Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Columbia City Skilled Nursing Facility during CMS and state inspections, most recent first.
Unsafe dishwashing and food service sanitation practices: The facility failed to keep dishwashing and tray assembly sanitary for all residents receiving meals from the kitchen. The dishwasher repeatedly failed to reach the required final rinse temperature, and a Dietary Aid handled dirty items, then touched sanitized dishes without hand hygiene. The same aide also contaminated the clean tray area by leaning on the work surface, and wet trays and lids were used for meal service items, with moisture dripping onto prepared plates.
Meal Service Dignity Failure: Staff left the dining room during meal service, and residents were left yelling for food, drinks, and assistance while trays were served inconsistently and not by table. Several residents waited while others at their table had already been served, and one resident was served 22 minutes after tablemates. Affected residents had diagnoses including CVA, dementia, dysphagia, Parkinson’s disease, malnutrition, Alzheimer’s disease, and anxiety/depression, with varying levels of eating assistance needs.
Failure to follow physician orders for PRN Bumex and daily weights. A cognitively impaired resident with CAD, Afib, CHF, HTN, dementia, and asthma had repeated documented weight gains and edema, but the MAR lacked documentation that PRN Bumex was given or that the MD was notified. Daily weight entries were also missing on multiple occasions, and the DON stated staff had not been routinely documenting edema and that the MAR should not have blank spaces.
Missing Oxygen Order for Resident Receiving Supplemental Oxygen: A resident with chronic respiratory failure with hypoxia, CHF, and COPD was observed receiving oxygen by nasal cannula at 4 L/min, but the current physician orders did not include an oxygen order. Progress notes documented oxygen use per orders, while an RN confirmed the order was missing and the DON stated the oxygen order had not been entered after the resident returned from the hospital. The facility policy required nurses to verify physician orders before giving oxygen.
An RN left three residents’ medication cups on top of an unlocked med cart in a hallway while residents were nearby and no staff were immediately present. The RN said she was rushing to complete the med pass by 10:00 AM while also covering other duties. Records showed the affected residents had current med orders and were cognitively intact or oriented, and facility policy required med carts to be locked when unattended.
The facility failed to maintain safe food storage practices, affecting all residents. During a kitchen tour, staff were found to be unsure of proper leftover storage durations, with some items undated or past the facility's 72-hour discard policy. The Certified Dietary Manager in training acknowledged the lack of proper labeling and incorrect storage durations.
The facility failed to maintain safe and comfortable temperatures between 71 and 81 degrees, affecting four residents who reported feeling cold. The Administrator acknowledged the issue, and a delay in activating the boiler heating system led to discomfort for several days. Temperature logs showed consistent readings below the required range, and the facility did not follow its policy to address the issue promptly.
The facility failed to ensure proper hand hygiene and cleaning of blood glucose monitors during care for four residents. An LPN washed her hands for less than the recommended 20 seconds after administering medications and did not perform hand hygiene or change gloves after obtaining blood glucose results. The LPN also failed to properly disinfect the blood glucose meter. During wound care, the DON, CNA, and NP did not adhere to proper hand hygiene protocols, with the NP handing a resident a glass of juice while wearing contaminated gloves. Facility policies on hand hygiene and glucose meter cleaning were not followed.
A resident with multiple health conditions, including diabetes, was found with long, unclean fingernails and reported inadequate assistance with perianal cleansing. Despite needing help with ADLs, the facility failed to document nail care or refusals of care, and policies requiring licensed nurses to trim diabetic residents' nails were not followed.
A facility failed to ensure the safe storage of treatment supplies for a resident, as various items were found unsecured in the resident's room and bathroom. Staff interviews revealed that the supplies should have been locked in a treatment cart, but the responsible aide did not have the keys. The facility's policy mandates secure storage of medications, accessible only to authorized personnel.
