Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Dunkirk Skilled Nursing Facility, The during CMS and state inspections, most recent first.
A facility failed to protect cognitively impaired residents from sexual abuse when a resident with moderate dementia was observed performing oral sex on a resident with severe dementia and a documented history of sexually inappropriate behaviors. The male resident had prior episodes of inappropriate touching, exposure, and agitation when redirected from female peers, and his care plan for inappropriate personal boundaries had been resolved despite ongoing concerns. The female resident had impaired cognition, poor memory, and a care plan that allowed companionship and affectionate contact but did not reflect a formal assessment of her capacity to consent to sexual activity. Staff interviews and records showed that no sexual consent capacity assessment was completed before the incident and that behavior monitoring and interventions for the male resident’s hypersexuality were inconsistent, leading surveyors to cite the facility for failing to protect residents from abuse and to assess and manage sexual behaviors appropriately.
The facility failed to monitor and develop individualized interventions for sexually focused behaviors in multiple cognitively impaired residents. Several residents with dementia had documented histories of inappropriate touching, hypersexuality, or intimate relationships with other residents, yet behavior monitoring orders and tools focused only on depression, anxiety, or general boundary issues. One resident was observed performing oral sex on another resident, and another was found receiving oral sex, while another made explicit sexual comments and requests to CNAs. Care plans for companionship emphasized hand holding and social engagement but did not include specific monitoring or tailored interventions for sexual behaviors, and the facility had no formal assessment for sexual behaviors despite policy requiring daily monitoring of target behaviors and social services involvement in behavior care planning.
Two residents with dementia and significant cognitive impairment were involved in an incident where one was observed performing oral sex on the other, with the male resident’s pants partially down and his buttocks exposed. A QMA intervened, directed the male resident to leave, and reported the event to the charge nurse (an RN). The RN documented a behavioral note but did not immediately report the allegation to leadership, believing residents could have a sexual relationship. As a result, the DON and Administrator were not informed until the following day, delaying required notification to the State Agency, contrary to the facility’s abuse reporting policy that mandates immediate reporting of suspected abuse up the chain of command and to state authorities.
The facility failed to adhere to menus and residents' preferences, affecting several residents. Observations showed discrepancies between posted menus and actual meals served, with frequent shortages of items like hot dogs and milk. A resident who often refused meals did not receive her preferred hot dog due to shortages. Another resident reported unmet meal preferences, leading to dissatisfaction. The facility's outsourced dining service struggled with maintaining adequate food supplies, impacting residents' dietary needs.
The facility's dishwasher failed to meet sanitization requirements, operating at 113°F instead of the required 150°F, potentially affecting all 31 residents. Additionally, food storage practices were unsanitary, with uncovered items in the refrigerator and freezer, and a dirty toaster. Staff acknowledged these issues, which violated facility policies.
The facility failed to provide palatable and quality meals, as residents and staff reported issues such as watery eggs, overly salty gravy, and hard muffins. Residents with specific dietary needs were dissatisfied with the meals, which were often inedible. Staff interviews confirmed these complaints, and the facility's policies on meal presentation and satisfaction were not followed.
The facility failed to notify residents and their representatives in writing of transfer/discharge appeal rights during hospitalizations. Three residents were transferred to the hospital for various medical reasons, but there was no documentation of them receiving the necessary appeal rights paperwork. Interviews with staff revealed inconsistencies in providing these notifications, and the facility lacked a specific policy on transfer/discharge appeal rights.
The facility failed to ensure that the results from their last annual IDOH survey report were accessible to residents. The State Survey Binder was repeatedly observed on a lower shelf, making it difficult for residents with mobility limitations to access it. Interviews confirmed the binder's inaccessibility, and the Administrator was unaware of its relocation. The facility's policy required the survey results to be posted in a prominent, accessible area.
A resident with right side hemiplegia required extensive assistance for mobility, but a CNA, unaware of the need for a two-person assist, attempted a transfer alone, resulting in the resident sustaining a right ankle fracture. The facility lacked specific policies for staff-assisted transfers, and the CNA did not reference assignment sheets, leading to the improper transfer.
