Inspection Reports for The Waters of Wakarusa Skilled Nursing Facility
300 N WASHINGTON ST, IN, 46573
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 19, 2025, found the facility in compliance with Medicare/Medicaid participation requirements and Life Safety Code standards, with no deficiencies noted. Prior inspections showed a pattern of Life Safety Code and emergency preparedness deficiencies, including issues with outdoor smoking area maintenance, emergency generator testing, and fire safety equipment, as well as care-related deficiencies such as discharge planning, medication management, and infection control. Complaint investigations were mostly unsubstantiated, except for a substantiated complaint in January 2025 that identified immediate jeopardy related to unsafe discharge practices and other care concerns; enforcement actions or fines were not listed in the available reports. Earlier complaints related to discharge planning were substantiated, but subsequent revisits confirmed correction of those issues. The overall trend shows improvement in Life Safety Code compliance and emergency preparedness in the most recent inspections after addressing prior deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
23 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
448% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
59% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 19, 2025
Visit Reason
The document is a paper compliance submission for the Post Survey Revisit (PSR) related to the Life Safety Code Recertification and State Licensure Survey that exited on 05/23/2025.
Findings
The Waters of Wakarusa Skilled Nursing Facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, and applicable state regulations.
Inspection Report
Re-Inspection
Census: 78
Capacity: 133
Deficiencies: 1
Date: Jun 6, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on previous Emergency Preparedness and Life Safety Code Recertification surveys that exited on 04/21/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was not in compliance with Life Safety Code requirements due to failure to provide ashtrays and metal containers with self-closing covers in outdoor smoking areas. Corrective actions were implemented to address the deficiency.
Deficiencies (1)
Failed to provide ashtrays and metal containers with self-closing cover devices in outdoor smoking areas.
Report Facts
Certified beds: 133
Dually certified beds: 109
Medicare only beds: 24
Census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Henke | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Life Safety
Census: 77
Capacity: 133
Deficiencies: 12
Date: Apr 21, 2025
Visit Reason
An Emergency Preparedness and Life Safety Code Recertification survey was conducted to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility maintenance.
Findings
The facility was found not in compliance with emergency preparedness requirements including lack of tracking system for staff and residents during emergencies, incomplete emergency communication plans, failure to conduct required emergency exercises, and missing documentation for emergency generator testing. Life Safety Code deficiencies included improperly mounted kitchen fire suppression pull station, incomplete fire alarm out-of-service policy, sprinkler system maintenance issues, missing GFCI protection on electrical receptacles near sinks, incomplete fire drill documentation, inadequate smoking area maintenance, improper use of power strips, and oxygen storage room ventilation and cylinder segregation issues.
Deficiencies (12)
Failed to ensure emergency preparedness policies included a system to track location of on-duty staff and sheltered residents during and after an emergency.
Failed to ensure emergency preparedness communication plan included required contact information for emergency officials.
Failed to conduct required emergency preparedness exercises at least twice per year including unannounced staff drills.
Failed to document 36-month emergency generator load testing for 1 of 1 emergency generators.
Failed to maintain kitchen extinguishing system pull station at proper height per NFPA 96 and NFPA 101.
Failed to provide complete written fire alarm out-of-service policy including required contact procedures.
Failed to maintain wet sprinkler system antifreeze solution freezing point and failed to conduct required internal pipe inspection.
Failed to provide GFCI protection for electrical receptacles within 6 feet of sinks in multiple locations.
Failed to conduct fire drills in accordance with NFPA 101 including missing documentation of participants and alarm signal verification.
Failed to provide ashtrays and metal containers with self-closing covers in outdoor smoking areas; cigarette butts found scattered.
Failed to ensure flexible cords were not used as a substitute for fixed wiring; multiple power strips plugged into each other.
Failed to ensure oxygen storage/transfilling room had properly working mechanical ventilation and make-up air; oxygen cylinders not segregated or marked.
Report Facts
Certified beds: 133
Census: 77
Medicare and Medicaid certified beds: 109
Medicare only certified beds: 24
Deficiency count: 12
Cigarette butts counted: 27
Emergency generator load test duration: 1.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Henke | HFA | Facility representative signing report |
Inspection Report
Annual Inspection
Census: 83
Deficiencies: 11
Date: Mar 14, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00454200 and IN00453772.
