Inspection Reports for The Waters of Middletown Skilled Nursing Facility
981 BEECHWOOD AVE, IN, 47356
Back to Facility ProfileInspection Report Summary
The most recent inspections on January 8, 2025, found the Waters of Middletown Skilled Nursing Facility in compliance with all applicable federal and state regulations, including Life Safety Code requirements, and corrected previously investigated complaints. Earlier inspections showed a pattern of deficiencies primarily related to Life Safety Code compliance, such as fire safety equipment maintenance and door hardware, as well as resident care issues including dignity, medication administration, infection control, and staffing adequacy. Complaint investigations substantiated deficiencies involving abuse prevention, staffing, and care planning, though several complaints were also found unsubstantiated or corrected. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent clean inspections suggest improvement in addressing prior deficiencies.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
98% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35% occupied
Based on a December 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The inspection was conducted as part of the Annual Recertification and State Licensure survey, including investigation of two complaints (IN00440964 and IN00441092).
Complaint Details
Complaints IN00440964 and IN00441092 were investigated and found to be corrected.
Findings
The Waters of Middletown 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 paper review. Both complaints investigated were corrected.
Report Facts
Complaint IDs: IN00440964 and IN00441092
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The Life Safety Code Recertification and State Licensure Survey was conducted to assess compliance with fire safety and state licensure requirements.
Findings
The Waters of Middletown Skilled 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, Chapter 19, Existing Health Care Occupancies, and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 21
Capacity: 60
Deficiencies: 4
Date: Dec 17, 2024
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and related fire safety codes.
Findings
The facility was found not in compliance with Life Safety Code requirements, including issues with door latches on a public restroom, lack of approved method for returning kitchen appliances to their designed location, failure to conduct internal sprinkler pipe inspections within required timeframes, and incomplete fire drill documentation regarding fire alarm signal transmission.
Deficiencies (4)
Public restroom in the main entrance lobby door was equipped with an independent dead bolt in addition to the code locked doorknob, requiring more than one operation to open.
Failed to provide an approved method for returning cooking appliances to their designed location under the kitchen hood extinguishing system.
Failed to ensure automatic sprinkler piping systems were examined for internal obstructions where conditions exist that could cause obstructed piping; last inspection was over five years ago.
Failed to ensure 5 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station between 6:00 a.m. and 9:00 p.m.
Report Facts
Certified beds: 60
Census: 21
Fire drills reviewed: 12
Fire drills deficient: 5
Sprinkler internal pipe inspection interval: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Blackmon | HFA | Facility representative signing the report |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Regional Maintenance Director | Interviewed regarding deficiencies and corrective actions | |
| Administrator | Involved in corrective action plans and exit conference | |
| Maintenance Supervisor | Responsible for corrective actions and preventive maintenance | |
| Dietary Manager | Involved in corrective actions related to kitchen appliance |
Inspection Report
Annual Inspection
Census: 19
Deficiencies: 6
Date: Dec 9, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the investigation of three complaints (IN00448522, IN00441092, IN00440964).
Complaint Details
Complaint IN00448522 - No deficiencies related to the allegations were cited. Complaint IN00441092 - Federal/state deficiencies related to food safety were cited at F812. Complaint IN00440964 - Federal/state deficiencies related to homelike environment and room repair were cited at F921.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, quality of care related to blood pressure monitoring and medication administration, pain management, food safety and sanitation, infection control during medication administration, and maintaining a homelike environment with rooms in good repair.
Deficiencies (6)
Failed to ensure a resident was treated with dignity and respect during incontinent care interactions.
Failed to ensure orthostatic blood pressures and pulse were properly obtained and documented prior to medication administration.
Failed to timely inform the physician of changes in a resident's pain and ensure proper pain management prescriptions.
Failed to ensure food items were closed to air and contaminants, expired food was disposed of timely, and food containers were properly labeled with date opened and discard dates.
Failed to maintain infection control during medication administration by not utilizing hand hygiene, glove usage, and touching pill medication with bare hands.
Failed to ensure a homelike environment with residents' rooms that were not in good repair (gouged windowsill, scrapes and missing paint, missing trim, ceiling stains).
Report Facts
Survey dates: December 4, 5, 6, and 9, 2024
Census: 19
Deficiency counts: 6
Pain medication administration frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Blackmon | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| RN 3 | Observed medication administration deficiencies including hand hygiene and glove use | |
| Director of Nursing | DON | Provided policies, conducted in-services, and interviews related to deficiencies |
| Executive Director | ED | Provided incident reports, environmental tour, and interviews |
| Certified Nursing Assistant 7 | CNA | Witnessed resident dignity incident |
| Qualified Medication Aide 6 | QMA | Involved in resident dignity incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 26, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Complaint Survey IN00430719, IN00431980, and IN00432008.
Complaint Details
The visit was complaint-related, reviewing paper compliance for three complaint surveys. The facility was found to be in compliance.