Failure to Protect Cognitively Impaired Residents From Sexual Abuse and Inadequate Consent Assessment
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from sexual abuse by not adequately assessing capacity to consent to sexual activity and not implementing effective interventions for a resident with known sexually inappropriate behaviors. Resident B had diagnoses including unspecified dementia, major depressive disorder, and a cognitive communication deficit, with an MDS showing moderate cognitive impairment and moderate impairment in decision-making for daily tasks. Her care plans addressed impaired cognition, poor safety awareness, and impulsiveness, and she used a position change alarm due to attempts to self-transfer. A care plan for promotion of safe intimate/sexual practices, created shortly before the incident, stated she was alert, aware, and coherent in choosing to engage in an intimate/sexual relationship and included interventions such as assessing her understanding of the nature of the act and her ability to refuse, encouraging appropriate touch, and reminding her that sexual partners must be able to provide mutual consent. Her representatives were notified that she was seeking companionship with a male resident and agreed to hand-holding and companionship, but they did not agree to more intimate acts. Resident C had diagnoses including unspecified dementia with behavioral disturbance and delusional disorders, with an MDS indicating severe cognitive impairment. His record documented a history of inappropriate personal boundaries manifested by inappropriate touching, such as rubbing another person’s back, reaching for a leg, and shoulder rubbing. He had been treated with medroxyprogesterone for hypersexuality and was also on risperidone. Behavior notes and staff interviews described increased friendliness and physical contact with multiple female residents, including patting arms, hand holding, rubbing arms and legs, and entering female residents’ rooms, sometimes becoming agitated or hostile when redirected. Staff, including a housekeeper and an RN, reported that he had been seen with his penis exposed in a lounge, asking a female resident to put her hands in his pants, pulling a female resident’s hand toward his genital area over clothing, and touching a female resident’s breast. Despite this pattern, his care plan for inappropriate personal boundaries was resolved, and the Social Service Director and DON indicated that, after discussions with the Ombudsman, care plans regarding sexual behaviors were resolved based on the view that such behaviors were residents’ rights rather than maladaptive behaviors. On the evening of 3/22/26, a Qualified Medication Aide observed Resident C in Resident B’s room with his pants partially down, exposing his buttocks, while Resident B, seated in her recliner and leaning forward, was performing oral sex on him. Resident B’s roommate was in the hallway at the time. The QMA instructed Resident C to leave; he became angry but complied. Resident B said little and, after the incident, had forgotten that anything had occurred. Subsequent nursing documentation noted that Resident B would not or could not discuss the incident, described the male resident as a friend, and denied unwanted touching. Interviews with Resident B’s representative indicated that Resident B had moderate to severe dementia, sometimes did not recognize family, frequently asked where she was and when she was going home, and that performing oral sex was not consistent with her prior behavior or values. Resident B later demonstrated significant disorientation, unable to state where she was, what town she was in, or the year, and denied having a male friend or male visitors in her room. Additional interviews and records showed that staff were aware of Resident C’s ongoing sexually focused behaviors and the need for redirection. Behavior notes shortly before the incident documented increased agitation and interactions with female peers, his anger when asked to visit females only in public areas, and an episode of inappropriate behavior with a confused female resident from whom he was redirected. The Psychiatric NP reported that the facility had been concerned about Resident C’s sudden focus on female residents and that he had required medication to prevent escalation of inappropriate touching. The NP also stated that staff had to redirect Resident C several times related to female residents and that he became agitated when redirected. The acting Administrator acknowledged that a Sexual Consent Capacity Assessment was not completed for the residents prior to the incident and that behavior documentation was only maintained if behaviors were considered maladaptive. The surveyors determined, using the reasonable person concept, that this failure to assess capacity to consent and to implement interventions to mitigate Resident C’s sexually inappropriate behaviors resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B. Other residents and staff expressed concerns related to Resident C’s behaviors. A cognitively intact resident reported hearing from staff and in the hallway that a female resident had performed oral sex on Resident C and expressed fear that he might enter her room and touch her, stating she did not want to be touched. The Social Service Director described Resident C as social with many female residents, with hypersexuality increasing as he formed more relationships, and acknowledged that staff struggled to distinguish between appropriate social interaction and infringement on residents’ rights. Several residents, including Residents F and E, had histories of dementia and prior care plans for inappropriate personal boundaries that were later resolved, and some had care plans for companionship with male peers that included general interventions such as assessing understanding and ability to refuse, but the records lacked individualized monitoring and interventions specifically addressing intimate or sexual behaviors for all involved residents. The combination of Resident C’s known sexually inappropriate behaviors, his severe cognitive impairment, Resident B’s moderate cognitive impairment and poor memory, the absence of a formal sexual consent capacity assessment prior to the incident, and the lack of sustained, effective behavioral interventions for Resident C led to the cited deficiency for failure to protect residents from sexual abuse. The surveyors concluded that the facility failed to ensure residents were protected from sexual abuse when Resident B, with moderate cognitive impairment, was found performing oral sex on Resident C, who had severe cognitive impairment and a known history of sexually inappropriate behaviors. They found that the facility did not assess the residents’ capacity to consent to sexual activity prior to the incident and did not implement interventions to mitigate Resident C’s sexually inappropriate behaviors. Using the reasonable person concept, they determined that this deficient practice resulted in severe psychosocial harm, including dehumanization and humiliation, for Resident B.
