Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Fort Wayne Skilled Nursing Facility, The during CMS and state inspections, most recent first.
Two residents with significant ADL dependence and behavioral/vision impairments reported that a CNA repeatedly yelled at them, used harsh tones, and at times cursed at them and in the hallway, making them feel like children and leading them to tell the CNA to leave their room and to report concerns to the charge nurse. Both residents stated they did not want this CNA to provide their care, yet the CNA continued caring for at least one of them, and their care plans did not document their requests to avoid certain staff. Confidential staff/resident interviews corroborated that some staff yelled and cursed when providing care, and leadership was aware of prior verbal warnings to the CNA about her attitude but had no formal written warnings on file.
A resident with atrial fibrillation, diabetes, significant ADL dependence, and recent homelessness was repeatedly informed that insurance coverage was ending and that he would need to pay privately or leave, with discussions about discharge to a motel or other settings. Despite his expressed interest in Medicaid and his reports that he was not physically able to get in and out of his vehicle or out of bed due to pain, documentation did not show that he was assessed as safe for discharge, offered assistance with a Medicaid application, or given the required written discharge notice with appeal rights before an involuntary discharge was pursued. When a family payment failed to clear, he was told he had to leave that day without documented physician clearance or a safe discharge plan, and he ultimately called 911 for transfer to the hospital.
A resident with a history of dementia, heart failure, and a prosthetic heart valve did not receive prescribed doses of Coumadin on several occasions, and required PT/INR blood tests were missed without documentation or physician notification. This led to subtherapeutic INR levels and subsequent changes in medication dosing, contrary to facility policy and physician orders.
A resident with severe cognitive impairment and a history of falls was repeatedly left unattended in a Broda chair without a pillow, despite care plan and hospice recommendations. After the resident fell and sustained facial injuries, staff failed to complete required neuro checks, did not document all injuries, and did not update the care plan with new interventions. Staff interviews revealed a lack of awareness of required interventions, and hospice notes were not available in the chart, resulting in poor coordination of care.
The facility did not maintain complete and accurate documentation for two residents, including missing follow-up notes and injury details after a fall for a resident on hospice, and incomplete PT/INR lab records for a resident on anticoagulant therapy. Staff failed to include all relevant assessments and hospice notes in the clinical record, and interventions were not consistently updated or implemented as required.
Surveyors found that medications and biologicals on a medication cart were not consistently labeled with open dates or resident identifiers, as required by facility policy and regulations. Multiple medications, including inhalers, oral suspensions, and eye drops, were missing open dates or name labels. The ADON was observed adding dates during the inspection, and the DON confirmed the assigned RN was new to the cart and had received education on labeling practices.
The facility did not maintain required temperature logs for cooked foods, refrigerators, freezers, and the dishwasher, resulting in incomplete or missing documentation for multiple days and equipment. This failure was confirmed by staff and management, and affected nearly all residents who consumed food prepared in the facility kitchen.
Two residents with significant health conditions were observed over several days with untrimmed facial hair, despite care plans requiring staff assistance with ADLs. One resident's care plan did not address facial hair, while the other had a preference not to be shaved daily but was unaware of her grooming schedule and could not locate her preferred electric razor. Staff confirmed that women should not have visible facial hair and that grooming should be maintained according to facility policy.
A resident with multiple chronic conditions experienced significant weight loss over six months, despite being on weight monitoring and prescribed nutritional supplements. Staff discontinued nutrition risk monitoring prematurely, failed to alert the NP of continued weight loss, and did not provide recommended meal assistance or special interventions during meals, resulting in inadequate support for the resident's nutritional needs.
The facility failed to follow physician orders for weight monitoring for two residents, leading to deficiencies in care. One resident with heart failure experienced significant weight gain without timely physician notification, resulting in hospitalization. Another resident's weekly weight monitoring was not documented, with no indication of refusal or physician notification. These actions violated facility policies on weight monitoring and physician order compliance.
A facility failed to monitor side effects of antipsychotic medication for a resident with dementia, bipolar disorder, and anxiety. The resident was prescribed Abilify, but there were no physician orders to monitor side effects, and no documentation was found in the MAR or progress notes. The DON acknowledged the oversight, and the facility's policy requires monitoring for efficacy and adverse reactions, which was not followed.
A resident with a history of falls and multiple medical conditions experienced significant injuries after two falls. The facility failed to ensure proper assessment, monitoring, and follow-up, leading to the resident's decline and hospitalization.
