Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Middletown Skilled Nursing Facility, The during CMS and state inspections, most recent first.
Care plan missing limited ROM needs: A resident was observed sitting in a Broda chair with her head and chin tucked into her right shoulder and unable to bring her head to midline. Record review showed no documentation of decreased ROM in the care plan, despite therapy notes indicating she could straighten her neck to midline with assistance but was resistant. The DON stated the limited ROM should have been included in the care plan, and the facility policy required measurable objectives, timelines, and any recommended rehab services.
Incomplete and inconsistent behavior documentation for a resident with dementia and behavioral disturbance led to a deficiency. The resident’s care plan addressed sexually inappropriate touching and remarks, but behavior forms, TAR entries, and progress notes often did not match, with missing triggers, interventions, or effectiveness. An LPN and the SSD stated staff should document behaviors, interventions, and outcomes, yet several records were left incomplete or showed conflicting information.
The facility failed to ensure proper food storage and labeling, affecting all 19 residents. Observations revealed an open bag of sugar, moldy bread, and several improperly labeled or expired items in the refrigerator, including cottage cheese, hard-boiled eggs, and pre-mixed salad. The facility's policy on labeling and dating was not followed, resulting in outdated and undated items.
A facility failed to maintain infection control during medication administration for five residents. An RN was observed not performing hand hygiene before, during, or after administering medications, handling pills with bare hands, and not disinfecting equipment. The facility's policies emphasized the importance of hand hygiene, which was not adhered to.
A resident, who was cognitively intact and dependent on staff for toileting, reported being spoken to disrespectfully by a staff member during incontinent care. The incident occurred when the resident requested assistance after a bowel movement, and the staff member responded with inappropriate language. Another staff member present confirmed the account, noting rough care and the use of an expletive. The facility's guidelines stress the importance of treating residents with dignity and respect.
The facility failed to document orthostatic blood pressures and vital signs before administering heart medication to two residents. One resident, with atrial fibrillation and hypertension, experienced a fall, and the required orthostatic blood pressure readings were not documented. Another resident, with hypertension and anemia, did not have blood pressure and heart rate readings documented before receiving metoprolol, as ordered by the physician.
A resident with a history of hypertension and heart failure experienced increased pain levels, but the facility failed to inform the physician or nurse practitioner of the changes in pain management needs. Despite a care plan requiring notification of uncontrolled pain, there was no documentation of communication regarding the resident's increased pain or the absence of hydrocodone from the facility. The resident's pain levels were consistently high, leading to enrollment in hospice care for better management.
The facility failed to maintain a homelike environment in three residents' rooms, which were not in good repair. A resident's room had a gouged windowsill, while two residents shared a room with scrapes, missing paint, and a yellow ring on the ceiling. The Executive Director confirmed these issues during an environmental tour, noting that the facility was undergoing remodeling and the rooms were on a list for repairs.
The facility failed to post the nursing staffing information for five consecutive dates. Observations on two separate occasions showed outdated postings, which were only updated after five days. The Executive Director admitted to not noticing the outdated postings despite overseeing the nursing work schedules.
A resident reported rough treatment and verbal confrontation by a new CNA during incontinence care. The facility terminated the CNA and reported the incident to the state health department, following their zero-tolerance policy towards abuse.
A resident with cerebral infarction and hemiparesis reported rough treatment and verbal intimidation by a new CNA during incontinence care. The CNA was terminated, but the incident revealed a failure in the facility's implementation of abuse prevention policies.
The facility failed to ensure adequate night shift staffing, leaving the memory care unit unstaffed and its door unlocked. The ED was informed and found the unit unsecured, with only one RN and one CNA on duty for 24 residents.