Complaint Details
Complaint IN00453772 resulted in federal deficiencies cited at F691 related to urostomy care. Complaint IN00454200 had no deficiencies related to the allegations.
Findings
The facility was found deficient in multiple areas including inconsistent documentation of advance directives, failure to follow physician medication orders, incomplete hospice documentation, failure to provide ordered skin emollients, missed sliding scale insulin doses, inadequate urostomy care and supplies, improper storage and use of respiratory equipment, failure to assess dialysis fistula, lack of gradual dose reduction for psychotropic medications, improper medication storage, failure to obtain ordered labs, failure to follow pureed meal recipes, unsanitary food storage, and failure to follow infection control precautions.
Deficiencies (11)
Failed to ensure a resident's choice of Advance Directive was documented consistently in the medical record and staff were aware of the resident's choice.
Failed to follow physician orders to hold hypotensive medication, keep complete hospice binder, follow hypertensive medication orders, provide recommended emollients, and provide sliding scale insulin as ordered.
Failed to provide urostomy care and required urostomy supplies for a resident with a urostomy.
Failed to provide non-invasive mechanical ventilation equipment and failed to properly store respiratory treatment equipment.
Failed to assess a dialysis fistula for a resident receiving dialysis.
Failed to attempt a gradual dose reduction for a resident on psychotropic medication.
Failed to ensure medications were stored appropriately, had resident labels, and medication carts were free of loose pills.
Failed to obtain a physician ordered lab for a resident.
Failed to ensure recipes were followed when preparing pureed meals.
Failed to store food under sanitary conditions; foods were not tightly sealed and some were outdated.
Failed to ensure staff followed infection control practices regarding enhanced barrier precautions and failed to maintain an infection prevention and control program.
Report Facts
Survey dates: March 10-14, 2025
Census: 83
Medication administration counts: 42
Medication administration counts: 28
Medication administration counts: 7
Audit frequency: 10
Audit frequency: 5
Audit frequency: 5
Audit frequency: 5
Audit frequency: 3
Audit frequency: 3
Audit frequency: 5
Audit frequency: 3
Audit frequency: 1
Audit frequency: 10
Audit frequency: 5
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 8 | Interviewed regarding conflicting advance directive documentation for Resident 31 | |
| DON | Director of Nursing | Interviewed multiple times regarding advance directives, medication administration, hospice care, emollient orders, insulin administration, respiratory equipment, infection control, and other findings |
| Regional Nurse | Provided policies and interviewed regarding advance directives, medication administration, dialysis care, infection control | |
| LPN 7 | Interviewed regarding medication administration for Resident 24 | |
| CNA 5 | Interviewed regarding resident behaviors and care | |
| LPN 4 | Interviewed regarding medication storage | |
| RN 13 | Interviewed regarding medication storage | |
| CNA 10 | Observed and interviewed regarding gown use for enhanced barrier precautions | |
| CNA 3 | Observed and interviewed regarding gown use and knowledge of enhanced barrier precautions | |
| Nurse 9 | Interviewed regarding resident skin tears and enhanced barrier precautions | |
| CNA 11 | Interviewed regarding gown and glove use for contact precautions |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 14, 2025
Visit Reason
The inspection was conducted as part of the Annual Recertification and State Licensure Survey and included investigation of Complaint IN00453772.
Complaint Details
Investigation of Complaint IN00453772 was completed during the survey.
Findings
Waters of Wakarusa Skilled Nursing Facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.5-3.1 regarding the Annual Recertification and State Licensure Survey.
Inspection Report
Re-Inspection
Census: 79
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00450476, IN00450474, IN00449158, IN00448896, and IN00448438 completed on January 8, 2025.
Complaint Details
This was a Post Survey Revisit to verify correction of complaints IN00450476, IN00450474, IN00449158, IN00448896, and IN00448438. All complaints were found to be corrected.
Findings
The facility, Waters of Wakarusa Skilled Nursing Facility, was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of the listed complaints. All complaints were corrected.