A resident with PTSD and a need for modesty was exposed during personal care by two CNAs, who laughed at her despite her requests to be covered. The resident's care plan did not include her specific needs, leading to the incident.
A resident experienced verbal abuse from staff on two occasions, involving derogatory language and profanity. The incidents were reported by witnesses, and the facility's abuse prevention policy was not followed, resulting in the mistreatment of the resident.
Failure to Ensure Respectful and Dignified Staff–Resident Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with respect and dignity during verbal interactions, specifically in relation to two residents who reported being yelled at and cursed at by a CNA. Resident O, who had diagnoses including diabetes, anxiety, and bipolar disorder and was dependent on staff for most ADLs, reported that CNA 6 repeatedly came into her room and “barked out orders,” telling her to get up, get dressed, go to the bathroom, and go down to eat in a raised voice with a harsh tone and attitude. She stated that CNA 6 sometimes cursed at her and her roommate and could be heard cursing in the hallway. Resident O reported these concerns to the charge nurse and told CNA 6 not to come into her room again, but indicated that CNA 6 continued to provide her care despite her request. Her care plan, which included interventions such as emphasizing dignity, using soothing and kind speech, not rushing her, and providing care consistent with her schedule, did not document her request to avoid care from certain staff. Resident P, who was blind with additional diagnoses of dementia and stroke, and who was dependent on staff for ADLs, reported overhearing CNA 6 yelling at her roommate on several occasions and stated that the CNA also yelled at her. She responded by cursing at the CNA and telling her to get out of the room and reported her concerns to the charge nurse. Resident P stated that she felt like a child when yelled at, expressed anger and concern for her roommate, and indicated she did not want CNA 6 to provide her care. Her care plan, which included interventions to approach her calmly and explain care before providing it, also did not reflect her request to avoid certain staff. Confidential interviews indicated that some staff were not always respectful, with reports of staff yelling in hallways, yelling at residents, and cursing during care, and specifically identified CNA 6 as yelling at Resident O and cursing in the hallways. The Interim DON acknowledged awareness of prior verbal warnings to CNA 6 about her attitude and manner of speaking with residents but stated there were no formal written warnings in the employee file and that she had not been informed of the residents’ wishes not to receive care from CNA 6.
Failure to Provide Required Notice and Discharge Planning Before Involuntary Discharge
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice with appeal rights and discharge planning prior to an involuntary discharge for one resident. The resident had persistent atrial fibrillation, diabetes, and required assistance with ADLs including toileting hygiene, dressing, personal hygiene, and bed mobility, and was receiving PT. He had no cognitive impairment and had previously been homeless, living in his car, and was admitted for continued medical management, therapy, and safe discharge planning. His care plan documented his wish to discharge to the community and the need for community referral, with interventions to establish and evaluate a pre-discharge plan. During the stay, the resident expressed interest in obtaining Medicaid and in moving to assisted living or a pay-by-the-week motel. A discharge planning meeting documented that his managed insurance would no longer pay for his care as of a specified date, and staff discussed discharge versus remaining and paying privately. The resident wanted to appeal the insurance decision and was informed he would be responsible for costs if he remained after coverage ended. However, at that time he was not provided a written discharge notice, and the documentation did not indicate that he was physically able to be safely discharged or that assistance with a Medicaid application was offered, despite his earlier expressed interest. Subsequent discharge planning notes recorded that a family member’s payment temporarily covered his room and board and that staff and the resident discussed discharge locations, payment, transportation, and using therapy time to get stronger, with a planned discharge date. Again, the notes did not document that he was physically able to be safely discharged, that he was offered help applying for Medicaid, or that he received a written discharge notice with appeal rights, even though he was told he would be discharged on a specific date. Later, when a family check failed to clear, the resident was informed he owed the facility and was told he needed to leave that day, despite his report that he could not get out of bed due to pain. There was no physician documentation that he was safe for discharge, no discharge plan put in place, and no written discharge notice with appeal rights or Medicaid assistance documented prior to his involuntary discharge attempt, leading him to call 911 for transfer to the hospital.