Care Plan Missing Limited ROM Needs
Penalty
Summary
The facility failed to ensure a comprehensive plan of care was completed to address limited range of motion for Resident 26. During an observation on 01/27/2026 at 8:56 AM, Resident 26 was sitting in a Broda chair in the common area with her eyes closed and her head and chin tucked down and bent into her right shoulder without support. She denied pain and was able to shake her head yes or no, but when asked to bring her head to her left shoulder, she was unable to bring her head to midline. A second observation on 01/28/2026 at 8:45 AM showed Resident 26 still sitting in a Broda chair in the common area with a pillow under her right side, and her chin and face tucked into her right shoulder. Record review beginning on 01/27/2026 at 9:10 AM found no documentation of decreased range of motion in her care plan. A discharge therapy note and evaluation dated 03/25/2025 indicated Resident 26 could straighten her neck to midline with assistance but was resistant. In interview on 01/27/2026 at 11:55 AM, the DON stated the limited range of motion should have been in the care plan and that the MDS coordinator would be contacted to address it. The facility policy stated the comprehensive care plan should include measurable objectives, timelines, and specialized services or rehab services recommended to be provided.
Incomplete and Inconsistent Behavior Documentation
Penalty
Summary
The facility failed to ensure behaviors were accurately recorded and managed for a resident with dementia, moderate, with behavioral disturbance. The resident’s current care plan identified sexually inappropriate touching and verbal remarks, with interventions including distraction, evaluation of what the resident was trying to communicate, redirection, assertive communication to stop the behavior, and psychiatric referral. The resident’s MDS assessment indicated a BIMS score of 14 and no behavior occurrences in the prior 7 days, despite the care plan documenting ongoing behavioral concerns. Record review showed multiple behavior tracking forms that were incomplete or inconsistent with progress notes and TAR documentation. One form documented sexually inappropriate touching of staff during care but did not identify triggers or whether redirection was effective. Another form documented a behavioral issue in the resident’s room but did not specify the behavior or the type and purpose of touching, although it noted redirection and repositioning with improvement. Additional forms documented sexually inappropriate remarks or other behavior issues, but several did not indicate whether interventions were successful, and some TAR entries showed no behaviors or no interventions despite behavior forms documenting incidents. Progress notes around the same dates often stated that no behavior issues had occurred, and in several instances no corresponding progress notes were available for review. The TAR did not include shift monitoring for behavior issues in September 2025, and other TAR entries contained behavior tracking information that did not match the behavior forms. In interviews, the LPN and SSD stated that staff should record behaviors, interventions, and effectiveness, and that behavior forms should be fully completed and consistent across paper and electronic records. The SSD stated she did not know why the forms were not fully completed and that incomplete areas prevented staff from determining effective behavior interventions.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and labeling practices in their kitchen, which could potentially affect all 19 residents residing at the facility. During an inspection, it was observed that a bag of sugar was left open to air in the dry storage area, and a loaf of cinnamon bread with visible mold was found on the bread rack. The kitchen coordinator acknowledged that the sugar should not have been exposed to air and that the moldy bread had been on the rack for approximately two weeks. In the kitchen refrigerator, several items were found to be improperly labeled or expired. These included a container of cottage cheese past its use-by date, a large bucket of hard-boiled eggs without an open date, and three bags of pre-mixed salad, one of which was opened and half gone. Other items such as a box of prune juice, a pitcher of unsweet tea, a box of pasteurized eggs, a bowl of chopped cucumbers, and containers of half and half were either missing open dates or were past their best-by dates. The facility's policy requires that all leftovers and open foods be labeled with a discard date, but this was not adhered to, leading to the presence of outdated and undated items in the refrigerator.