Report Facts
Census Bed Type - SNF/NF: 68
Census Bed Type - SNF: 11
Total Census: 79
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 51
Census Payor Type - Other: 15
Inspection Report
Complaint Investigation
Census: 86
Capacity: 86
Deficiencies: 6
Date: Jan 8, 2025
Visit Reason
Investigation of multiple complaints alleging deficiencies related to resident discharge, care, and facility practices.
Complaint Details
This visit was triggered by multiple complaints alleging unsafe discharge practices, inadequate discharge planning, and other care concerns. Immediate jeopardy was identified related to unsafe discharge of Resident E to a hospital waiting area without admission arrangements or nutrition support.
Findings
The facility was found to have multiple deficiencies including unsafe discharge practices resulting in immediate jeopardy, failure to provide written discharge notice, inadequate discharge planning and preparation, failure to provide bathing as per resident preferences, incomplete documentation of tube feedings, and improper food handling and temperature maintenance during meal service.
Deficiencies (6)
Failed to ensure a notice of discharge was provided in writing, discharge planning was completed, and a resident's discharge was safe with continuity of care ensured.
Failed to ensure a notice of discharge was provided in writing prior to a facility-initiated discharge.
Failed to ensure preparation and orientation for a resident's discharge was completed to minimize anxiety and ensure a safe and orderly discharge.
Failed to ensure dependent residents received bathing opportunities according to their twice a week preferences.
Failed to ensure tube feedings were documented as ordered by the physician.
Failed to ensure hot food and cold liquids were served and maintained in a sanitary and safe manner related to staff touching food with the same gloved hands and not keeping room tray meal cart food at proper serving temperature.
Report Facts
Survey dates: 6
Census: 86
Total Capacity: 86
Medicare Census: 2
Medicaid Census: 59
Other Payor Census: 25
Deficiencies cited: 20
Shower refusals: 5
Tube feeding missed times: 17
Plate warmers: 10
Resident units: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed handling food with same gloved hands and acknowledged improper practice | |
| Dietary Aide 28 | Observed handling food with same gloved hands during meal service | |
| Licensed Practical Nurse 21 | LPN | Observed with undated piston syringe and water bottle for tube feeding |
| Director of Nursing | DON | Provided multiple interviews regarding discharge planning, documentation, and tube feeding practices |
| Social Service Director | SSD | Interviewed regarding discharge planning and communication with resident and family |
| Administrator | Interviewed regarding discharge plans and facility policies | |
| Regional Administrator | Interviewed regarding discharge and immediate jeopardy removal | |
| Regional Nurse Consultant | Provided policy information and interviews regarding bathing and tube feeding documentation |
Inspection Report
Complaint Investigation
Census: 87
Deficiencies: 0
Date: Nov 15, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00447230.
Complaint Details
Complaint IN00447230 - 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: 87
Census SNF/NF beds: 4
Census NF beds: 83
Census Payor Type Medicare: 7
Census Payor Type Medicaid: 55
Census Payor Type Other: 25
Inspection Report
Re-Inspection
Census: 87
Capacity: 133
Deficiencies: 0
Date: Jul 1, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to follow up on the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 05/01/24.
Findings
At this PSR, The Waters of Wakarusa Skilled Nursing Facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including Medicare and Medicaid participation standards. The facility was determined to be fully sprinklered with appropriate fire alarm systems and smoke detectors.
Report Facts
Certified beds: 133
Medicare and Medicaid dually certified beds: 109
Medicare only certified beds: 24
Resident census: 87
Emergency generator power: 230
Resident rooms with battery operated smoke detectors: 73
Inspection Report
Routine
Census: 87
Capacity: 133
Deficiencies: 8
Date: May 1, 2024
Visit Reason
Routine Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including fire door self-latching, fire alarm system time accuracy, sprinkler system antifreeze protection, smoke barrier penetrations, smoking policy enforcement, and oxygen transfilling signage.
Deficiencies (8)
Failed to maintain an Emergency Preparedness Plan based on a documented, facility-based and community-based risk assessment utilizing an all-hazards approach including missing residents and strategies for addressing emergency events.
Failed to ensure emergency preparedness communication plan includes contact information for federal, state, tribal, regional, and local emergency preparedness staff, state licensing and certification agency, state long-term care ombudsman, and other sources of assistance.
Failed to ensure 1 of 1 occupancy separation fire doors were self-closing and latched into the frame.