Unsafe dishwashing and food service sanitation practices
Penalty
Summary
The facility failed to maintain safe food distribution, storage, preparation, and sanitation of tableware for 45 of 45 residents who eat meals prepared in the kitchen. During observation, the dishwasher rinse cycle thermometer showed 173 degrees F, then 172 degrees F on a second run and 175 degrees F on a third run, all below the required sanitizing temperature. The Dietary Manager stated staff would use the three-sink sanitizer until the dishwasher was fixed. A review of the Dishwasher Temperature Logs for December 2025 showed temperatures were below the required sanitizing temperature on 12/5/25 during the evening shift, with a note that dishes were to be sanitized using the 3-sink method until the dishwasher was fixed. During observation, a Dietary Aid picked up a bowl from the floor, placed it in the dirty dishes area, and then touched sanitized dishes without hand hygiene. Later, the same Dietary Aid leaned forearms on the clean work surface where meal trays were assembled and rested a bent elbow on a clean stack of trays. Water droplets were observed between clean stacked trays, and those wet trays were used for flatware, a dinner plate warmer, a paper meal ticket, and a dessert plate. Stacked lids used to cover meal plates were also wet and dripped liquid onto prepared plates. The Dietary Manager stated trays and lids should be dry. The Dietary Manager later stated she knew the dishwasher had failed to meet the required temperature since 12/5/25 and that staff used the 3-sink method until the dishwasher returned to the required temperature.
Meal Service Dignity Failure
Penalty
Summary
The facility failed to ensure dignity during meal service for 6 of 14 residents seated together in the main dining room. During a continuous observation of dining service, staff passed drinks and then left the room while 14 residents remained present. Several residents began yelling for lunch, asking for more to drink, requesting staff to wipe another resident’s face, and expressing concern that no staff were available to respond. One resident stated she was bored and wanted to return to her room, while another resident said he did not know whether he would be able to eat and wondered if any cooks had come to work that day. As meal carts arrived, trays were served inconsistently and not by table. One CNA served four trays to residents who ate slowly, including residents seated at separate tables, then removed the cart from the dining room. Residents seated with one another were left waiting while other residents were served from later carts. One resident repeatedly voiced concern about not receiving food and said he did not know if he would get any food that day. Another resident yelled that he just liked to complain. The last resident in question was served 22 minutes after tablemates had been served. Record review showed the affected residents had diagnoses including cerebral infarction, dementia with agitation, dysphagia, Parkinson’s disease with dyskinesia, vascular dementia, severe protein-calorie malnutrition, Alzheimer’s disease, adult failure to thrive, anxiety, depression, and generalized anxiety disorder. MDS assessments showed some residents were cognitively intact while others had severe cognitive impairment, and several required supervision, touching assistance, partial/moderate assistance, or total dependence with eating. The DON stated residents seated at the same table should be served within the next few minutes and should not have to wait long periods after others at their table had been served. The facility’s dignity policy stated meal trays should be served by table so residents do not experience long waits when others at their table have been served.
Failure to Follow PRN Diuretic Orders and Document Daily Weights
Penalty
Summary
The facility failed to follow physician orders for a resident with coronary artery disease, atrial fibrillation, chronic heart failure with mildly reduced ejection fraction of 41-49%, enlarged heart, hypertension, progressive neurological conditions, dementia, psychotic disorder, metabolic encephalopathy, and asthma. The resident’s quarterly MDS showed a BIMS score of 5, indicating cognitive impairment. Physician orders dated 9/22/25 directed Bumex 2 mg every 24 hours as needed for weight gain of 2-3 pounds, shortness of breath, and/or edema, and an order dated 9/23/25 directed daily weights to be completed and recorded with additional Bumex administered if needed. The MAR showed multiple instances where weight gain or edema was documented without corresponding documentation that the PRN Bumex was given or that the physician was notified. On 10/2/25 and 10/11/25, 3-pound weight gains were documented with no record of PRN Bumex administration. On 11/10/25, a 4-pound weight gain was documented with no documentation of Bumex administration or physician notification, and on 11/28/25 a 2.5-pound weight gain was documented with no record of Bumex being given. In December, daily weight documentation was missing on 12/2/25 and 12/9/25, a 2-pound weight gain was documented on 12/5/25 with no documentation of Bumex administration, and on 12/10/25 increased swelling with 2+ edema was documented with no record of PRN Bumex being given. The DON stated on 12/9/25 that staff had not been routinely documenting edema prior to that date and that there should not have been blank spaces for scheduled administration or tasks on the MAR.
