Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Chesterfield Skilled Nursing Facility during CMS and state inspections, most recent first.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices: The facility did not document that written transfer/discharge notices or bed hold policy information were provided to the resident and/or representative for three residents transferred to the hospital. The records showed phone notification, eInteract transfer forms, and bed hold notifications were completed, but no written copies were documented as given. The residents involved had significant medical and cognitive conditions, and staff and the DON described completing online forms and sending resident information with EMTs, while the Administrator stated the facility had not been printing the online notices for residents or representatives.
An LPN failed to follow EBP during medication administration for a resident with a PEG tube, moderate cognitive impairment, dysphagia, and GERD. The LPN wore gloves but did not don a gown while performing direct care, including checking the g-tube, flushing it, and giving liquid potassium, despite the resident’s EBP order and care plan for feeding-tube-related precautions.
A resident with specific dietary needs related to a vegetarian diet did not have her preferences reflected in her care plan or clinical record, despite repeated requests and a physician's order. The dietary department was aware of the preference but lacked access to update the clinical record, and the resident and her family experienced ongoing dissatisfaction with meal options and preparation. Multiple complaints to facility leadership went unresolved for an extended period, contrary to the facility's grievance policy.
The ADM at an LTC facility failed to maintain safe and sanitary food handling practices during a lunch meal service. He used the same pair of gloves to handle various items and food without changing them or washing his hands, leading to potential cross-contamination. The facility's policies on food handling, glove use, and handwashing were not followed.
The facility failed to provide a varied and dignified menu for residents on pureed diets, serving them meals that did not match the regular diet menu and lacked variety. This affected residents with severe cognitive impairments and medical conditions requiring pureed diets, as their meals often repeated items like pureed buttered carrots and mashed potatoes, and did not align with the facility's policy on resident rights.
The facility failed to provide the required 48-hour notification of Medicare A Non-coverage for two residents. The necessary forms were signed on the last covered day instead of two days prior, as required. Interviews revealed communication issues and process adherence failures, despite weekly meetings to discuss upcoming discharges.
A resident with heart failure and edema experienced significant weight increases on multiple occasions, but the facility failed to notify the physician as required by orders. Despite documentation of weights in the electronic medical record, interviews with staff revealed no evidence of physician notification, violating facility policy.
The facility failed to ensure proper labeling and disposal of insulin vials on a medication cart. An expired vial of Lantus insulin was found, and two other vials were undated despite being used. RN 6 and the DON confirmed that insulin should be dated when opened and discarded after 28 days, as per facility policy.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide residents and/or their representatives with written notice of transfer/discharge and the bed hold policy for 3 of 3 residents reviewed for hospitalizations. Resident 2 had diagnoses including unspecified heart failure, oropharyngeal dysphagia, and GERD, was moderately cognitively impaired, and used a feeding tube. After the resident’s blood sugar was found to be high, the on-call physician ordered transfer to the emergency room. The record showed an eInteract Transfer Form and an Indiana Bed Hold Notification form documenting phone contact with the family, but it lacked documentation that a written copy of the transfer/discharge form and/or bed hold policy was provided. Resident 30 had Alzheimer’s disease, chronic atrial fibrillation, and major depressive disorder, and was moderately cognitively impaired. After returning from a family visit, the resident verbalized self-harm concerns, was placed on 1:1 care, and the NP ordered a psychiatric referral and transfer for evaluation and treatment. The record showed the resident’s daughter was contacted and an eInteract Transfer Form and bed hold notification were completed, but there was no documentation that the resident and/or representative received a written copy of the transfer/discharge form and/or bed hold policy. Resident 46 had type 2 diabetes mellitus, hyperlipidemia, and paroxysmal atrial fibrillation; one assessment showed the resident was cognitively intact. On two separate occasions, the resident was transferred to the emergency room after symptoms including nausea, vomiting, shaking, blood in the urinary catheter, low urine output, and abnormal lab values. In both events, staff documented phone notification to the wife and completed eInteract Transfer Forms and bed hold notifications, but the clinical record lacked documentation that a written copy of the transfer/discharge form and/or bed hold policy was provided. Staff interviews indicated nurses printed resident information for EMTs and completed online forms, and the Administrator stated the facility had not been printing the online transfer/discharge forms or bed hold notifications to provide to residents or representatives.
