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Complaint Investigation

Waters Of Covington, The

October 20, 2025 · Covington, IN · 1600 E Liberty St
Citations 2
CMS Rating 1/5
Beds 119
Provider ID 155223
Healthcare Facility
Waters Of Covington, The
Covington, IN  ·  View full profile →
Inspection Summary

WATERS OF COVINGTON, THE in COVINGTON, IN — inspection on October 20, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

shall be implemented when an employee or agent become aware of abuse or neglect of a resident or of an allegation of suspected abuse or neglect of a resident by a 3rd party. employees are required to report any incident, allegation, or suspicion of potential abuse, neglect or mistreatment they observe, hear about or suspect to the Administrator or an immediate supervisor who will immediately report the allegation to the Administrator.

The Administrator is the Abuse Coordinator.

All incidents will be documented, whether or not abuse occurred, was alleged or suspected.

Any incident or allegation involving abuse or mistreatment will result in an abuse investigation.

For any incident involving suspicion of abuse, neglect, or mistreatment, the Administrator or person appointed by the Administrator will gather further facts prior to making a determination to conduct an abuse investigation.

The immediate jeopardy that began on 9/24/25 was removed on 10/17/25, when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff provided supervision and required care to all residents residing at the facility.

The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring.

This citation relates to Intake 2633270. 3.1-27(a)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Covington, The

1600 E Liberty St Covington, IN 47932

SUMMARY STATEMENT OF DEFICIENCIES

According to the facilities proactive audit reviews, Resident G triggered for no BMs on 10/9/25 and 10/10/25 with Hospice being notified on 10/10/25. d. On 10/16/25 at 1:28 p.m., a record review was completed for Resident H. He had the following diagnoses which included but were not limited to major depressive disorder, heart transplant, hypertension, muscle weakness, and unsteadiness on feet.

His brief interview mental status (BIMS) score on 9/28/25 was 15, indicating his mental status was intact.

His MDS, dated [DATE], indicated he was continent of bowel and not receiving a bowel management program.

Resident H was prescribed Miralax 17 grams (gm) daily in a large glass of water for bowel health dated 8/30/25. He was prescribed Milk of Magnesia (MOM) 30 milliliters (ml) daily as needed for constipation dated 9/30/25. He had no bowel movement from 9/30/25 through 10/3/25.

On 10/4/25 at 21:59 he had a medium sized bowel movement.

Resident's care plan lacked any mention of the potential for constipation.

During an interview on 10/16/25 at 11:50 a.m., the DON indicated some of the time discrepancies may be due to a technological date/time recording error for some new tables that had been used by the aides to chart.

Some of the tablets were several hours behind the actual time zone, and had not been fixed yet.

During an interview on 10/17/25 at 11:45 a.m., the Administrator indicated it was his expectation for nursing staff to immediately respond to Resident B's complaints of pain and take appropriate measures to assist him or send him to the emergency room.

Further, it was his expectation that nursing staff should be charting accurately, and following the new facility protocol as implemented by the DON and MD. On 10/16/25 at 10:25 a.m., the Administrator provided a copy of facility policy titled, Bowel Protocol, dated 10/1/25. At this time the ADM indicated, there had been a bowel regimen in place at the time Resident B experienced his obstruction and hospitalization, but it was evidently not being implemented or monitored effectively, so the DON and MD with the clinical team got together to create a revised protocol, which he provided at that time.

The new protocol indicated, .use stepwise approach: A. no BM for 3 days [give] M.O.M. 30 ml by mouth once daily. B. If no BM for 4 days, notify the physician or NP. 5.

Documentation: record all bowel movements (date, time, consistency, amount), note interventions used and resident response, notify provider if: no BM 4+ days, signs of bowel obstructions or impaction, persistent diarrhea or bleeding. 6.

Special considerations: Opioid-induced constipation; initiate stimulant laxative at some time as opioid.

May require methylnaltrexone if refractory.

Palliative/Hospice Residents: prioritize comfort, liberal use of laxatives and suppositories as needed.

The immediate jeopardy that began on 9/24/25 was removed on 10/17/25, when the facility ensured a systemic plan to include education and monitoring of staff to ensure staff assessed and monitored residents for pain and change in condition, and that staff followed the facility bowel protocol.

The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring.

This citation relates to Intake 2633270. 3.1-37(a)

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COVINGTON, IN, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WATERS OF COVINGTON, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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