MUNCIE, IN - State health inspectors documented multiple violations at Waters of Muncie nursing home during a March 2025 survey, including failures in respiratory care management, medication oversight, and resident safety protocols that affected vulnerable elderly residents with dementia and chronic health conditions.
Critical Respiratory Care Failures Endangered Resident Health
Inspectors found that a resident with chronic obstructive pulmonary disease and lung cancer was repeatedly deprived of properly humidified oxygen therapy over multiple days. The resident, identified as Resident F in the inspection report, was observed on three separate occasions between March 25-26 with an empty humidification bottle attached to their oxygen concentrator, despite physician orders requiring continuous humidity with oxygen therapy at three liters per minute.
The humidification bottle, dated March 21, remained empty for at least five days while staff administered oxygen at five liters per minute - nearly double the prescribed rate. When questioned, nursing staff acknowledged the resident's oxygen was ordered at three liters per minute and that "the humidity should not have been empty."
Proper humidification during oxygen therapy prevents nasal passage dryness, reduces risks of nosebleeds, and maintains mucous membrane integrity. For patients with chronic lung conditions, dry oxygen can cause airway irritation, increased mucus production, and breathing difficulties. The higher flow rate compounds these risks while potentially causing oxygen toxicity if sustained over time.
The facility's own oxygen administration policy required staff to check orders for accurate oxygen flow rates and maintain humidifier bottles with changes no less than weekly. Despite these protocols, multiple staff members failed to correct the improper oxygen delivery over several days.
Controlled Medication Oversight Compromised
A pattern of incomplete narcotic counts created significant vulnerabilities in the facility's controlled substance management system. Inspectors reviewed medication cart records from March 1-28 and found extensive documentation gaps affecting 11 residents who received controlled medications.
The 400 Unit medication cart showed 14 instances of missing signatures, incomplete counts, or unexplained discrepancies. On March 28 alone, staff failed to complete required narcotic counts during both the morning shift change and a mid-day cart exchange. The 300 Unit cart revealed 15 additional documentation failures, including multiple unexplained discrepancies marked only as "error" without resolution.
Controlled substance accountability requires dual verification at every shift change and cart exchange to prevent drug diversion and ensure proper pain management for residents. Without complete documentation, facilities cannot detect missing medications, verify appropriate administration, or protect vulnerable residents from potential medication errors.
The Director of Nursing admitted awareness of these deficiencies, stating she had identified the problem earlier in March during an audit for medication misappropriation. Despite conducting staff re-education, the violations persisted through the inspection period. This represented a repeat violation from the facility's previous annual survey in May 2024, when similar controlled substance documentation failures were cited.
Resident Safety Compromised by Inadequate Dementia Care
A resident with severe dementia experienced two physical altercations with other residents within weeks of admission, highlighting systemic failures in behavioral management and safety planning. Resident B, diagnosed with frontotemporal neurocognitive disorder and delusional disorders, entered other residents' rooms on January 22 and February 4, resulting in physical confrontations where he was struck by other residents defending their space.
Between these incidents, documentation revealed escalating behavioral challenges including physical aggression toward staff, public urination, and persistent wandering into restricted areas. Despite these warning signs, the facility discontinued one-on-one supervision after just five days following the first altercation, determining the resident was "easily redirected" without subsequent incidents.
Standard dementia care protocols require comprehensive behavioral assessments, individualized interventions, and sustained supervision adjustments based on ongoing risk factors. The premature removal of enhanced supervision directly preceded the second altercation, which resulted in the resident being struck across the face and requiring emergency room evaluation.
Staff interviews revealed ongoing challenges managing the resident's behaviors even after the second incident. Care plans documented interventions such as "redirect as needed" and "remove from areas immediately," but these generic approaches failed to address the specific triggers and patterns driving the resident's intrusive behaviors.
Entrapment Risk from Improper Bed Rail Assessment
Another dementia resident faced entrapment hazards when found with their head wedged between a mattress and side rail. On March 11, Resident B was discovered on their knees beside the bed with their head trapped between the mattress and an "enabler bar" - a type of bed rail intended to assist with mobility.
The incident occurred despite facility policy requiring comprehensive assessment before implementing any bed rails or enabler bars, quarterly re-evaluations, and documentation of medical necessity. The resident's severe cognitive impairment and supervision needs for all mobility tasks should have triggered heightened safety protocols.
Bed rail entrapment poses risks of asphyxiation, neck compression, and circulation restriction, particularly for confused residents who may become disoriented during transfer attempts. Following the incident, staff immediately discontinued the enabler bars, but the initial assessment had failed to identify the entrapment risk for this cognitively impaired resident.
Additional Issues Identified
Inspectors documented several other violations including failure to maintain current daily nurse staffing postings, with information remaining unchanged for multiple consecutive days despite policy requirements for daily updates. The facility's Quality Assurance Performance Improvement program failed to prevent repeat deficiencies in medication management despite previous citations and corrective action plans.
The March 31, 2025 inspection revealed systemic breakdowns in fundamental care processes affecting the facility's 46 residents. Medical protocols designed to protect vulnerable elderly residents were repeatedly bypassed or incompletely followed, creating preventable risks to resident health and safety.
These violations occurred in a 46-bed facility where consistent adherence to established protocols and physician orders represents basic professional standards. The pattern of failures - from respiratory care to medication management to behavioral interventions - indicates organizational challenges beyond individual staff errors.
The documented violations demonstrate how seemingly routine care lapses compound into significant safety risks for nursing home residents. Proper oxygen humidification, accurate medication counts, appropriate dementia supervision, and thorough safety assessments form the foundation of quality long-term care. When these fundamental processes fail, vulnerable residents face preventable suffering and potentially life-threatening complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Muncie, The from 2025-03-31 including all violations, facility responses, and corrective action plans.
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