Waters of Chesterfield: Infection Protocol Failure - IN
The resident, identified in inspection records only as Resident 2, has heart failure, difficulty swallowing, and gastroesophageal reflux disease. Because she cannot swallow, she receives nutrition and medication through a gastrostomy tube, a device surgically placed through the abdominal wall directly into the stomach. Residents with feeding tubes face elevated risk for multidrug-resistant organism transmission, which is why the facility had placed an Enhanced Barrier Precautions order on her care as far back as January 14, 2026.
The order was posted on a sign outside the resident's door. It said staff needed to wear gown and gloves for any direct patient care.
On the morning of March 26, 2026, at 9:27 a.m., LPN 5 washed her hands, gathered paper towels, two cups of warm water, and the resident's liquid potassium medication, and entered the room. She set her supplies on the bedside table, paused the tube feed pump, and walked into the bathroom to put on gloves. Then she came back out, leaned against the resident's bed, and stayed there.
She checked the tube for residual fluid. She examined the insertion site. She flushed the tube with 30 milliliters of warm water, pushed the potassium through, flushed again with another 30 milliliters. She restarted the feeding pump, collected the trash, and pulled off her gloves. Her clothing had been in contact with the resident's bed and bedsheets from start to finish.
No gown.
When inspectors spoke with LPN 5 at the time of the observation, she acknowledged the sign on the door. She knew what it required. She said she had simply forgotten to put the gown on before she started.
The director of nursing, interviewed on March 30, 2026, said the Enhanced Barrier Precautions protocol exists because feeding tubes, wounds, and lines all create pathways for infection to move from a resident's body onto a caregiver's clothing, and then to the next room, the next resident, the next surface. She confirmed that all staff providing direct contact care to Resident 2 were required to wear both gown and gloves. LPN 5 should have worn a gown, she said.
The facility's own written policy, last revised in December 2022, spells out the reasoning in plain terms. Enhanced barrier precautions apply during high-contact care activities that create opportunities for multidrug-resistant organisms to transfer from blood or body fluids onto a caregiver's hands or clothing. Feeding tubes of any type appear explicitly on the list of devices that trigger the requirement. Device care involving feeding tubes appears explicitly on the list of activities that require it.
The sign was on the door. The policy was in writing. The nurse knew both.
Federal inspectors cited the violation at a level of minimal harm, the lowest tier on CMS's harm scale. The citation covers one resident because inspectors reviewed one resident for tube feeding compliance. That resident, moderately cognitively impaired according to a February 2026 assessment, was present in the room throughout.
What the inspection record does not say is whether Resident 2's tube site showed signs of infection, or whether she had experienced previous infections. It does not say how many times LPN 5 had provided tube care before this observation, or whether she had worn a gown on those occasions. It does not say whether anyone had audited compliance with the Enhanced Barrier Precautions order between January, when it was placed, and late March, when an inspector happened to be watching.
The resident lay in her bed while a nurse leaned against her sheets, tended to the tube entering her abdomen, and moved through the entire procedure in clothing that the facility's own policy identified as a vector for infection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Chesterfield Skilled Nursing Facility from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Waters of Chesterfield Skilled Nursing Facility
- Browse all IN nursing home inspections
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 17, 2026 · Our methodology
WATERS OF CHESTERFIELD SKILLED NURSING FACILITY in CHESTERFIELD, IN was cited for violations during a health inspection on March 30, 2026.
The resident, identified in inspection records only as Resident 2, has heart failure, difficulty swallowing, and gastroesophageal reflux disease.
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.
Frequently Asked Questions
- What happened at WATERS OF CHESTERFIELD SKILLED NURSING FACILITY?
- The resident, identified in inspection records only as Resident 2, has heart failure, difficulty swallowing, and gastroesophageal reflux disease.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in CHESTERFIELD, IN, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from WATERS OF CHESTERFIELD SKILLED NURSING FACILITY or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 155617.
- Has this facility had violations before?
- To check WATERS OF CHESTERFIELD SKILLED NURSING FACILITY's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.