Waters of Huntingburg, the

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's lab and vital signs were monitored following an increase in medication (digoxin) dosage per physician orders and the resident's plan of care that resulted in a hospitalization for 1 of 3 residents reviewed for hospitalizations (Resident D). Resident D was admitted to the hospital with a diagnosis of digoxin poisoning and life-threatening hyperkalemia (elevated potassium).

Inspectors wroteBased on interview and record reivew, the facility failed to ensure required resident admission assessments were completed timely for 1of 3 resident records reviewed. admission assesments were not completed within the first 14 days following admission. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to esnure a base-line care plan was deveolped for a newly admitted resident within 48 hours of admission for 1 of 3 newly admitted residents with pressure ulcers. A resident's baseline care plan was not created. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 2 of 3 residents reviewed for pharmacy services. Residents did not receive physician prescribed routine medications timely following admisstion to the facilty due to the medications not being available. (Resident B, Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure required resident admission assessments were completed timely for 2 of 4 resident records reviewed. admission assessments were not completed within the first 14 days following admission. (Resident C, Resident D)

Inspectors wroteBased on interview, and record review, the facility failed to provide necessary treatment and services for 2 of 4 residents reviewed for dementia care. Resident behaviors were not monitored, and the plan of care was not updated following new behaviors, known behaviors were not documented, denture cleaning tablets were left unsecured in a dementia unit, and staff failed to offer redirection. (Resident B, Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician prescribed diets were followed for 2 of 4 residents reviewed for dietary services. An order to receive ice cream with meals and an order to receive finger foods was not followed during 1 of 1 mealtimes observed. (Resident B, Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received food at safe and appetizing temperatures for 1 of 1 meal trays tested for taste and temperature of food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for 1 of 1 kitchen observed. Food temperature logs were not completed for all meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper notification following a change of condition for 1 of 3 residents reviewed for falls. (Resident 17)

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of assessments for 3 of 21 residents reviewed for assessments. Minimum Data Set (MDS) assessments did not accurately reflect medications the residents were taking. (Resident 13, Resident 2, Resident 6)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure implementation of care plan interventions for 2 of 3 residents reviewed for falls. A call light was observed out of reach, nonslip material was not placed under furniture, and a resident was not taken to the common area or toileted after a meal as indicated in risk for falls care plans. (Resident 6, Resident 35)

Inspectors wroteBased on interview and record review, the facility failed to revise care plans with new interventions to prevent falls for 3 of 3 residents reviewed for falls. (Resident 17, Resident 6, Resident 35)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physicians orders were followed for insulin administration and blood glucose monitoring (blood sugar testing) for 1 of 9 residents randomly observed during medication administration. Resident 2 was observed to receive the wrong dose of insulin and Resident 2 and Resident 8's medications were left blank on the Medication Administration Record (MAR). (Resident 8, Resident 2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff provided a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinence care and 4 of 9 residents observed during medication passes. Multiple items were touched with gloved hands and the same gloves were used to perform care, hand hygiene was not done between dirty to clean tasks, a resident was left with a brown substance on his bottom, staff washed hands with less then 15 second lather, and staff did not sanitize hands between residents during medication passes. (Resident 5, Resident 14, Resident 33, Resident 36, Resident 27)

Inspectors wroteBased on observation and interview, the facility failed to post up-to-date nurse staffing information on the posted nurse staffing form for 6 of 6 days reviewed for posted nurse staffing. The posted nurse staffing form did not have specific hours listed for the nursing staff. (9/7/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate receiving of routine medications for 1 of 3 residents reviewed for unnecessary medications. A physician's order was entered incorrectly which led to an interruption of a resident's routine medication and an unprescribed dosage reduction. (Resident B)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate staff was available on a locked dementia unit. A licensed nurse was not stationed on the unit during 2 of 2 days during the survey, monitoring and documenting of behaviors was not being completed during a 30-day review period, and staffing patterns did not meet the facility's Alzheimer's/Dementia Special Care Unit staffing specifications. (Memory Springs unit, Resident C, Resident D)

Inspectors wroteBased on interview, and record review, the facility failed to provide necessary treatment and services for 2 of 3 residents reviewed for dementia care. Resident behaviors were not monitored and known behaviors were not documented by nursing staff. (Resident C, Resident D)

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of resident records for 3 of 3 records reviewed. Staff members that initialed they were completing assessments were not on the schedule as worked at the time of the assessments. (Resident B, Resident C, Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician in regard to a need to alter treatment for 2 of 5 residents reviewed for unnecessary medications. The physician was not notified of resident's elevated blood sugar readings and elevated weights. (Resident 30, Resident L, Resident J, Resident F)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection during 1 of 4 observations of care. The facility failed to track all infections for 3 of 5 residents reviewed for infections. Staff lathered hands for 6 seconds, touched items with gloved hands before care was performed, wiped the residents buttock's first, failed to perform hand hygiene when gloves were changed, and touched multiple items with soiled gloves after care. (Resident G, Resident J, Resident K, Resident M)

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 5 residents reviewed for unnecessary medications. A resident's clinical record lacked an antianxiety, antipsychotic, antiplatelet, and diabetes care plans. A resident's clinical record lacked a care plan for smoking and an order to add NAS (no added salt) to a resident's diet was not implemented. (Resident 18, Resident 30)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and a comprehensive person-centered care plan for 1 of 1 residents reviewed for bowel and bladder incontinence. Physician orders were not followed, physician was not notified related to change in condition, treatments were being done without an order, care plans were not updated, and wound assessments were not completed. (Resident J)