Infection Control Lapses During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for five residents. Registered Nurse (RN) 3 was observed administering medications without performing hand hygiene before, during, or after the process. For Resident D, RN 3 used her bare hands to handle capsule medications and did not disinfect scissors used to cut a capsule. Additionally, she touched the mouth portion of a straw with her bare hands before placing it in a cup of water for the resident. For Resident 11, RN 3 did not perform hand hygiene before or after administering pill medications and eye drops. Similarly, for Resident 8, RN 3 touched her nose, used hand sanitizer, and then continued medication preparation without further hand hygiene after picking up a medication packet from the floor. For Resident 12, RN 3 did not perform hand hygiene after administering medications to Resident 8 or before obtaining vital signs and preparing medications for Resident 12. In the case of Resident 19, RN 3 gathered supplies and donned gloves without performing hand hygiene. She then obtained a blood sugar reading and administered insulin without hand hygiene before or after the procedure. Interviews with RN 3 and Nurse Consultant 8 confirmed the lack of adherence to hand hygiene protocols, and the facility's medication administration policy emphasized the importance of washing hands before and after medication administration.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as evidenced by an incident involving a staff member and a resident. The resident, who was cognitively intact and dependent on staff for toileting, reported that a staff member spoke to her disrespectfully during incontinent care. The resident had activated her call light around 10:00 p.m. to request assistance after a bowel movement. Upon responding, the staff member made an inappropriate comment regarding the timing of the resident's need for care, using an expletive. Another staff member was present during this interaction. The incident was reported to the Executive Director the following morning, and a reportable incident form was completed. A Certified Nursing Assistant who witnessed the event confirmed the resident's account, noting that the staff member was rough during care and used inappropriate language. The staff member involved was not available for an interview. The facility's guidelines emphasize the importance of treating residents with dignity and respect, highlighting the deficiency in this situation.
Failure to Document Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to properly obtain orthostatic blood pressures and to document blood pressure and pulse readings as ordered by the physician for two residents. Resident 17, who had a history of atrial fibrillation and hypertension, experienced a fall in the shower room. The interdisciplinary team recommended monitoring orthostatic blood pressures for 72 hours, but the Medication Administration Record (MAR) lacked documentation of these readings. Additionally, there was no documentation of pulse rate checks before administering metoprolol, a heart medication, as required by the physician's order. Similarly, Resident 20, diagnosed with hypertension and anemia, was to receive metoprolol succinate ER with specific instructions to hold the medication if the systolic blood pressure was less than 100 or the heart rate was less than 60. However, the MAR for November and December did not contain the necessary blood pressure and heart rate readings prior to medication administration. The Director of Nursing confirmed that the physician's orders specified the need for these parameters to be checked and documented before administering the medication.
Failure to Timely Inform Physician of Resident's Increased Pain
Penalty
Summary
The facility failed to timely inform the physician of changes in a resident's pain management needs, specifically for Resident 13, who was reviewed for pain management. Resident 13 had a history of hypertension and heart failure and was prescribed hydrocodone-acetaminophen for pain management. Despite having a care plan that included notifying the physician of uncontrolled pain, the facility did not document any communication with the physician or nurse practitioner regarding Resident 13's increased pain levels or the absence of hydrocodone in the facility from November 12 to November 26, 2024. Resident 13's pain levels were documented in the Medication Administration Records (MAR) as consistently high, with pain levels ranging from 4 to 8 on a scale of 1 to 10. The resident was observed to be in significant pain, as noted by family members and staff, and was eventually enrolled in hospice care for better pain management. Interviews with family members and staff indicated that Resident 13 had been experiencing increased pain for several weeks, and the current pain management interventions were not effective. The facility's Guidelines for Pain Management policy required timely assessment and management of pain, including notifying the physician if a resident's pain was not relieved by current interventions. However, the clinical record lacked documentation of any such communication, and the facility did not adhere to its policy of notifying the physician when a resident requested PRN pain medications multiple times a day for several consecutive days. This oversight contributed to the deficiency in providing appropriate pain management for Resident 13.