Failure to Monitor and Individualize Care for Sexually Focused Behaviors in Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to monitor and develop individualized interventions for cognitively impaired residents who exhibited sexually focused or intimate behaviors. Five residents with dementia or significant cognitive impairment had either documented sexually focused behaviors, hypersexuality, or intimate relationships with other residents, yet their behavior monitoring and care plans did not include specific assessments, monitoring, or individualized interventions for sexual or intimate behaviors. Instead, behavior monitoring orders and tools focused on depression, anxiety, delusions, or general boundary issues, and there was no structured assessment for sexual behaviors in use at the facility. One resident with moderate cognitive impairment and dementia (Resident B) had behavior monitoring ordered for depression-related symptoms and a care plan for impaired cognition and poor safety awareness, but no monitoring or individualized interventions for intimate or sexually focused behaviors. Social services documented that she sought companionship with a male resident, ate meals with him, and sat in the lounge with him, with her representatives agreeing to the relationship and the facility stating it would continue to monitor. Subsequently, staff observed her performing oral sex on a male resident in her room, after which staff intervened and removed the male resident. Prior to this event, her record lacked behavior monitoring or care plan interventions specifically addressing intimate or sexual behaviors. Another resident with severe cognitive impairment and delusional disorder (Resident C) had a history of inappropriate personal boundaries, including touching others’ arms and legs, and was treated with medroxyprogesterone for hypersexuality with multiple dose adjustments and a failed gradual dose reduction. His resolved care plan for inappropriate boundaries included general boundary-setting strategies, and a current care plan acknowledged his companionship with female peers and allowed affectionate acts such as hand holding and putting his arm around them. However, his clinical record did not include monitoring tools or individualized interventions specifically targeting intimate or sexual behaviors. Nursing and social service notes documented increased friendliness and physical contact with female residents, agitation when redirected, and an incident where he was found in a female resident’s room receiving oral sex, but behavior monitoring tools reflected only irritability, anxiety, and searching for family, not sexual behaviors. Residents D, E, and F, all with dementia and varying levels of cognitive impairment, had prior care plans for inappropriate personal boundaries that were later resolved and replaced with care plans describing mutual companionship with male peers, including hand holding and arm-around contact. These care plans emphasized acknowledging the need for connection, assessing understanding and ability to refuse, encouraging appropriate touch, offering privacy, and psychosocial visits, but did not include individualized monitoring or interventions specifically for sexually focused behaviors. Resident E exhibited verbally explicit sexual comments toward CNAs, including references to genital areas and suggesting sexual acts involving staff and another male resident, yet her behavior monitoring orders and tools addressed only depression and did not capture or target sexualized behaviors. Resident F’s record showed a long-standing close relationship with a male resident, family awareness of his frequent touching of her hands and legs, and discussion of possible environmental interventions, but her behavior monitoring focused on anxiety and searching for her daughter, with no documented monitoring or individualized interventions for intimate or sexual behaviors. The Social Service Director confirmed that the facility did not have a sexual behavior assessment, that behavior tools used by CNAs did not include sexual behaviors for these residents, and that decisions about resolving or framing care plans were influenced by discussions with the Ombudsman about residents’ rights rather than by structured behavioral health assessment and monitoring. Overall, the facility’s behavior management process, as described in policy and interviews, required nursing to monitor target behaviors daily and social services to maintain a list of residents with behaviors and assist with behavior care plans. However, for these five residents with documented sexually focused behaviors, hypersexuality, or intimate relationships, the facility did not implement behavior monitoring specific to sexual behaviors, did not develop individualized behavioral health interventions addressing those behaviors, and did not use a formal assessment tool for sexual behaviors. Behavior sheets and monitoring focused on other symptoms such as depression, anxiety, irritability, and confusion, leaving sexually focused behaviors unmonitored and without individualized, documented interventions in the clinical record.