Inspectors wroteBased on interview and record review, the facility failed to ensure measures to heal existing pressure ulcers and prevention of additional pressure ulcers for 1 of 3 residents reviewed for pressure ulcers. Care plan interventions were not followed, orders were not placed, pressure ulcers were not staged correctly, and dressings were not completed as ordered for a resident with chronic pressure ulcers. (Resident D)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and prevent falls for 1 of 2 residents reviewed for accidents. Fall risk assessments and neuro (neurological) assessments were not completed after a resident fell. The care plan was not updated after a fall. (Resident L)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice and a comprehensive person-centered care plan for 1 of 2 residents reviewed for respiratory care. The resident was receiving oxygen without monitoring oxygen saturation (O2 sat) levels (level of oxygen in the blood) or monitoring how often and what LPM (Liter Per Minute) of oxygen was being used by the resident. The order lacked perimeters for the staff to determine accurate LPM needed and a care plan was not developed for oxygen use. (Resident 30)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for Urinary Tract Infections (UTI). A resident with a UTI missed 4 of 28 ordered doses of an intravenous (IV) antibiotic. (Resident F)

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe and secure storage of medications for 1 of 2 medication carts observed. A narcotic box was unlocked. (100/200 Hall)

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety for 1 of 1 observations of the kitchen. The food temperature log lacked food temperatures for food served 12 of 19 days reviewed.

Inspectors wroteBased on interview and record review, the facility failed to administer or properly document the pneumococcal immunization for 3 of 5 residents reviewed for immunizations. Clinical records lacked documentation that the resident received or refused a pneumococcal vaccine when a consent was signed to receive the vaccine. (Resident 20, Resident 5, Resident 4)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets were posted and contained the correct information daily for 1 of 6 days reviewed during the survey. (September 24)

Inspectors wroteBased on interview, and record review, the facility failed to monitor a resident's behaviors, as needed psychotropic medications were given beyond 14 days without a rational to continue, orders were not followed, for 1 of 3 residents reviewed for behaviors. (Resident B)

Inspectors wroteBased on interview, and record review, the facility failed to provide necessary treatment and services for 1 of 3 residents reviewed for dementia care. A resident's plan of care was not updated, and physician orders were not implemented following an incident of new and escalated inappropriate sexual behaviors with a resident that resulted in an additional similar incident with another resident in a locked dementia unit. (Resident B, Resident C, Resident D)

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper treatment and care to maintain mobility and good foot health for 5 of 5 residents reviewed for foot care. Four residents had long, thick toe nails curling over the end of their toes. One resident had long nails and ingrown toenails. (Resident B, Resident C, Resident D, Resident E, Resident F)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable environment for residents, staff and the public. Resident room floors were sticky in 11 of 29 rooms observed. (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER])

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dependent residents received the necessary services to maintain good grooming, and personal hygiene for 2 of 3 residents observed for care. A CNA continued to wipe a resident during perineal care after the resident complained of pain. A CNA did not wipe appropriately for one resident. (Resident B, Resident E)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 3 of 3 residents during observation of perineal care and a bed bath. Staff failed to wash hands or sanitize and gloves were not changed between dirty and clean tasks during peri care. (Resident B, Resident D, Resident E)

Inspectors wroteBased on interview and record review, the facility failed to designate one or more individual(s) as the Infection Preventionist with qualifying training or certification. The facility did not have a current certified Infection Preventionist for 5 of 5 days of the survey.

Inspectors wroteBased on interview and record review, the facility failed to deliver mail to the residents on Saturdays for 4 of 9 residents interviewed about mail service. During a resident council meeting, residents indicated they failed to get mail every Saturday. (Resident 10, Resident 20, Resident 27, Resident 32)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program for 1 of 4 units observed and 1 of 1 resident council meetings. (Hope Springs Dementia Unit, Resident 13, Resident 38, Resident 42, Resident 36, Resident 37, Resident 97, Resident 35, Resident 10)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards, and ensure residents received adequate supervision and assistive devices to prevent accidents for 3 of 4 residents reviewed for accidents, and 1 of 4 units reviewed for hot water. The water temperature in resident areas exceeded 120 degrees Fahrenheit, care plans were not updated with new interventions following falls, neurological checks were not completed following falls, and interventions were observed out of place. (Hope Springs Dementia Unite, Resident 35, Resident 13, Resident 38)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accommodations for a resident in a timely manner for 1 of 1 resident reviewed for accommodation of needs. The facility failed to provide a bariatric air mattress for a resident, or an appropriate lift for transfers. (Resident 34)

Inspectors wroteBased on interview and record review, the facility failed to ensure a notice of transfer or discharge was completed and given to residents or resident representatives for 2 of 3 residents reviewed for hospitalizations. The clinical records lacked documentation of the residents or representatives receiving a completed notice of transfer or discharge at the time they were transferred from the facility. (Resident 5, Resident 32)

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed hold policy was provided to residents or resident representatives for 2 of 3 residents reviewed for hospitalizations. The clinical records lacked documentation of the resident or family representatives receiving a bed hold policy at the time they were transferred from the facility. (Resident 5, Resident 32)

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS (Minimum Data Set) Assessments were accurate for 2 of 5 residents reviewed for unnecessary medications. (Resident 5, Resident 16)

Inspectors wroteBased on interview and record review, the facility failed to provide care plan conferences quarterly for 2 of 6 residents reviewed for care plan conferences. (Resident 26, Resident 5)

Inspectors wroteBased on observation and interview, the facility failed to ensure proper storage of medications in 1 of 2 medication storage rooms. Discontinued/expired medications were stored in the storage room and not appropriately disposed. (100 Hall Medication Storage Room)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly labled and not expired during 1 of 2 kitchen observations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure completed nurse staffing sheets were posted daily for 4 of 5 days during the survey.