Missing Oxygen Order for Resident Receiving Supplemental Oxygen
Penalty
Summary
The facility failed to ensure oxygen orders were in place for one resident who was observed lying in bed with a nasal cannula in place and an oxygen concentrator running at 4 liters per minute. The resident stated she had been using oxygen for a long time for chronic respiratory illnesses. Her record showed diagnoses of chronic respiratory failure with hypoxia, chronic diastolic heart failure, and chronic obstructive pulmonary disease, and her current admission MDS showed a BIMS score of 15. Review of the resident’s current physician orders showed no order for oxygen administration, even though progress notes documented that she received oxygen by nasal cannula per orders on two separate occasions. An RN stated the current physician orders did not contain an oxygen order and that there should have been one. The DON stated the resident had recently returned from the hospital and that she must have forgotten to enter the oxygen order in the medical record when the resident returned. The facility policy titled Initiation of Oxygen stated nurses should verify physician’s orders for oxygen prior to administration.
Unsecured Medications Left on Unlocked Cart
Penalty
Summary
Medications were left unsecured on top of an unlocked medication cart in the hallway next to the conference room, with three cups of pills visible and accessible while residents were present in the hallway and nearby dining room. No staff were in the immediate area at the time of the observation. During interview, the RN stated she should not have left the pills unattended on top of the cart and identified the cups as belonging to three residents. She explained that she prepared more than one resident’s medications at a time because the 10:00 AM medications would otherwise be late, and said she felt rushed in the morning because she was also assigned to assist residents in the dining room, obtain blood sugar readings, administer insulin, administer an IV medication, assist with call lights, and complete her medication pass by 10:00 AM. Record review showed the three residents whose medications were left unsecured had current medication orders and were cognitively intact or oriented. One resident had diagnoses including syncope and collapse, hypertension, and chronic kidney disease stage 3B, with notes indicating intact long- and short-term memory and alert and oriented status. Another resident had diabetes type 2 and paroxysmal atrial fibrillation, with a BIMS score of 14. The third resident had diagnoses including Alzheimer’s disease and bipolar disorder, and the record included a BIMS score of 14. The DON stated staff should work together to monitor the dining room, managers were available to help, and medications should be secured in the medicine cart when not directly attended. Facility policy stated medication carts should be locked when unattended and no medications should be left on top of carts accessible to residents.
Improper Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices for facility-prepared leftovers, affecting all 27 residents. During a kitchen tour, five plastic containers with dates ranging over a week were found on the counter, and staff were unsure of the proper duration for keeping leftovers. Additionally, a pan of meatloaf and a container of meat sauce in the walk-in cooler were either undated or past the facility's policy of discarding food after 72 hours. The Certified Dietary Manager in training acknowledged the lack of proper labeling and the incorrect duration for keeping leftovers, which contradicted the facility's policy requiring all food to be labeled with the date opened and discarded after 72 hours.
Failure to Maintain Safe and Comfortable Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable temperatures between 71 and 81 degrees in resident areas, affecting four residents. Observations and interviews revealed that the ambient temperature in the building was cold, with specific instances of residents feeling cold and requiring extra blankets. For example, Resident 4's room was recorded at 61 degrees, and other residents expressed discomfort due to the cold temperatures. The facility's Administrator acknowledged the issue and indicated that a Heating Ventilation and Air Conditioning (HVAC) technician was scheduled to activate the boiler heating system. However, the delay in addressing the temperature issue resulted in residents experiencing discomfort for several days. Maintenance staff were aware of the low temperatures but hesitated to notify the HVAC company until daytime temperatures were cooler, relying on outside temperatures to determine when to activate the boiler system. Temperature logs showed consistent readings below the required range in various areas of the facility, including resident halls and common areas. The facility's policy required temperatures to be checked and recorded during each shift, with deviations reported to the Administrator and other relevant personnel. However, the logs did not include temperatures from individual resident rooms, and the facility did not follow its policy to notify appropriate parties or arrange for technical service when temperatures fell outside the acceptable range.