Failure to Follow EBP During G-Tube Medication Administration
Penalty
Summary
The facility failed to follow enhanced barrier precautions (EBP) during medication administration for a resident with a PEG tube. The resident had diagnoses including unspecified heart failure, oropharyngeal dysphagia, and GERD, and the clinical record showed an order for EBP related to the PEG tube for infection prevention. The resident’s MDS indicated moderate cognitive impairment and use of a feeding tube, and the care plan directed staff to follow EBP guidelines when providing care and coming into direct contact with potentially infected materials or devices, including feeding tubes. During a medication administration observation, an LPN completed hand hygiene, gathered supplies, entered the resident’s room, and donned gloves in the bathroom, but did not put on a gown. The LPN paused the tube feed pump, leaned her hips and thighs against the resident’s bed and bedsheets throughout the procedure, checked the g-tube for residuals and the site, flushed the tube, administered liquid potassium, flushed again, restarted the feeding, and removed her gloves at the end. The LPN stated she had forgotten to put on the gown, and the DON stated that residents with lines, wounds, or catheters required EBP and that staff should wear a gown during the medication administration because the resident had a g-tube.
Failure to Promptly Resolve Grievance Regarding Vegetarian Diet
Penalty
Summary
The facility failed to promptly resolve a grievance related to a resident's request for a vegetarian diet. The resident, who had diagnoses including hypothyroidism, gastro-esophageal reflux disease, and hypertension, was admitted with a physician's order for a regular vegetarian diet. Despite this, the clinical record and care plan did not reflect the resident's dietary preference, and the quarterly dietary assessment did not mention the need for a vegetarian diet. The resident and her family repeatedly expressed dissatisfaction with the vegetarian food options and preparation, with the family even providing plant-based protein due to ongoing issues. Interviews revealed that the Dietary Manager was aware of the resident's vegetarian preference within 24 hours of admission and provided available vegetarian items, but this information was not incorporated into the resident's clinical record or a multidisciplinary care plan. The dietary department lacked access to the electronic clinical record, further hindering coordinated care. The resident reported that meals often consisted of repetitive items like eggs, dairy, and peanut butter, and that food brought in by her family was sometimes improperly prepared by staff. Documentation and interviews indicated that the resident's family had communicated their concerns to multiple facility leaders, including the Administrator and DON, without resolution for an extended period. The Ombudsman confirmed that the issue persisted since admission and that the facility, resident, and family were unable to resolve the concern until a care plan meeting was eventually held. The facility's grievance policy required prompt review and resolution of complaints, but this was not achieved in the resident's case.
Failure to Maintain Safe and Sanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure food was prepared and served under safe and sanitary conditions, impacting all 39 residents. During a lunch meal service, the Acting Dietary Manager (ADM) was observed wearing gloves and handling various items such as meal tickets, trays, bowls, and utensils, as well as food items like chicken nuggets and rolls, without changing gloves or washing hands. The ADM touched multiple surfaces and food items with the same pair of gloves, leading to potential cross-contamination. Throughout the meal service, the ADM left the kitchen area multiple times, touching door handles, countertops, and other surfaces with contaminated gloves. He also handled food items directly with his gloved hands, including chicken nuggets, rolls, and broccoli, without using utensils. The ADM admitted during an interview that he should have used tongs but chose not to due to time constraints, and he did not believe his gloves were contaminated. The facility's policies on food handling, glove use, and handwashing were not followed. The policies required the use of utensils to avoid hand contamination, changing gloves when soiled, and washing hands before putting on new gloves. The ADM's actions were contrary to these policies, as he continued to use the same gloves for multiple tasks without washing his hands, increasing the risk of cross-contamination.
