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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 →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
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.

Inspection Findings

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies

The results were received on 9/23/25 at 2:14 p.m., and the results confirmed constipation.

The record

jeopardy to resident health or 2025 Medication Administration Record (MAR) indicated Resident B received one as needed (PRN) safety docusate (stool softener) on 9/23/25 at 2:07 p.m. but it was recorded as ineffective. On 9/23/25 at 5:31 p.m., the resident received a dose of Miralax (laxative), which was also recorded as ineffective.

constipation) 25 mg every morning for constipation. He received Amitiza (treats certain types of chronic constipation) 24 microgram (mcg) two times a day for constipation.

Resident B's September MAR indicated he received Tramadol (opioid pain medication) 50 mg three times a day for pain.

Resident B's corresponding hospital records, dated 9/25/25, were reviewed and indicated Resident B arrived at the hospital on 9/25/25 at 10:21 a.m. He presented with ongoing abdominal pain for 4 days associated with decreased bowel movements, mild nausea and 7 out of 10 pain.

When Resident B arrived at the hospital he was in Atrial Fibrillation (AFib) (an irregular and often rapid heart rhythm that occurs when the heart's upper chambers beat chaotically due to electrical signal problems.) with Rapid Ventricular Response (RVR) (a fast and irregular heartbeat often associated with atrial fibrillation.) with heart rates in the 140s. A computed topography (CT) scan indicated there was a large stool burden with wall thickening (The bowel wall has become thicker than normal, which can be a sign of inflammation, infection, or a tumor) and pericolonic stranding (this refers to increased density in the fat around the colon, visible on a CT scan. It is caused by inflammatory fluid and cellular changes in the fat tissue.).

This CT scan indicated Resident B was severely impacted with stool.

The resident underwent manual disimpaction (a medical procedure used to treat fecal impaction by manually breaking up and removing hardened stool from the rectum with a gloved and lubricated finger) under monitored anesthesia care.

Approximately 2 liters of fecal matter was removed.

Resident B was transferred from the local hospital to a larger hospital for continued care and reported in route to the EMS crew 0 out of 10 pain after his disimpaction. An NP progress note, dated 10/2/25, indicated Resident B was being seen for readmission to the facility for malignant neoplasm of the gallbladder (gallbladder cancer).

Cross reference F-F684. On 10/16/25 at 1:34 p.m., the ADM provided a copy of current facility policy titled, Abuse Prevention Program, dated 10/22/22.

The policy indicated, .It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property.

Each resident received care and services in a person-centered environment in which all individuals are treated as human beings.

The following procedures 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)

155223 10/20/2025

Waters of Covington, The 1600 E Liberty St Covington, IN 47932

dated 10/1/25. At this time the ADM indicated, there had been a bowel regimen in place at the time

jeopardy to resident health or implemented or monitored effectively, so the DON and MD with the clinical team got together to safety 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

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)

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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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.