Failure to Administer Anticoagulant and Monitor Labs as Ordered
Penalty
Summary
The facility failed to ensure that physician orders for anticoagulant medication and required blood test monitoring were followed for a resident receiving Coumadin therapy. Specifically, the resident, who had diagnoses including dementia, heart failure, and a prosthetic heart valve, was prescribed Warfarin Sodium (Coumadin) with instructions for daily administration and PT/INR blood tests twice weekly. Record review showed that several doses of Coumadin were not administered on specific dates, with no documented reason for the missed doses and no evidence that the physician or nurse practitioner was notified. Additionally, a scheduled PT/INR lab test was not performed as ordered, again without documentation or notification to the appropriate medical provider. As a result of these missed doses and lab tests, the resident's PT/INR levels were found to be below the therapeutic range, prompting subsequent adjustments to the Coumadin dosage. Interviews with staff revealed that PT/INR testing was dependent on the availability of test strips, and if unavailable, samples were sent to the hospital. Facility policies required that all physician orders be implemented and that residents on Coumadin be monitored through regular blood testing, but these protocols were not consistently followed for this resident.
Failure to Assess, Document, and Prevent Falls for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to thoroughly assess injuries following falls, determine the root cause of falls, and develop effective interventions to prevent further falls for a resident with Alzheimer's dementia and a history of falls. The resident, who was non-ambulatory, dependent on staff for all activities of daily living, and receiving hospice care for end-stage dementia, was repeatedly observed seated in a Broda chair without a pillow, despite care plan interventions and hospice recommendations. Staff were often not present or attentive while the resident was in common areas, and the resident was able to sit up and lean forward in the chair, which contributed to her falling out of the chair and sustaining injuries, including a nosebleed and bruising around the eye. After the fall, documentation was incomplete and inconsistent. There was no documentation of the resident's bruise to her right eye, and required neurological checks were not completed according to facility policy. The care plan was not updated to include the hospice intervention of placing a pillow in front of the resident while seated at a table, and staff were unaware of this intervention. Additionally, hospice nurse notes were not available in the resident's chart, hindering coordination of care between hospice and facility staff. Interviews with staff revealed a lack of awareness regarding the resident's required interventions and inconsistent follow-through with post-fall assessments and documentation. The facility's policy required thorough assessment, documentation, and care plan updates following falls, but these steps were not consistently followed. The failure to implement and document effective interventions, assess injuries, and update care plans contributed to the deficiency cited by surveyors.
Incomplete Documentation of Falls, Hospice Services, and Anticoagulant Therapy
Penalty
Summary
The facility failed to maintain complete and accurate documentation for two residents regarding falls, hospice services, and anticoagulant therapy. For one resident with Alzheimer's dementia receiving hospice care, there was incomplete documentation following a fall from a Broda chair. Although the care plan identified a risk for falls and interventions were updated, the clinical record lacked documentation of observed injuries, such as bruising around the eye, and did not include required 72-hour follow-up notes. Neurological checks were not performed as scheduled, and hospice progress notes were not available in the resident's record, requiring staff to contact the hospice provider for information. Additionally, an intervention noted by hospice staff was not incorporated into the resident's care plan or observed in practice. For another resident with dementia, heart failure, and a prosthetic heart valve, the facility did not maintain accurate records of PT/INR lab results required for monitoring anticoagulant therapy. The care plan required regular PT/INR testing and prompt reporting of critical results, but the clinical record showed missing or unscheduled lab results and incomplete documentation on the Medication Administration Record (MAR). Facility staff sometimes used a log book at the nurses' station to record PT/INR results, but these logs were not included in the resident's clinical record as required by facility policy. Interviews with staff and administration confirmed that documentation practices did not align with facility policy, which requires all assessments and records from facility staff and contracted professionals to be included in the resident's clinical record. The lack of thorough and timely documentation affected the facility's ability to coordinate care and ensure accurate records for both residents.
Failure to Label Medications with Open Dates and Resident Identifiers
Penalty
Summary
Surveyors observed that the facility failed to ensure medications and biologicals were properly labeled with open dates and resident identifiers, as required by professional standards and facility policy. During an inspection of a medication cart, multiple medications belonging to several residents were found without open dates, including inhalers, oral suspensions, ophthalmic solutions, and liquid supplements. Additionally, some unopened medications and eye drops lacked resident name labels. The Assistant Director of Nursing (ADON) was present during the observation and began adding open dates to the medications that were missing them. The ADON also indicated a misunderstanding regarding the required dating of inhalers. The Director of Nursing (DON) later confirmed that the nurse assigned to the cart was new and had been educated on labeling practices by the usual nurse, who was on vacation. Record reviews for the affected residents showed that they had various diagnoses, including chronic obstructive pulmonary disease, asthma, myotonic muscular dystrophy, and hemiplegia, and were prescribed medications such as albuterol, Breo Ellipta, atropine sulfate, sucralfate, milk of magnesia, and bismuth subsalicylate. The facility's policy requires medications to be labeled in accordance with state and federal laws, as well as facility requirements. Despite this, the survey found multiple instances where medications were not labeled with open dates or resident names, constituting a failure to comply with labeling and storage regulations.
