Waters Of Dillsboro-ross Manor, The
WATERS OF DILLSBORO-ROSS MANOR, THE in DILLSBORO, IN — inspection on March 26, 2026.
Found 9 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
During an interview, on 03/24/2026 at 2:53 P.M., the Activity Director, who assisted the residents with the Resident Council meetings, indicated she typed up the concerns voiced by the residents at the meetings, then she distributed the concerns to each department.
The paper given to each department was called a Resident Council Action Form.
Then, she attached the completed action forms to the Resident Council Meeting Minutes the issues were brought up in for each month.
During an interview, on 03/26/2026 at 9:44 A.M., the Regional Director of Operations indicated the concern forms were completed following a Resident Council Meeting, distributed to the identified departments, the response was documented on the forms, the forms were then placed with the Resident Council Meeting Minutes record to be reviewed with the residents at the next meeting.
There were no Resident Council Action Forms completed for the August, September, October, or December 2025, Resident Council Meetings indicating the residents' concerns were addressed.
The current GUIDELINES FOR RESIDENT COUNCIL policy, dated 06/20/2023, was provided by the Administrator on 03/24/2026 at 3:39 P.M.
The policy indicated, .Residents have the right to be involved in making decisions that affect their lives .Group Concerns and Follow-Up .The council group members who voice a concern usually expect a timely response about the resolution to their concern.
This must happen.
The Administrator monitors this process .A concern is any issue identified by the group that requires a response from the facility in the form of a resolution to some degree that satisfies the group with an explanation and comment . 410 IAC (Indiana Administrative Code) 16.2-3.1-3(l) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
During an observation, on 03/23/2026 at 11:18 A.M., the resident was sitting in his wheelchair, he indicated there was something wrong with his prosthetic leg.
The prosthesis was leaning against the side of his bed. He indicated he used to wear the prosthetic leg.
During an interview, on 03/25/2026 at 11:12 A.M., Licensed Practical Nurse (LPN) 10 indicated Resident 3 did wear his prosthetic leg sometimes.
During an interview, on 03/25/2026 at 1:52 P.M., Certified Nurse Aide (CNA) 3 indicated Resident 3 used to wear his prosthetic leg daily and occasionally needed staff assistance with putting it on and taking it off.
During an interview, on 03/25/2026 at 2:20 P.M., the Therapy Manager indicated the resident participated in therapy from 12/10/2025 to 02/11/2026.
During that time, he wore his prosthetic leg.
Interview for Care plan tag at Waters of Dillsboro The clinical record for Resident 3 was reviewed on 03/23/2026 at 1:50 P.M. An admission Minimum Data Set (MDS) assessment, dated 12/15/2025, indicated the resident was moderately cognitively impaired.
The diagnoses included, but were not limited to, hypertension (high blood pressure), diabetes (metabolic disease characterized by high blood glucose due to the body's inability to produce enough insulin or effectively use the insulin), and acquired absence of the left leg.
There was no indication the resident had a limb prosthesis.
The resident admitted to the facility on [DATE].
The resident's Care Plans were reviewed on 03/23/2026 at 1:55 P.M.
The resident's Care Plan lacked a plan of care related to the resident's care and interventions related to the resident's prosthetic leg.
During an interview, on 03/26/2026 at 9:18 A.M., the MDS Coordinator indicated she started baseline and admission care plans.
She would update the care plans based on any new orders or assessments of the resident.
There should have been a care plan for the resident's prosthetic leg.
The current facility policy, titled Baseline Care Plan Assessment/Comprehensive Care Plans, with a revision date of 03/23/21, was provided by the Director of Nursing (DON) on 03/25/2026 at 2:40 P.M.
The policy indicated, .The Comprehensive Care Plans will be reviewed and updated every quarter at a minimum.
The facility may need to review the care plans more often based on changes in the resident's condition 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
During an interview, on 03/23/2026 at 11:29 A.M., Resident 33 indicated she had cataract removal surgery some time ago, but she still needed eyeglasses to read.
She had an appointment with the eye doctor, but he referred her to a specialist.
She went to the specialist, and he referred her back to the regular eye doctor.
She kind of got the runaround and did not know what was happening with getting eyeglasses.
She enjoyed coloring and reading, but she needed readers.
The resident's record was reviewed on 03/23/2026 at 2:16 P.M. A document, scanned into the resident's Electronic Health Record (EHR), indicated the resident visited the ophthalmologist's office on 01/16/2026.
The document was a prescription for the resident's eyeglasses.
During an interview, on 03/24/2026 at 2:37 P.M., the Social Services Director (SSD) indicated a company routinely came to the facility and provided ancillary services that included dental, vision, and podiatry services.