Failure to Immediately Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff immediately reported an allegation of abuse to the Administrator, which delayed required reporting to the State Agency. Resident B, who had diagnoses including unspecified dementia with moderate cognitive impairment, major depressive disorder, and cognitive communication deficit, was observed on 3/22/26 by a Qualified Medication Aide (QMA 7) performing oral sex on Resident C in her room. QMA 7 saw Resident C standing in front of Resident B with his pants partially down, exposing his buttocks, while Resident B, seated in a recliner and leaning forward, was performing oral sex. QMA 7 instructed Resident C to leave the room, and he became angry but complied. QMA 7 then reported the incident to the charge nurse, and staff kept Resident C away from Resident B and other female residents. Resident C, who had diagnoses including unspecified dementia with severe cognitive impairment and delusional disorders, was later documented in an SBAR summary as having been observed receiving oral sex from a female resident, after which he was asked to leave the room and was closely monitored. When QMA 7 reported the initial observation to Registered Nurse (RN) 16, RN 16 did not report the allegation to anyone else at that time and only made a behavioral note, indicating she believed residents were allowed to have a sexual relationship. The Administrator later stated that the incident was not reported to the State Agency until the day after it occurred, because RN 16 did not notify the DON until the following morning, and the DON then notified the Administrator. This sequence of events conflicted with the facility’s Abuse Prevention Program policy, which required the person observing suspected abuse to immediately report it to the charge nurse, and the charge nurse to immediately report it to the Administrator, who must immediately notify the State Licensing and Certification Agency.
Inconsistent Menu Adherence and Food Shortages in Dining Services
Penalty
Summary
The facility failed to ensure that menus and residents' preferences were consistently followed, affecting 3 of 5 residents reviewed for dining services. Observations revealed discrepancies between the posted menu options and the meals actually served. For instance, a sign indicated options like grilled cheese and hot dogs, but these were not available on certain days, leading to unmet resident preferences. Resident 14, who often refused meals but would eat a hot dog, did not receive one because the kitchen ran out. This issue was compounded by frequent shortages of other items, such as milk and hot dogs, which disrupted meal service. Resident 12 reported that the meals served often did not match the menu or her requests. She noted that the facility frequently ran out of eggs and that her meal preferences, such as receiving scrambled eggs in a bowl, were not honored. This inconsistency led to dissatisfaction and a loss of appetite. Her clinical record indicated dietary needs for a consistent carbohydrate diet, which were not consistently met due to these discrepancies. Resident 26 also experienced issues with meal service, noting that her requests for alternatives like hot dogs and cottage cheese were not fulfilled due to shortages. She frequently received items she did not prefer, such as Italian dressing instead of ranch, and meals that did not match the posted menu. The facility's dining service, outsourced to another company, faced challenges in maintaining adequate food supplies, leading to these deficiencies in meeting residents' dietary needs and preferences.
Dishwasher and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure the high-temperature dishwasher functioned at the required sanitization level, potentially impacting all 31 residents receiving meals from the kitchen. During an inspection, the dishwasher's washing temperature was recorded at 113°F, below the required 150°F. The Maintenance Director confirmed the issue, noting the temperature had been below range since the previous Friday, yet the dishwasher continued to be used. The Dietary Manager initially believed the dishwasher was safe to use, and the Maintenance Assistant identified a loose thermostat wire as the cause of the problem. The facility's policy mandates stopping the dishwashing process if it is not sanitizing properly and contacting the appropriate personnel. Additionally, the facility failed to store and distribute food under sanitary conditions. Observations during a kitchen tour revealed uncovered drinks and fruit in the refrigerator, an uncovered bowl of fruit in the freezer, and loose biscuits. The toaster was found with crumbs and a white substance on it. Dietary staff acknowledged that items should have been covered and labeled, as per the facility's food storage policy, which requires food to be stored and prepared in a clean and sanitary manner in compliance with guidelines.
Facility Fails to Ensure Palatable and Quality Meals for Residents
Penalty
Summary
The facility failed to ensure the palatability and quality of meals served to residents, as evidenced by multiple complaints and observations. Residents reported that the food was often unappetizing, with issues such as green meatloaf, watery eggs, and overly salty gravy. Observations confirmed these complaints, with meals being described as bland, mushy, or excessively salty. The facility's outsourcing of kitchen services was noted as a potential factor in the decline of food quality. Several residents, including those with specific dietary needs due to medical conditions such as diabetes and gastroparesis, expressed dissatisfaction with the meals. They reported that the food was either over-seasoned or under-seasoned, and often inedible. The facility's failure to provide meals that met the residents' dietary requirements and preferences was evident in the repeated complaints and observations of uneaten food. Staff interviews corroborated the residents' complaints, with reports of hard muffins, watery eggs, and a lack of flavor in the meals. The facility's policies on meal presentation and resident satisfaction were not adhered to, as meals were not served attractively or at appropriate temperatures. The facility's administrator acknowledged previous concerns about food quality, but the issues persisted, indicating a systemic problem with the dining services.