Failure to Maintain Food and Equipment Temperature Logs
Penalty
Summary
The facility failed to maintain complete and accurate temperature logs for cooked foods, refrigerators, freezers, and the dishwasher throughout the month of June 2025. Observations revealed missing and incomplete documentation for food temperature logs, with no records available for several days in June for any of the three meals served. Additionally, temperature logs for two of three refrigerators were incomplete, and one refrigerator had no log at all. Only one freezer log was available for three freezers, and it was also missing multiple entries. The dishwasher temperature log was not dated with the month or year, and several meals were not recorded. These deficiencies were confirmed through interviews with facility staff and the Regional Dietary Manager, who acknowledged the missing and incomplete logs after a thorough search. Facility policies required that dish machine temperatures be logged after each meal and kept on file for one year, and that refrigerator and freezer temperatures be checked and recorded twice daily. The food temperature tray line policy also required temperatures to be recorded before serving. Despite these policies, the required documentation was not maintained, affecting 38 of 39 residents who consumed food prepared in the facility kitchen. No additional logs for the missing days or months were found, and the lack of documentation was confirmed by both staff and management.
Failure to Provide Grooming Assistance for Residents Unable to Perform ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) related to grooming for two residents who were unable to perform these tasks themselves. Observations over several days showed that one resident had multiple long chin hairs that remained untrimmed, despite a care plan indicating staff were responsible for meeting all ADLs. The care plan did not specifically address facial hair for this resident. The resident's diagnoses included macular degeneration, osteoporosis, and weakness, indicating a need for staff assistance with personal grooming. A second resident was observed with a full beard and mustache that were not shaved over multiple days. This resident's care plan included a preference to not be shaved daily, but during an interview, the resident was unaware of her grooming schedule and indicated she was overdue for shaving. She also expressed a refusal to be shaved with a regular razor, preferring an electric razor, which she could not locate. Staff interviews confirmed that residents should be shaved on shower days or as needed, and that women should not have visible facial hair. The facility's policy required staff to maintain good grooming and hygiene for residents unable to perform ADLs.
Failure to Ensure Adequate Nutrition and Weight Maintenance
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate nutrition and weight maintenance for one resident with multiple medical diagnoses, including anxiety, osteoarthritis, depression, glaucoma, anemia, cataracts, macular degeneration, neuropathy, and a pacemaker. Over a six-month period, the resident experienced a weight loss of 12.77%, dropping from 141 lbs to 123 lbs. The resident was placed on weight monitoring and classified as Nutrition at Risk due to a wound, but this monitoring was discontinued in March after staff determined weights were stable, despite continued weight loss. The resident was prescribed a nutritional supplement (Boost) twice daily starting in late February, but still lost an additional 3.5 lbs after the supplement was initiated. Progress notes from the physician inaccurately stated there was no weight loss, and the Nutrition at Risk Quarterly Review recommended only continued monitoring without further interventions. Meal consumption records showed the resident ate less than 50% of meals for 35 out of 90 recorded meals in June. Interviews revealed that the nurse practitioner was unaware of the ongoing weight loss and expected to be alerted by the DON or the facility's computer system if a resident lost 10% of their weight in six months, which did not occur. The registered dietician noted the weight loss followed a pattern and was not alarmed, relying on the DON or ADON to communicate follow-up needs. Observations showed the resident was not provided with special utensils, visual aids, or redirection during meals, despite care plan interventions indicating the need for assistance and encouragement with eating, as well as monitoring for significant weight changes and offering meal substitutes when intake was low.