Findings
Waters of Middletown 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 Complaint Survey.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 24
Deficiencies: 4
Date: Apr 24, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430719, IN00431711, IN00431980, and IN00432008.
Complaint Details
Complaint IN00430719 and IN00432008 related to abuse and staffing deficiencies with substantiated deficiencies cited at F732. Complaint IN00431980 related to staffing and supervision deficiencies cited at F741. Complaint IN00431711 had no deficiencies related to the allegations.
Findings
The facility was found to have deficiencies related to abuse and neglect, failure to post nurse staffing information for five consecutive days, and inadequate nursing staff coverage for the long-term care and secured dementia care units. Specific abuse allegations involved verbal and physical abuse by a staff member towards a resident, and the memory care unit was found unlocked and understaffed during a night shift.
Deficiencies (4)
Failed to protect resident's right to be free from verbal and physical abuse by a staff member (Resident D, CNA 6).
Failed to develop and implement policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property.
Failed to post nurse staffing information daily for five consecutive dates.
Failed to ensure adequate nursing staff coverage for the long-term care and secured dementia care units during night shift.
Report Facts
Residents present: 24
Licensed capacity: 24
Medicare residents: 1
Medicaid residents: 10
Other residents: 13
Residents in memory care unit: 7
Residents in long-term care unit: 17
Staffing audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nursing Assistant | Named in abuse finding; terminated for violation of zero tolerance abuse policy |
| Resident D | Resident | Subject of abuse allegation |
| Executive Director | Executive Director | Interviewed regarding abuse allegations, staffing issues, and facility policies |
| RN 4 | Registered Nurse | Named in staffing deficiency related to night shift coverage |
| CNA 3 | Certified Nursing Assistant | Named in staffing deficiency related to night shift coverage |
Inspection Report
Life Safety
Census: 25
Capacity: 60
Deficiencies: 0
Date: Nov 6, 2023
Visit Reason
A Post Survey Revisit (PSR) to 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).
Findings
The Waters of Middletown Skilled 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, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinkled except for a detached wooden storage building.
Report Facts
Facility capacity: 60
Census: 25
Inspection Report
Complaint Investigation
Census: 24
Capacity: 24
Deficiencies: 2
Date: Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417042 and IN00418633. Complaint IN00417042 resulted in federal/state deficiencies cited, while Complaint IN00418633 had no deficiencies related to the allegations.
Complaint Details
Complaint IN00417042 was substantiated with federal/state deficiencies cited at F584 and F656. Complaint IN00418633 was not substantiated with no deficiencies cited.
Findings
The facility failed to ensure a safe, clean, comfortable, and homelike environment by not eliminating a strong urine odor in Resident B's room despite multiple cleaning efforts. Additionally, the facility failed to develop and implement a comprehensive care plan addressing Resident B's incontinence and urinating in inappropriate locations throughout the facility.
Deficiencies (2)
Failure to ensure an odor-free room environment for Resident B, who was frequently incontinent of urine, resulting in a strong urine odor persisting despite cleaning efforts.
Failure to develop and implement a comprehensive care plan for Resident B related to incontinence care and urinating in inappropriate locations.
Report Facts
Census: 24
Total Capacity: 24
Medicare Census: 4
Medicaid Census: 16
Other Payor Census: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roberta Scott Shull | Facility Representative | Signed the report |
| Activity Director | Interviewed regarding urine odor and cleaning practices in Resident B's room | |
| Director of Nursing (DON) | Interviewed regarding mattress replacement and cleaning interventions for Resident B's room | |
| Assistant Director of Nursing (ADON) | Interviewed regarding mattress replacement for Resident B | |
| Administrator | Interviewed regarding facility expectations and cleaning policies related to odor management |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to a complaint survey IN00417042 completed on October 12, 2023.
Complaint Details
The complaint survey IN00417042 was reviewed and found to be in compliance; no deficiencies were cited.
Findings
Waters of Middletown 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 complaint survey.
Inspection Report
Life Safety
Census: 23
Capacity: 60
Deficiencies: 6
Date: Oct 2, 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 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to ensure hazardous area doors had properly working self-closing devices, unsafe electrical junction boxes, failure to enforce smoking policies, lack of annual fire door inspections, inadequate access to electrical panels, and missing documentation for electrical receptacle testing.
Deficiencies (6)
Failed to ensure hazardous area doors, such as storage rooms, were provided with properly working self-closing devices.
Failed to ensure electrical junction boxes in the attic were maintained in a safe operating condition with covers and secured wiring.
Failed to enforce non-smoking policies on facility property.
Failed to ensure annual inspection and testing of fire door assemblies were completed and documented.
Failed to maintain access and working space in enclosures housing electrical apparatus in maintenance offices.
Failed to ensure documentation of electrical outlet receptacle testing at all resident rooms was available for review.
