Census Payor Type: 17
Census Payor Type: 15
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Jun 25, 2024
Visit Reason
This visit was conducted to investigate two complaints, IN00435853 and IN00436571, regarding the Waters of Columbia City Skilled Nursing Facility.
Findings
No deficiencies related to the allegations in either complaint were cited. The facility was found to be in compliance with applicable federal and state regulations.
Complaint Details
Complaint IN00435853 and Complaint IN00436571 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 33
Census Bed Type - SNF: 2
Census Bed Type - SNF/NF: 31
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 20
Census Payor Type - Other: 11
Inspection Report
Re-Inspection
Census: 29
Capacity: 29
Deficiencies: 0
Mar 22, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00428695 completed on February 22, 2024.
Findings
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 PSR to the Investigation of Complaint IN00428695. The complaint was corrected.
Complaint Details
Complaint IN00428695 - Corrected.
Report Facts
Census: 29
Total Capacity: 29
Medicaid Census: 15
Other Payor Census: 14
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Feb 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427464 and IN00428695, resulting in a Partially Extended Survey due to Substandard Quality of Care with Immediate Jeopardy.
Findings
The facility failed to ensure proper assessment and monitoring of Resident Q after a medication error where she was given MS Contin 30 mg not prescribed for her. This failure led to a change in condition and subsequent death. The Immediate Jeopardy was identified on 2/16/24 and removed on 2/22/24 after corrective actions including staff education and monitoring were implemented.
Complaint Details
Complaint IN00427464 had no deficiencies related to the allegations. Complaint IN00428695 resulted in federal/state deficiencies cited at F684 and F760 related to medication error and inadequate monitoring leading to Resident Q's death.
Severity Breakdown
SS=J: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to adequately assess respiratory status after a medication error for Resident Q, resulting in change of condition and death. | SS=J |
| Failure to ensure Resident Q did not receive an opioid medication prescribed for another resident and failure to monitor for adverse reactions, resulting in death. | SS=J |
Report Facts
Census: 31
Medication error date: Feb 16, 2024
Immediate Jeopardy removal date: Feb 22, 2024
Narcotic dose: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Immediately interviewed and suspended pending investigation after medication error discovery on 02/16/24 |
| LPN 7 | Licensed Practical Nurse | Administered incorrect medication to Resident Q and monitored vital signs; notified Nurse Practitioner |
| RN 8 | Registered Nurse | Took over care after LPN 7, failed to monitor oxygen saturation and respiratory status adequately |
| Nurse Practitioner | Nurse Practitioner | Notified of medication error, gave monitoring instructions, but was not informed of Resident Q's condition changes |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Jan 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00424438.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00424438 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 37
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 15
Census Payor Type - Other: 20
Inspection Report
Re-Inspection
Census: 38
Capacity: 84
Deficiencies: 0
Nov 30, 2023
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 10/24/23.
Findings
At this Post Survey Revisit, The Waters of Columbia City Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Medicare and Medicaid Participating Providers and Suppliers.
Inspection Report
Census: 36
Capacity: 84
Deficiencies: 4
Oct 24, 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 to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements, failing to conduct required emergency plan exercises twice per year including unannounced staff drills. Life Safety Code deficiencies included failure to protect a storage room with combustible materials as a hazardous area, malfunctioning self-closing door on the elevator machine room, and missing fire drills on each shift for 2 of 4 quarters.
Severity Breakdown
SS=E: 2
SS=F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using emergency procedures. | SS=F |
| Failed to ensure storage room with large amounts of combustible storage and greater than 50 square feet was protected as a hazardous area; door held open by a box. | SS=E |
| Elevator machine room door self-closing device did not fully close and latch the door. | SS=E |
| Failed to conduct fire drills on each shift for 2 of 4 quarters. | SS=F |
Report Facts
Facility capacity: 84
Census: 36
Deficiency count: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Barnes | Executive Director | Signed the report |
| Maintenance Director | Interviewed regarding emergency preparedness exercises and elevator door deficiency | |
| Administrator | Interviewed and involved in exit conference and corrective action plans |
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 5
Sep 29, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 26 to 29, 2023.
Findings
The facility was found deficient in multiple areas including resident dignity related to catheter privacy, privacy during resident council meetings, confidentiality of medical records, sufficient nursing staff to meet resident needs, and infection prevention and control practices.
Severity Breakdown
SS=D: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure dignity for residents with indwelling catheters by not covering catheter bags, visible from hallway. | SS=D |
| Failure to provide a private setting for resident council meetings, resulting in interruptions by staff. | SS=E |
| Failure to ensure privacy and confidentiality of medical records; medication carts left unattended with resident information visible. | SS=D |
| Failure to maintain sufficient nursing staff to implement fall prevention and provide personal assistance as preferred by residents. | SS=E |
| Failure to consistently implement infection prevention strategies including hand hygiene and proper handling of linens and utensils. | SS=E |
Report Facts
Census: 37
Residents with recent falls: 20
Residents requiring 2 staff for mechanical lift: 6
Staffing ratios: 17
Staffing ratios: 10
Staffing ratios: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Laurie Barnes | Executive Director | Signed the inspection report |
| Director of Nursing | Director of Nursing | Provided policies and interviews regarding dignity, privacy, staffing, and infection control |
| LPN 2 | Licensed Practical Nurse | Observed leaving medication cart unattended with resident information visible and failing to perform hand hygiene between tasks |
| CNA 4 | Certified Nurse Aide | Observed unable to assist resident due to staffing shortages |
| Cook 8 | Cook | Observed removing dirty dishes without gloves and wiping hands on pants |
| Qualified Medicine Aide 6 | Qualified Medicine Aide | Observed touching resident equipment and cups without hand hygiene |
| Activity Director | Activity Director | Interviewed regarding resident council meeting privacy |
| Administrator | Administrator | Interviewed regarding resident council meeting privacy and hand hygiene expectations |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 29, 2023
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
The Waters of Columbia City was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Jun 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409156.
Findings
No deficiencies related to the allegations in Complaint IN00409156 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00409156 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 30
Census Bed Type - SNF: 7
Census Total: 37
Census Payor Type - Medicare: 3
Census Payor Type - Medicaid: 24
Census Payor Type - Other: 10
Census Payor Type - Total: 37
Inspection Report
Life Safety
Census: 38
Capacity: 84
Deficiencies: 0
Jan 4, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code (LSC) Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility is fully sprinklered except for a shed providing facility services which was not sprinklered.
Report Facts
Facility capacity: 84
Census: 38
Inspection Report
Renewal
Census: 39
Capacity: 39
Deficiencies: 0
Dec 1, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from November 28 to December 1, 2022.
Findings
Waters of Columbia City 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 Recertification and State Licensure Survey.
Report Facts
Census Bed Type: 39
Census Payor Type: 39
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