Failed to ensure fire alarm system was continuously in proper operating condition; fire alarm control panel displayed incorrect time.
Failed to maintain automatic sprinkler system antifreeze protection to meet minimum temperature requirements.
Failed to ensure smoke barrier walls were constructed to requirements; penetrations above ceiling tiles were sealed with non-fire rated drywall compound.
Failed to enforce non-smoking policy; cigarette butts found outside exit door #7.
Failed to provide signage on liquid oxygen storage/transfer room indicating when transfilling is occurring.
Report Facts
Certified beds: 133
Medicare and Medicaid dually certified beds: 109
Medicare only certified beds: 24
Current census: 87
Residents affected by fire door deficiency: 25
Residents affected by smoke barrier deficiency: 35
Residents affected by oxygen signage deficiency: 20
Residents affected by smoking policy deficiency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roberta Shull Scott | Laboratory Director or Provider/Supplier Representative | Signed the report. |
| Maintenance Director | Interviewed and involved in findings related to emergency preparedness, fire door, fire alarm, sprinkler system, smoke barriers, oxygen signage, and smoking policy. | |
| Administrator | Interviewed and involved in findings and corrective actions throughout the report. | |
| Maintenance Supervisor | Responsible for corrective actions and monitoring related to fire door, fire alarm, sprinkler system, smoke barriers, oxygen signage, and smoking policy. | |
| Director of Nursing (DON) | Involved in corrective actions and staff inservices related to emergency preparedness and oxygen policies. | |
| Housekeeping Supervisor | Involved in corrective actions related to smoking policy enforcement. |
Inspection Report
Annual Inspection
Census: 95
Capacity: 95
Deficiencies: 4
Date: Apr 3, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days from March 26 to April 3, 2024.
Findings
The facility was found deficient in several areas including failure to notify physicians of significant weight gain, inadequate provision of ADL care such as showers and nail care, failure to supervise a resident to prevent elopement, and failure to ensure timely physician visits every 60 days as required.
Deficiencies (4)
Failed to notify the physician of weight gain per physician orders for 1 of 1 resident reviewed for edema (Resident 60).
Failed to provide necessary ADL services related to nail care, facial hair removal, and showers for 2 of 3 residents reviewed (Residents 1 and 82).
Failed to supervise a resident with severe cognitive deficits and wandering behaviors to prevent elopement (Resident 86).
Failed to provide medical doctor visits every 60 days as required for 1 of 2 residents reviewed for nutrition (Resident 21).
Report Facts
Census: 95
Total Capacity: 95
Weight increase: 2.2
Weight increase: 5
Deficiency completion date: May 6, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roberta Scott Shull | Executive Director | Signed the report and involved in facility oversight |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 3, 2024
Visit Reason
The inspection was conducted as the Annual Recertification and State Licensure Survey for the Waters of Wakarusa Skilled Nursing Facility.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.5-3.1 regarding the Annual Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 22, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00428769 completed on February 21, 2024.
Complaint Details
The visit was complaint-related for Complaint IN00428769. The facility was found to be in compliance with no deficiencies noted.
Findings
Waters of Wakarusa 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 investigations.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 1
Date: Feb 21, 2024
Visit Reason
This visit was for the investigation of Complaint IN00428769 regarding federal/state deficiencies related to discharge planning process.
Complaint Details
Complaint IN00428769 was substantiated with federal/state deficiencies cited at F660 related to discharge planning process failures.
Findings
The facility failed to develop a comprehensive discharge care plan for 2 of 3 residents reviewed for discharge (Residents C and B). The Social Service Director admitted to not creating discharge care plans as required, and documentation was incomplete or missing for discharge planning.
Deficiencies (1)
Failed to develop a comprehensive discharge care plan for 2 of 3 residents reviewed for discharge (Residents C and B).
Report Facts
Census: 96
Total Capacity: 96
Medicare Census: 3
Medicaid Census: 56
Other Payor Census: 37
Residents reviewed for discharge: 3
Residents with deficient discharge plans: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roberta Scott Shull | Executive Director | Signed the report |
| Social Service Director | Interviewed regarding discharge planning process failures; admitted to not creating discharge care plans as required | |
| Physical Therapist Assistant 2 | Interviewed; unaware of Resident C discharge | |
| Therapy Program Manager | Interviewed; stated Resident C was discharged early to avoid co-payment despite safety concerns |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Date: Jan 24, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00425091.