Facility Fails to Maintain Homelike Environment in Residents' Rooms
Penalty
Summary
The facility failed to maintain a homelike environment in three residents' rooms, which were not in good repair. Resident B's room was observed with a gouged and chipped windowsill. The resident's representative confirmed the need for repairs. Resident F and Resident C shared a room where Resident C's side had scrapes and missing paint on the walls, and an electrical outlet was pulling away from the wall. Resident F's side had a missing trim piece and a large yellow ring on the ceiling. Resident F indicated that the yellow ring had been present since her admission to the facility approximately a year ago. An environmental tour with the Executive Director confirmed these observations, and it was noted that the facility was undergoing remodeling. The Executive Director acknowledged that the rooms of Residents B, F, and C were on the maintenance director's list for repairs, but they had not been addressed yet. The facility's policy requires that all room contents, including walls and ceilings, be clean and in good repair, which was not adhered to in these instances. This deficiency was related to a specific complaint, IN00440964.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to post the nursing staffing information for five consecutive dates. On 4-24-24 at 9:55 a.m., the posted staffing was observed to be outdated, showing dates for 4-18-24 and 4-19-24. This remained unchanged during a subsequent observation on 4-24-24 at 1:35 p.m. The posting was finally updated on 4-25-24 at 1:56 p.m. to reflect the current date. In interviews conducted on 4-25-24, the Executive Director admitted to overseeing the nursing work schedules but had not noticed that the daily posted nursing staffing sheets were not current. This deficiency was related to Complaints IN00430719 and IN00432008.
Failure to Protect Resident from Verbal and Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and physical abuse by a staff member. Resident D, who has a history of cerebral infarction and is non-ambulatory, reported that a new CNA, identified as CNA 6, was rough during incontinence care and did not listen when the resident expressed pain. The resident also reported that the CNA later returned and raised her voice in a confrontational manner after learning that the resident had reported the incident to the administration. The facility's Executive Director confirmed that CNA 6 was terminated due to inappropriate language and intimidation, in line with the facility's zero-tolerance policy towards abuse. The incident was reported to the Indiana Department of Health's Long-Term Care Division on the same day the allegation was received. A review of CNA 6's employee file indicated that she had completed the required training on resident rights, abuse prohibition, and dementia care before her hire date. The facility conducted follow-up interviews with other residents, provided staff education, and monitored Resident D for any negative effects following the incident. The facility's Abuse Prevention Program policy mandates immediate suspension of staff suspected of abuse pending investigation, which was followed in this case.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement policies and procedures protecting a resident's right to be free from verbal and physical abuse by a staff member. Resident D, who has a diagnosis of cerebral infarction affecting the non-dominant left side with hemiplegia and hemiparesis, reported an incident where a new CNA, identified as CNA 6, was rough during incontinence care and did not listen to her complaints of pain. Resident D also reported that CNA 6 later confronted her in a raised voice, expressing displeasure about being reported, which was perceived as intimidating behavior. The Executive Director confirmed that CNA 6 was terminated due to inappropriate language and intimidation, in line with the facility's zero-tolerance policy towards abuse. The incident was reported to the Indiana Department of Health's Long-Term Care Division, and an investigation was conducted. Despite the facility's policies and initial staff training on abuse prevention, the incident occurred, indicating a failure in the implementation of these policies and procedures to protect residents from abuse.
Inadequate Night Shift Staffing and Unsecured Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate nursing staff coverage for both the long-term care portion and the secured dementia care unit during the night shift. On a specific night, only one RN and one CNA were on duty, leading to the memory care unit being left unstaffed and its door unlocked. The Executive Director (ED) was informed of the situation by the CNA and immediately came to the facility, finding the memory care unit door open and unlocked. The ED then directed the nurse to the memory care unit and secured the door. The facility's census on that date included 7 memory care unit residents and 17 long-term care unit residents, totaling 24 residents. A confidential interview revealed that there have been a few instances where the locked unit was left unstaffed and unlocked during the night shift. The staff member did not report these incidents to management, assuming they were already aware due to their role in scheduling. The facility's staffing plan, as outlined in the Facility Assessment Tool, requires a minimum of one nurse or QMA on days/evenings and a night staff aide for the memory care unit. The ED confirmed that the memory care unit should always be locked and staffed at all times.
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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 Middletown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Middletown Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Waters Of Chesterfield Skilled Nursing Facility | 4.6 mi | ★★★★★ | 4 | 0 |
| Envive Of Anderson | 7.3 mi | ★★★★★ | 9 | 0 |
| Bethany Pointe Health Campus | 7.5 mi | ★★★★★ | 4 | 1 |
| Countryside Manor Health & Living Community | 7.7 mi | ★★★★★ | 20 | 0 |
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