Waters of Covington: Immediate Jeopardy Neglect Case - IN
By the time he reached the hospital on the morning of September 25, 2025, Resident B was in atrial fibrillation with rapid ventricular response, his heart beating chaotically at rates in the 140s. A CT scan showed his colon was severely impacted. Doctors removed approximately two liters of fecal matter from his body under anesthesia. He was then transferred to a larger hospital for continued care. He reported zero pain after the procedure.
Federal inspectors cited The Waters of Covington with an Immediate Jeopardy violation following the incident, the most serious level of deficiency CMS issues, reserved for situations where a facility's failures have placed a resident in serious danger or caused serious harm. The inspection was completed October 20, 2025.
Resident B was on tramadol, an opioid painkiller, three times a day for pain. Opioids are well understood to cause constipation, which is why the facility was also giving him two separate prescription medications specifically to counteract that effect: naloxegol oxalate, taken every morning, and Amitiza, taken twice a day. He was already on a regimen designed to keep his bowels moving. It wasn't enough, and when it stopped working, the response from staff was inadequate.
On September 23, inspectors noted, an X-ray of his abdomen, a KUB, came back at 2:14 in the afternoon confirming constipation. The record contained no documentation of any new orders or new interventions in response to that confirmed finding. Seven minutes earlier, at 2:07 p.m., he had received a dose of docusate, a basic stool softener. The medication administration record noted it was ineffective. That evening at 5:31, he received Miralax. Also recorded as ineffective.
No new orders followed. No documentation of a call to a physician or nurse practitioner. No escalation of any kind that inspectors could find in the record.
The next day was September 24. The Immediate Jeopardy was determined to have begun on that date. Resident B remained at the facility. He had now been in abdominal pain, by the hospital's account, for four days, with decreased bowel movements and nausea, rating his pain at seven out of ten when he finally arrived at the emergency room the following morning.
What the CT scan found was not a minor backup. The imaging showed a large stool burden, bowel wall thickening, which can indicate inflammation, infection, or a tumor, and pericolonic stranding, meaning inflammatory fluid had spread into the fat tissue surrounding the colon. His heart, meanwhile, was in atrial fibrillation with rapid ventricular response, a fast and chaotic rhythm that carries its own serious risks. His heart rate was in the 140s.
The manual disimpaction required monitored anesthesia care. Doctors broke up and removed the hardened stool manually. Two liters came out.
He told the EMS crew en route to the second hospital that his pain was zero.
A nurse practitioner's progress note from October 2 documented Resident B's readmission to The Waters of Covington for a separate, grave diagnosis: malignant neoplasm of the gallbladder, gallbladder cancer. He had returned to the same facility.
The Immediate Jeopardy was not removed until October 17, 2025, more than three weeks after it began and more than three weeks after Resident B had been rushed to the hospital in atrial fibrillation. The facility ended the Immediate Jeopardy designation by implementing what inspectors described as a systemic plan that included education and monitoring of staff to ensure they provided supervision and required care to all residents. The citation remained active at a lower severity level after that, because the facility still required continued monitoring.
The facility's own abuse prevention policy, provided to inspectors by the administrator on October 16, states that it is the policy of the facility to prevent resident neglect and that all incidents will be documented whether or not abuse occurred, was alleged, or suspected. The policy designates the administrator as the abuse coordinator and requires that any suspicion of neglect be reported immediately.
What the inspection record shows is a gap between that written commitment and what actually happened to Resident B across those four days in September.
Opioid-induced constipation is a recognized, manageable medical complication. Patients on around-the-clock opioids are routinely placed on bowel regimens precisely because the drugs slow the gut and can cause dangerous impaction if the problem goes unaddressed. Resident B had two prescription medications targeting that specific risk. When a confirmed X-ray result arrived showing constipation had taken hold anyway, and when two back-to-back medications failed to produce results within hours, the clinical picture called for escalation. Inspectors found no evidence it happened.
Fecal impaction, when severe, can cause more than pain. The bowel wall thickening and pericolonic stranding documented on Resident B's CT scan reflect a body under significant inflammatory stress. The atrial fibrillation with rapid ventricular response that greeted emergency room staff when he arrived is a serious cardiac arrhythmia. Whether the prolonged impaction contributed to the cardiac event is not something the inspection report addresses, but the timeline places both conditions in the same body on the same morning, after four days of documented abdominal pain at a nursing facility that had an X-ray result in hand and did not act on it.
The Waters of Covington is located at 1600 East Liberty Street in Covington, Indiana, a small county seat in the western part of the state. The complaint that triggered this inspection was logged under intake number 2633270. The inspection was a complaint survey, meaning someone reported a concern that prompted regulators to investigate.
The Immediate Jeopardy citation covers the period from September 24 through October 17. That is 23 days from the point inspectors determined the jeopardy began to the point they determined it had been addressed. Resident B had been hospitalized, disimpacted under anesthesia, transferred to a second hospital, and readmitted to the facility before the citation was formally resolved.
He came back to The Waters of Covington with a cancer diagnosis.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Covington, The from 2025-10-20 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
WATERS OF COVINGTON, THE in COVINGTON, IN was cited for immediate jeopardy violations during a health inspection on October 20, 2025.
A CT scan showed his colon was severely impacted.
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.