Waters of Fort Wayne: Medical Records Failures - IN
That's what state inspectors found when they visited The Waters of Fort Wayne Skilled Nursing Facility on November 12 and filed a complaint-based inspection report.
Resident C had dementia, heart failure, and a prosthetic heart valve. He had been prescribed 8 milligrams of Warfarin daily, a high dose of one of the most closely monitored medications used in nursing homes. Warfarin thins the blood to prevent dangerous clots, but too much of it can cause uncontrolled bleeding. The difference between safe and dangerous often comes down to a single number: the PT/INR, a blood test measuring how quickly the blood clots. His orders called for that test every Monday and Thursday, with results reported to his nurse practitioner.
The facility ran those tests in-house using a machine with test strips. When they had strips, they ran the test. When they ran out of strips, they sent the blood to the hospital.
That arrangement produced gaps. The MAR, the medication administration record that tracks what gets done and when, showed tests completed on October 2, 6, 9, and 13. Then the test was held on October 16. On October 20, the MAR listed the test as "not applicable" with no results recorded. No results appeared for October 23 or October 30 either. Two results from October 20 and 22 turned up in his record, processed at the hospital, but those weren't scheduled lab days, and they weren't documented on the MAR.
When inspectors interviewed LPN 4 on November 12, she explained the strip situation plainly. The facility tested the resident's blood when they had supplies to do it. When they didn't, the sample went to the hospital. Dose changes based on results were noted in the nurse notes and initialed on the MAR.
What she didn't address was the logbook.
The Director of Nursing told inspectors that PT/INR results from the facility's own machine were recorded in a log kept at the nurses' station. She acknowledged, when asked directly, that those logs were not part of Resident C's clinical record. She said they should be.
That distinction matters. A physician or nurse practitioner reviewing a patient's chart to decide whether to adjust a Warfarin dose would look at the clinical record. If results from the facility's own machine never made it into that record, the person making dosing decisions was working with incomplete information. For a resident with a prosthetic heart valve already at documented risk for abnormal bleeding, incomplete information about clotting levels is not a minor paperwork problem.
The Regional Nurse Consultant, present during the inspection, provided a facility policy on assessments that stated resident records should contain all information from facility staff and contracted health professionals involved in a resident's care. The consultant confirmed the policy applied to this situation. The logbook entries did not meet that standard.
The second finding involved a different resident and a different kind of failure, smaller in scale but telling in its own way.
On November 9, a hospice note recorded that Resident H, a woman seated in a Broda chair in a common area, leaned forward and tumbled out, hitting her face on the ground. She was unable to say what had happened or whether she was in pain. She had a small abrasion on the bridge of her nose, a scab, and bruising at the inner corner of her right eye.
The hospice note described an intervention: place a pillow in front of the resident when she sits at a table so she can rest her head on it, since she is known to lean forward. That intervention was not in her care plan. When inspectors observed her during the visit, no pillow was in front of her.
The hospice progress notes themselves weren't even available in her record when inspectors first reviewed it. Staff had to contact the hospice company to obtain them.
The administrator told inspectors that circumstances surrounding a fall, including injuries and notifications to family and physician, should be documented in a resident's progress notes. The hospice notes that described the fall and the intervention existed only outside the facility's own recordkeeping system, and the intervention they described was not being followed.
Inspectors cited both findings under the federal regulation requiring that clinical records be complete, accurate, and accessible. The citation was tagged at the level of minimal harm or potential for actual harm.
For Resident C, the question that the inspection report leaves open is how many weeks of Warfarin dosing decisions were made without the full picture of what his blood was doing.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 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.
Resident C had dementia, heart failure, and a prosthetic heart valve.
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.