Failure to Follow Physician Orders for Weight Monitoring
Penalty
Summary
The facility failed to adhere to physician orders for weight monitoring for two residents, leading to deficiencies in care. Resident 10, who had multiple diagnoses including heart failure, was ordered to have daily weights taken to monitor for significant weight changes. However, the facility did not document weights on several days in July 2024, and there was a failure to notify the physician of significant weight gains as required. This oversight resulted in Resident 10 experiencing a substantial weight gain over a short period, which was not promptly addressed, leading to her hospitalization. Resident 6, diagnosed with paraplegia and chronic osteomyelitis, was also subject to weight monitoring orders, requiring weekly weights to be recorded every Thursday. The facility failed to document weights on several occasions in July and August 2024, and there was no indication that the resident refused the weights or that the physician was informed of the missed recordings. This lack of documentation and communication represents a failure to follow physician orders and facility policy. The facility's policies on weight monitoring and following physician orders were not adhered to, as evidenced by the lack of systematic weight recording and failure to notify physicians of significant weight changes. The deficiencies highlight a breakdown in the facility's processes for monitoring and responding to residents' weight changes, which are critical for managing conditions such as heart failure and other health issues.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to monitor the side effects of antipsychotic medication for a resident diagnosed with unspecified dementia, bipolar disorder, and anxiety. The resident was prescribed Abilify (aripiprazole) 5 mg daily for bipolar disorder, starting on 5/21/2024. However, there were no physician orders to monitor the side effects of this medication. The care plan, dated 6/23/2024, included interventions to administer medications as ordered and monitor for adverse side effects and effectiveness, but this was not documented in the Medication Administration Record (MAR) or progress notes for August 2024. During an interview, the Director of Nursing (DON) acknowledged that there should have been a physician order to monitor side effects. The facility's policy on psychotropic medication requires monitoring for efficacy and adverse reactions, but this was not followed in this case. The policy also emphasizes that psychotropic drugs should only be used when necessary and after other interventions have failed. Despite these guidelines, the facility did not document monitoring for side effects or effectiveness of the medication for the resident in question.
Failure to Ensure Proper Follow-Up After Resident Falls
Penalty
Summary
The facility failed to ensure proper identification, assessment, and follow-up for acute changes in a resident's condition following two falls. Resident B, who had diagnoses including congestive heart failure, dementia, diabetes, and a history of repeated falls, experienced significant injuries after these falls. The first fall resulted in a mild headache and soreness, while the second fall led to lacerations, bruising, and a large hemothorax, which required hospitalization and the insertion of a chest tube to drain the blood. Despite these injuries, the facility's documentation and follow-up were inadequate, as evidenced by the lack of consistent neurological checks and pain assessments, and the failure to move the resident closer to the nurse's station as recommended by the IDT (Interdisciplinary Team). The resident's condition deteriorated, leading to hospitalization due to shortness of breath and other acute symptoms. The facility's failure to properly assess and monitor the resident's condition after the falls contributed to the resident's decline and subsequent hospitalization.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure triggers were identified and resident-specific approaches were initiated in providing trauma-informed care for Resident C. Resident C, who has a history of PTSD, depression, and anxiety, expressed that she felt helpless and ridiculed by staff due to her need for modesty. She reported an incident where two CNAs exposed her during personal care, despite her repeated requests to be covered. The CNAs laughed at her, making her feel vulnerable and ridiculed. The resident's care plan did not include her specific needs for modesty and privacy, which contributed to the incident. The facility's records indicated that Resident C had a history of trauma and required specific interventions to avoid re-traumatization. However, her care plan lacked detailed interventions to address her PTSD and modesty needs. The CNAs involved were not aware of her preferences, leading to the incident. The facility's policy on trauma-informed care emphasized the importance of creating a safe environment and respecting individual choices, but this was not effectively implemented in Resident C's case.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as Resident B, from verbal abuse by staff members on two separate occasions. The first incident involved a Certified Nursing Assistant (CNA 2) who, during an argument about the room's temperature, used derogatory language towards Resident B, including calling him a derogatory term and mocking his inability to walk. This incident was reported by another CNA who witnessed the inappropriate interaction. Resident B, who has a history of trauma related to abuse and is cognitively intact, felt disrespected and reported that his call light was ignored by CNA 2. In a second incident, another staff member, CNA 4, was recorded speaking inappropriately to Resident B, using profanity and encouraging him to argue. This recording was made by another resident, Resident C, who reported the incident to the Director of Nursing (DON) after a delay. The facility's policy on abuse prevention, which includes education on resident rights and the definition of abuse, was not adhered to in these instances, leading to the verbal mistreatment of Resident B.
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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 Fort Wayne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chateau Rehabilitation And Healthcare Center | 0.5 mi | ★★★★★ | 20 | 0 |
| Celebrate Senior Living Of Fort Wayne | 1.4 mi | ★★★★★ | 12 | 0 |
| Heritage Park | 1.5 mi | ★★★★★ | 7 | 0 |
| Byron Health Center | 1.8 mi | ★★★★★ | 15 | 0 |
| Golden Years Homestead | 1.8 mi | ★★★★★ | 7 | 0 |
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