Failure to Provide Varied and Dignified Pureed Diets
Penalty
Summary
The facility failed to provide a menu that encouraged intake and promoted dignity for residents on pureed diets. During a lunch meal observation, it was noted that the regular diet trays included breaded chicken nuggets, steamed broccoli, roasted herbed potatoes, and pudding as a substitute for peaches. However, residents on pureed diets were served pureed grilled chicken, mashed potatoes, and a pureed vegetable blend, which did not match the regular menu items. The Acting Dietary Manager admitted to not following the recipes and menus due to time constraints. Further review of the facility's menu and portion size guide for the week revealed a lack of variety and failure to serve residents on pureed diets the same meals as those on regular diets. For instance, pureed buttered carrots were served multiple times when the regular diet included different vegetables, and pureed pork was served twice in one day. Additionally, apple sauce was served for both lunch and dinner on the same day, and mashed potatoes were served multiple times throughout the week, sometimes twice in one day. The residents affected by this deficiency included those with severe cognitive impairments and various medical conditions such as dysphasia, diabetes mellitus, and congestive heart failure. These residents had physician's orders for pureed diets due to their conditions, and their care plans indicated they were at nutritional risk. The facility's policy on resident rights emphasized the importance of a dignified existence and self-determination, which was not upheld in this instance.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required 48-hour notification of Medicare A Non-coverage for two residents, resulting in a deficiency. Resident 37 was admitted to Medicare Part A Skilled Services and had their last covered day on 9/10/24. However, the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) and SNF Notice of Medicare Non-Coverage (NONMC) were only reviewed and signed on the same day, 9/10/24, instead of two days prior. Similarly, Resident 38, who was admitted to Medicare Part A Skilled Services, had their last covered day on 9/11/24, but the necessary forms were also signed on 9/10/24, not meeting the 48-hour requirement. Interviews with facility staff revealed a breakdown in communication and process adherence. The Social Service Director indicated that there were instances when she was not given the full two days' notice before services ended, making it challenging to complete the necessary documentation on time. The Speech Therapist mentioned that therapy discharge forms were prepared a week in advance and discussed in weekly Medicare A meetings, which were attended by the Social Services and Minimum Data Set departments. Despite these meetings, the facility did not adhere to its policy of issuing the SNF ABN and NONMC two days prior to the end of Medicare coverage, as required by the Center for Medicare and Medicaid Services (CMS) guidelines.
Failure to Notify Physician of Significant Weight Changes
Penalty
Summary
The facility failed to notify the physician as ordered for changes in daily weights for a resident with heart failure, hypertension, and unspecified edema. The physician's orders required daily weight monitoring and notification for an increase of 3 pounds in 24 hours or 5 pounds in 7 days. However, the resident experienced significant weight increases on multiple occasions without the physician being notified. Specifically, the resident's weight increased by 9.6 pounds in 24 hours on one occasion, 14.8 pounds on another, and 6.6 pounds on a third occasion, yet there was no documentation of physician notification. Interviews with facility staff, including an LPN and the DON, confirmed that while weights were documented in the electronic medical record, there was no evidence that the physician or Nurse Practitioner was notified of the weight gains as required by the orders. The facility's policy mandates that all physician orders be implemented and followed, but this was not adhered to in this case, leading to a deficiency in the care provided to the resident.
Failure to Properly Label and Dispose of Insulin Vials
Penalty
Summary
The facility failed to ensure proper labeling and disposal of insulin vials on the 200 hall medication cart. During an observation, one open vial of Lantus insulin was found to be expired, as it was dated beyond the 28-day usage period. Additionally, another vial of Lantus and a vial of Novolog insulin were found to be undated, despite having been used. RN 6 confirmed that insulin should be dated when opened and discarded after 28 days. The Director of Nursing (DON) reiterated that insulin pens should be dated upon opening and discarded when expired, in accordance with the facility's policy, which requires insulin to be labeled with the date of opening and considered expired after 28 to 45 days, depending on the manufacturer's instructions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chesterfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Pointe Health Campus | 2.9 mi | ★★★★★ | 4 | 1 |
| Envive Of Anderson | 3 mi | ★★★★★ | 9 | 0 |
| Countryside Manor Health & Living Community | 4.5 mi | ★★★★★ | 20 | 0 |
| Waters Of Middletown Skilled Nursing Facility, The | 4.6 mi | ★★★★★ | 10 | 0 |
| Beaumont Rehabilitation And Healthcare Center | 4.9 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.