Report Facts
Certified beds: 60
Census: 23
Cigarette butts counted: 30
Electrical junction box wires: 5
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roberta Scott Shull | Laboratory Director or Provider/Supplier Representative | Signed the inspection report. |
| Director of Maintenance | Interviewed and involved in findings related to hazardous doors, electrical junction boxes, fire door inspections, and electrical panel access. | |
| Maintenance Supervisor | Responsible for corrective actions including repairs, inspections, and preventive maintenance. | |
| Administrator | Participated in interviews, exit conference, and verified corrective actions. | |
| Housekeeping Supervisor | Involved in corrective actions related to smoking policy enforcement. | |
| Regional Property Manager | Involved in in-service training for maintenance supervisor on fire door inspections. |
Inspection Report
Renewal
Census: 22
Capacity: 22
Deficiencies: 4
Date: Sep 1, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of Complaint IN00410173. No deficiencies related to the complaint were cited.
Complaint Details
Complaint IN00410173 was investigated during the survey and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to respect and dignity regarding catheter drainage bag coverage, failure to assess and document bruising on a cognitively impaired resident, lack of physician order details for a Foley catheter, and failure to date oxygen tubing for a resident on oxygen therapy. Corrective actions and audits were planned and implemented for each deficiency.
Deficiencies (4)
Failed to ensure a Foley catheter drainage bag was covered to provide dignity for a resident with a Foley catheter.
Failed to assess and document bruising on a cognitively impaired resident.
Failed to ensure a resident had a physician's order specifying size of Foley catheter and balloon.
Failed to ensure oxygen tubing was dated for a resident receiving oxygen therapy.
Report Facts
Census: 22
Total Capacity: 22
Survey Dates: 5
Audit Frequency: 5
Audit Frequency: 3
Audit Frequency: 1
Compliance Threshold: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Jackman | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| LPN 1 | Interviewed regarding catheter bag coverage and demonstrated placing dignity cover on catheter bag | |
| Director of Nurses | Observed bruising on Resident 74 and involved in corrective action plans | |
| Administrator | Provided policies and information during the survey |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 1, 2023
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure Survey.
Findings
The facility, Waters of Middletown 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 compliance review.
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 0
Date: Jun 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409112.
Complaint Details
Complaint IN00409112 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: 21
Census Bed Type: 1
Census Bed Type: 20
Census Payor Type: 5
Census Payor Type: 16
Inspection Report
Complaint Investigation
Census: 19
Deficiencies: 0
Date: Feb 16, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00401731.
Complaint Details
Complaint IN00401731 was investigated and determined to be unsubstantiated due to lack of evidence.
Findings
The complaint was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census: 19
Medicare residents: 1
Medicaid residents: 15
Other payor residents: 3
Inspection Report
Life Safety
Census: 20
Capacity: 60
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 08/16/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Miller's Merry Manor 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. The facility is a one-story, fully sprinkled Type V construction with a fire alarm system and smoke detectors in resident sleeping rooms. The facility had a detached wooden storage building which was not sprinkled.
Report Facts
Facility capacity: 60
Census: 20
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on July 14, 2022.
Findings
Miller's Merry Manor Middletown 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
Life Safety
Census: 19
Capacity: 60
Deficiencies: 7
Date: Aug 16, 2022
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 not in compliance with Life Safety Code requirements. Deficiencies were identified related to fire alarm system maintenance, fire alarm out-of-service policy, sprinkler system maintenance and spare parts, sprinkler system out-of-service policy, corridor door closures, electrical receptacle GFCI protection, and annual fire door inspection.
Deficiencies (7)
Failed to ensure fire alarm system was maintained in accordance with NFPA 70 and NFPA 72; 4 smoke detectors failed sensitivity test and were not documented as replaced.
Failed to provide complete written policy for fire alarm system out-of-service procedures including required notification to Indiana State Department of Health.
Failed to maintain sprinkler system with spare sprinklers properly stored and unused; some spare sprinklers were previously used and not secured.
Failed to provide correct written policy for sprinkler system impairment procedures including fire watch and notification requirements.
Failed to ensure corridor doors closed and latched properly to resist passage of smoke; multiple doors required adjustment or replacement.
Failed to provide ground fault circuit interrupter (GFCI) protection for electrical receptacle powering ice machine in wet location.
Failed to ensure annual inspection and testing of fire door assembly in Oxygen Transfilling room was completed and documented.
Report Facts
Certified beds: 60
Census: 19
Failed smoke detectors: 4
Spare sprinklers: 12
Previously used spare sprinklers: 3
Corridor doors failed to latch: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding fire alarm system, fire watch policy, sprinkler system, corridor doors, electrical receptacle, and fire door inspection findings | |
| Director of Maintenance | Interviewed and involved in findings related to fire alarm system maintenance, sprinkler system, corridor doors, electrical receptacle, and fire door inspection |
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