Complaint Details
Complaint IN00425091 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00425091 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 89
Census Bed Type - SNF: 8
Total Census: 97
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 68
Census Payor Type - Other: 24
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 0
Date: Oct 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419449.
Complaint Details
Complaint IN00419449 was investigated and found to have no related deficiencies.
Findings
No deficiencies related to the allegations in Complaint IN00419449 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type - SNF/NF: 93
Census Bed Type - SNF: 8
Total Census: 101
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 48
Census Payor Type - Other: 49
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 0
Date: Jun 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406252.
Complaint Details
Investigation of Complaint IN00406252 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00406252 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 102
Census SNF beds: 18
Census NF beds: 84
Census Payor Medicare: 7
Census Payor Medicaid: 60
Census Payor Other: 35
Inspection Report
Re-Inspection
Census: 103
Capacity: 133
Deficiencies: 0
Date: May 10, 2023
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted for the 1st PSR survey exited on 04/17/23 related to the Life Safety Code Recertification survey that exited on 02/28/23, in conjunction with a PSR to the Life Safety Code Complaint Investigation Survey conducted on 04/19/23.
Findings
At this Life Safety Code PSR, The Waters of Wakarusa 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.
Report Facts
Certified beds: 133
Medicare and Medicaid dually certified beds: 109
Medicare only certified beds: 24
Inspection Report
Complaint Investigation
Census: 103
Capacity: 133
Deficiencies: 0
Date: May 10, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to investigate Complaint Number IN00406281 that exited on 04/19/23, in conjunction with a 2nd PSR for a Life Safety Code Recertification survey.
Complaint Details
Complaint IN00406281 was corrected as of the survey date 05/10/23.
Findings
The Waters of Wakarusa 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. The facility is fully sprinklered with a fire alarm system and smoke detectors in resident rooms.
Report Facts
Certified beds: 133
Dually certified beds: 109
Medicare only beds: 24
Census: 103
Inspection Report
Complaint Investigation
Census: 102
Capacity: 133
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
An investigation of Complaint Number IN00406281 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Complaint Details
This federal tag relates to complaint number IN00406281. The complaint investigation found the facility not in compliance due to exposed electrical wiring in the soiled linen room.
Findings
The Waters of Wakarusa Skilled Nursing Facility was found not in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. Specifically, exposed electrical wiring was found in the soiled linen room, which could affect approximately 19 residents in the Sunshine Pod.
Deficiencies (1)
Failed to ensure electrical wiring in the soiled linen room was protected; exposed wires at the open end of a conduit wrapped with electrical tape were observed.
Report Facts
Certified beds: 133
Census: 102
Residents potentially affected: 19
Resident rooms with smoke detectors: 73
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Schmidt | Administrator | Signed the report and involved in review of findings |
| Maintenance Director | Interviewed during observation of exposed wiring; involved in corrective actions | |
| Executive Director | Interviewed during observation of exposed wiring; involved in corrective actions | |
| Maintenance Supervisor | Replaced exhaust fan and corrected wiring to meet standards |
Inspection Report
Re-Inspection
Census: 101
Capacity: 133
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/28/23 was performed to verify correction of previous deficiencies related to generator testing and compliance with NFPA standards.
Findings
The facility was found not in compliance with the Life Safety Code requirements due to failure to exercise the emergency generator annually to meet NFPA 110 standards. The generator load testing was below the required 30% nameplate rating. A plan of correction was implemented including an annual load bank test and ongoing monitoring to ensure compliance.
Deficiencies (1)
Failed to exercise the emergency generator annually to meet NFPA 110, 2010 Edition requirements, specifically not achieving 30% of the nameplate kW rating during monthly load tests.
