Waters of Fort Wayne: Coumadin Monitoring Failure - IN
At Waters of Fort Wayne Skilled Nursing Facility, inspectors found that monitoring wasn't happening the way it was supposed to.
Federal inspectors visited the facility at 5544 East State Boulevard on November 12, 2025, following a complaint. What they documented, under citation tag F0684, was a failure to ensure that care was implemented and followed throughout the course of a resident's stay. Specifically, residents prescribed Coumadin were not being monitored through the required combination of observation and blood testing, the Prothrombin time and International Normalized Ratio measurements, known as PT/INR, that physicians had ordered to keep the medication safe.
The citation affected a few residents.
CMS rated the level of harm as minimal harm or potential for actual harm, its lower tier of concern. But the gap between "minimal" and "actual" in Coumadin management can close quickly. A resident whose INR climbs undetected doesn't announce it. There's no alarm. The first sign can be a bruise that won't stop spreading, blood in the urine, or a bleed that starts somewhere it shouldn't.
The inspection was complaint-driven, meaning someone, a resident, a family member, or a staff member, contacted authorities before inspectors ever walked through the door. The facility's own intake number, 2663465, is attached to this citation, a paper trail that began with someone deciding the situation was worth reporting.
Waters of Fort Wayne is a skilled nursing facility, meaning it serves residents who need a level of medical care beyond what an assisted living community provides. Coumadin management is not an edge case in that population. Residents in skilled nursing are frequently older, frequently dealing with atrial fibrillation, deep vein thrombosis, or histories of stroke, the exact conditions for which Coumadin is prescribed. Managing it is routine work, the kind of thing that should run on a schedule without anyone having to be reminded.
The inspection report does not describe what happened to any specific resident as a result of the missed monitoring. It does not say whether any resident experienced a bleeding event or a clot. What it says is that the required oversight was not in place and was not being followed consistently, and that a few residents were affected.
That absence of a documented injury is not the same as an absence of risk. When a facility loses track of PT/INR testing on a Coumadin patient, the danger doesn't wait for the next inspection to materialize.
The plan of correction for this citation is not included in publicly available inspection documents. Families seeking information about how the facility intends to fix the monitoring gap are directed to contact Waters of Fort Wayne or the Indiana State Department of Health directly.
What the record shows is a complaint, an inspection, and a finding. A small number of residents on one of the most closely managed medications in elder care were not being watched the way their doctors had ordered.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Fort Wayne Skilled Nursing Facility, The from 2025-11-12 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 3, 2026 · Our methodology
WATERS OF FORT WAYNE SKILLED NURSING FACILITY, THE in FORT WAYNE, IN was cited for violations during a health inspection on November 12, 2025.
At Waters of Fort Wayne Skilled Nursing Facility, inspectors found that monitoring wasn't happening the way it was supposed to.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.