Inadequate Hand Hygiene and Glucose Meter Cleaning
Penalty
Summary
The facility failed to ensure proper hand hygiene and cleaning of blood glucose monitors during care for four residents. During a medication pass, an LPN washed her hands for less than the recommended 20 seconds after administering medications to two residents. Additionally, the LPN did not perform hand hygiene or change gloves after obtaining blood glucose results for another resident. The LPN also failed to properly disinfect the blood glucose meter, wiping it for only three seconds instead of the required one minute. In another instance, during wound care for a resident, the DON, CNA, and NP did not adhere to proper hand hygiene protocols. The DON and CNA washed their hands for less than 20 seconds after removing gloves and gowns. The NP rinsed her hands for only two seconds and did not perform hand hygiene after touching the wound and before applying treatment. The NP also handed the resident a glass of juice while wearing contaminated gloves. The facility's policies on hand hygiene and cleaning of glucose meters were not followed. The LPN admitted to not cleaning the glucose meters immediately due to time constraints and was unclear on the current company policies. The DON was also unsure about the proper cleaning procedure for glucose meters. The facility's policies required handwashing for at least 20 seconds and specific procedures for cleaning glucose meters, which were not adhered to during the observations.
Deficiency in Personal Hygiene and Nail Care for a Resident
Penalty
Summary
The facility failed to ensure the personal hygiene of a resident, specifically regarding the care of fingernails and perianal cleansing. Resident 22 was observed with long, uneven fingernails and a dark brown substance underneath them on multiple occasions. The resident, who has a history of diabetes, heart failure, lung disease, and morbid obesity, reported difficulty in cleansing their perianal area and indicated that staff had not adequately assisted with this task. Despite the resident's need for assistance with activities of daily living (ADLs), including personal hygiene and toileting, the care plan did not reflect any refusal of care by the resident, and there was no documentation of such refusals in the point of care task sheets. The Director of Nursing (DON) acknowledged that nail care should be part of routine ADL care and that diabetic residents should have their nails trimmed by licensed nurses. However, the facility lacked a schedule for nail trimming and did not maintain a list of residents requiring nurse-provided nail care. Additionally, there was no documentation of when nail care was performed. Facility policies required cleaning under fingernails during morning care and maintaining nails at a safe length, with diabetic residents' nails to be trimmed by licensed nurses and documented appropriately. These policies were not followed, contributing to the deficiency in care for Resident 22.
Improper Storage of Treatment Supplies
Penalty
Summary
The facility failed to ensure the safe storage of treatment supplies for one resident, identified as Resident 11. During an observation, various treatment supplies, including a bottle of wound cleanser, a tube of medi-honey, nystatin powder, Calmoseptine cream, and an open bag of cough drops, were found in the resident's room. These items were not stored in a locked compartment as required. Resident 11 confirmed that these items were kept in the room for staff convenience. Further observation revealed that some of these supplies were placed on a table in the bathroom, which was not an appropriate storage location. Interviews with staff, including a Qualified Medicine Aide (QMA), revealed that the items should not have been stored in the resident's room or bathroom. The QMA admitted to moving the items to the bathroom but did not have the keys to lock them up in the treatment cart. The facility's administrator confirmed that treatment supplies should be kept locked for sanitary and security reasons. Resident 11's medical records indicated multiple physician orders for the use of these supplies, highlighting the need for proper storage. The facility's policy, provided by the Regional Nurse Consultant, also emphasized that medications should be stored securely and only accessible to authorized personnel.
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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 Columbia City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Miller's At Oak Pointe | 2.1 mi | ★★★★★ | 3 | 0 |
| Majestic Care Of West Allen | 10 mi | ★★★★★ | 10 | 1 |
| Sage Bluff Health And Rehab Center | 15.6 mi | ★★★★★ | 6 | 0 |
| Coventry Meadows | 15.6 mi | ★★★★★ | 8 | 0 |
| Majestic Care Of Jefferson Pointe | 16.1 mi | ★★★★★ | 18 | 1 |
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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.