Report Facts
Certified beds: 133
Census: 101
Medicare and Medicaid dual certified beds: 109
Medicare only certified beds: 24
Generator load test duration: 30
Generator load test frequency: 12
Generator load test interval: 20
Generator load test interval: 40
Generator continuous exercise duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Acknowledged generator load testing deficiencies and discussed corrective actions | |
| Executive Director | Participated in exit conference reviewing generator testing deficiency | |
| Administrator | Inserviced Maintenance Supervisor/designee on generator testing requirements and monitors compliance | |
| Maintenance Supervisor/designee | Responsible for ensuring monthly and annual generator load bank tests are conducted and documented |
Inspection Report
Routine
Census: 88
Capacity: 133
Deficiencies: 17
Date: Feb 28, 2023
Visit Reason
Routine Life Safety Code Recertification and Emergency Preparedness Survey conducted by the Indiana Department of Health.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including exit door latching mechanisms, means of egress obstructions, exit signage, smoke alarm maintenance, hazardous area door self-closing devices, cooking facility shutoff access, fire alarm system installation and maintenance, sprinkler head cleanliness, sprinkler system maintenance, HVAC combustion air intake, fire door assembly inspections, emergency generator testing and maintenance, power cord usage, and electrical equipment safety.
Deficiencies (17)
Exit doors from kitchen and beauty shop contained two latching mechanisms instead of one.
Means of egress corridor obstructed by a clothing cart.
Exit signage missing in one kitchen corridor leading to dishwasher area.
Documentation for preventative maintenance of 73 battery operated smoke alarms in resident rooms was incomplete.
Utility storage room door lacked proper self-closing and latching.
Staff lacked access to locked shutoff switch for cooktop in activities room.
Smoke detector improperly located near air return vent preventing proper operation.
Fire alarm pull station not tested annually and smoke detector sensitivity testing incomplete.
Three sprinkler heads in laundry area were loaded with lint and dirt.
Sprinkler system inspection documentation missing for last 5-year inspection.
Laundry room fuel-fired dryers intake air vent covered with lint and dirt.
Annual inspection and testing of one fire door assembly (occupancy barrier between assisted living and healthcare) not completed.
Emergency generator load testing did not meet minimum 30% nameplate rating and lacked annual load bank test documentation.
Annual fuel quality test for diesel generator not documented.
Emergency generator lacked a properly located and labeled remote manual stop station.
Power cord daisy chains used as substitute for fixed wiring in Business Office and Social Services Office.
Flexible power cords not properly secured causing strain in Social Services Office.
Report Facts
Certified beds: 133
Census: 88
Battery operated smoke alarms: 73
Sprinkler heads loaded: 3
Fire door assemblies: 17
Fire door assemblies inspected: 16
Generator load test minimum: 30
Generator load test documented: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Schmidt | Administrator | Named in relation to exit conference and verification of corrective actions. |
Inspection Report
Annual Inspection
Census: 93
Deficiencies: 7
Date: Feb 6, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 31, 2023 through February 6, 2023.
Findings
The facility was found deficient in multiple areas including failure to complete timely quarterly MDS assessments, failure to develop person-centered care plans for several residents, failure to revise care plans after falls, failure to provide restorative therapy programs, failure to provide individualized activities for cognitively impaired residents, failure to obtain complete respiratory care orders, and failure to properly monitor and document psychotropic medication side effects and behaviors.
Deficiencies (7)
Failure to ensure quarterly Minimum Data Set (MDS) assessments were completed in the required time frame for 2 of 2 residents reviewed.
Failure to develop person-centered care plans for 4 of 28 residents reviewed.
Failure to revise a care plan following a fall for 1 of 28 residents reviewed.
Failure to provide a restorative therapy program for 1 of 2 residents reviewed for rehabilitation.
Failure to provide individualized activities for a severely cognitively impaired resident for 1 of 3 residents reviewed for activities.
Failure to obtain complete respiratory care orders for 1 of 3 residents reviewed.
Failure to ensure side effects were monitored, behaviors were documented, and follow-up assessments were completed for 1 of 5 residents reviewed for unnecessary psychotropic medications.
Report Facts
Census: 93
Deficiency count: 7
Residents reviewed for care plans: 28
Residents reviewed for activities: 3
Residents reviewed for rehabilitation: 2
Residents reviewed for psychotropic medications: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| James Schmidt | Administrator | Signed the report |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 6, 2023
Visit Reason
Paper Compliance Review to the Recertification and State Licensure Survey completed on February 6, 2023.
Findings
The Waters of Wakarusa 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.
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Mar 14, 2025
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Mar 14, 2025
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