Failure to Notify Residents of Transfer/Discharge Appeal Rights
Penalty
Summary
The facility failed to ensure that residents and their representatives were notified in writing of their transfer/discharge appeal rights during hospitalizations. This deficiency was identified in the cases of three residents who were transferred to the hospital for various medical reasons. Resident 77 was sent to the hospital for evaluation after experiencing large amounts of dark red stool, but there was no documentation indicating that the resident or their representative received written notification of appeal rights. Similarly, Resident 17, who was his own representative, was transferred to the emergency room on multiple occasions due to chest pain and other symptoms, yet there was no record of him receiving the necessary appeal rights paperwork. Resident 127 was transferred to the emergency room following complications with a catheter, but again, there was no indication that the resident or their representative was informed of the appeal rights in writing. Interviews with facility staff, including the Assistant Director of Nursing, LPN, Social Services Director, and Director of Nursing, revealed that while certain transfer documents were sent with residents to the hospital, the appeal rights paperwork was not consistently provided to residents or their representatives. The facility also lacked a specific policy on transfer/discharge appeal rights, contributing to the oversight.
Inaccessible Survey Results for Residents
Penalty
Summary
The facility failed to ensure that the results from their last annual Indiana Department of Health (IDOH) survey report were posted at an accessible height for residents. The State Survey Binder, which contained the survey results, was observed multiple times on the lower shelf of a sofa table, approximately four inches off the floor, right outside the Administrator's office. This placement made it difficult for residents, particularly those with mobility limitations, to access the binder. The deficiency was noted during observations conducted over several days, from March 17 to March 20, 2025. Interviews with Resident 23 and QMA 10 confirmed that the binder's location was not reachable by all residents due to mobility limitations. The Administrator, who was responsible for the binder, indicated that it was generally kept on the top shelf of the sofa table and was unaware that it had been moved to the bottom shelf. The facility's policy, dated August 2017, required that the most recent annual survey and the facility's response to the findings be clearly posted in a prominent area easily accessible to residents, their family members, and legal representatives, as well as the public.
Inadequate Staffing and Transfer Protocols Lead to Resident Injury
Penalty
Summary
The facility failed to ensure adequate staffing and consistent procedures for physical transfers, resulting in a resident, identified as Resident B, sustaining a fracture to her right ankle. Resident B, who had a history of right side hemiplegia and hemiparesis following a stroke, required extensive assistance for mobility. On the day of the incident, a CNA, who was unaware of the resident's need for a two-person assist, attempted to transfer Resident B alone. During the transfer, the resident's right foot did not turn with her body, causing pain and eventually leading to the discovery of an acute ankle fracture. Resident B's care plan indicated she required extensive assistance with transfers, and her condition included moderate cognitive impairment and dependency on staff for daily activities. Despite these documented needs, the CNA involved in the incident was not informed of the requirement for a two-person assist and had observed other staff transferring the resident independently. The CNA assignment sheets, which contained critical information about resident care needs, were not referenced by the CNA, leading to the improper transfer. Interviews with staff revealed a lack of awareness and communication regarding the resident's transfer needs. The Assistant Director of Nursing (ADON) acknowledged that the CNA was expected to reference assignment sheets, but there was no specific policy in place regarding staff-assisted transfers. Other CNAs confirmed that Resident B was a two-person transfer prior to her injury, and the facility's failure to ensure this protocol was followed directly contributed to the resident's injury.
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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 Dunkirk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Albany Health Care & Rehabilitation Center | 6.8 mi | ★★★★★ | 13 | 0 |
| Envive Of Hartford City | 9.6 mi | ★★★★★ | 11 | 0 |
| Waters Of Hartford City Skilled Nursing Facility | 10.6 mi | ★★★★★ | 1 | 0 |
| Persimmon Ridge Rehabilitation Centre | 11.2 mi | ★★★★★ | 0 | 0 |
| Parker Health Care & Rehabilitation Center | 14.2 mi | ★★★★★ | 10 | 0 |
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