Usually, when the eye doctor examined a resident in the facility, they would write a prescription for eyeglasses, if needed.
The eyeglasses would be ordered and sent to the facility within a few weeks.
She would deliver the eyeglasses to the residents.
She reviewed the records and indicated there was a prescription for eyeglasses in the resident's chart dated 01/16/2026.
She reviewed the transportation logs and indicated that the resident did go out to an eye doctor appointment on 01/16/2026.
She was not sure why the prescription was uploaded to the resident's EHR but was not followed up on.
During an interview, on 03/24/2026 at 3:27 P.M., the SSD indicated the resident had been seen in the facility by the eye doctor and they had referred her to an ophthalmologist.
She came back from that appointment with a prescription for eyeglasses. It probably should have been followed up on sooner.
The current, undated facility policy, titled Vision and hearing services was provided by the Regional Nurse Consultant on 03/26/2026 at 10:41 A.M.
The policy indicated, .It is the standard of the organization to ensure that residents receive the proper treatment and assistive devices to maintain hearing and vision abilities . 410 IAC (Indiana Administrative Code) 16.2-3.1-39(a)(1)
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
During an observation, on 03/24/2026 at 2:59 P.M., Resident 4 was sitting in a recliner in the common area of the dementia unit.
The resident's urinary catheter drainage bag with a dignity flap, was touching the floor.
There was no dignity bag covering the urinary catheter bag.
During an observation, on 03/24/2026 at 3:15 P.M., Resident 4 was sitting in a recliner in the common area of the dementia unit.
Approximately four to five inches of the resident's urinary catheter drainage bag with a dignity flap, was touching the floor.
There was no dignity bag covering the urinary catheter bag.
During an interview, on 03/24/2026 at 3:19 P.M., Licensed Practical Nurse (LPN) 5 indicated residents' urinary catheter drainage bags should not be touching the floor.
The clinical record for Resident 4 was reviewed on 03/23/2026 at 2:52 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/09/2026, indicated the resident was severely cognitively impaired.
The resident's diagnoses included, but were not limited to, neurogenic bladder (a dysfunction of the lower urinary tract caused by damage to the nerves and muscles controlling bladder emptying).
The resident had an indwelling urinary catheter.
The resident used a wheelchair and was dependent on staff for care. A Progress Note, dated 02/13/2026 at 10:39 A.M., indicated the resident had new orders for an antibiotic for a UTI. A Progress Note, dated 03/19/2026 at 12:37 P.M., indicated the resident had a new physician's order to obtain a urine sample related to a foul-smelling odor. A Progress Note, dated 03/20/2026 at 2:09 P.M., indicated the Nurse Practitioner ordered to discontinue the residents Keflex (an antibiotic medication) and start Cefdinir 300 milligrams (mg), twice a day, for a UTI and cellulitis. 2.
During an interview and observation, on 03/23/2026 at 10:23 A.M., Resident 52 was sitting in her room in her wheelchair.
She indicated she had a urinary tract infection recently.
Her urinary catheter drainage bag, with a dignity flap, was hanging under her wheelchair with approximately two inches of the bag touching the floor.
There was no dignity bag covering the urinary catheter bag.
During an observation, on 03/23/2026 at 10:57 A.M., Resident 52 was sitting in the dining room with approximately one inch of her urinary catheter drainage bag, with a dignity flap, touching the floor.
There was no dignity bag covering the urinary catheter bag.
During an observation, on 03/23/2026 at 1:05 P.M., Resident 52 was sitting in the dining room.
Her urinary catheter drainage bag, with a dignity flap, was touching the floor.
There was no dignity bag covering the urinary catheter bag.
During an observation, on 03/24/2026 at 9:03 A.M., Resident 52 was sitting in the dining room.
Three to four inches of the resident's urinary catheter drainage bag, with a dignity flap, was touching the floor. there was no dignity bag covering the urinary catheter bag.
During an interview, on 03/24/2026 at 9:13 A.M., Qualified Medication Aide (QMA) 9 indicated residents' urinary catheter drainage bags should not touch the floor.
During an observation and interview, on 03/24/2026 at 9:15 A.M., the Assistant Director of Nursing (ADON) indicated the resident's urinary catheter drainage bag should not touch the floor and that she would fix it at that time.
The clinical record for Resident 52 was reviewed on 03/24/2026 at 2:55 P.M.
The resident had an impairment to the upper and lower extremities and was dependent on staff for care. A Progress Note, dated 02/27/2026 at 6:52 P.M., indicated a new order was received for IM Ertapenem related to a UTI.
The current facility policy titled, GUIDELINS FOR INDWELLING FOLEY CATHETER CARE dated 10/16/2024, was provided by the ADON on 03/24/2026 at 9:37 A.M.
The policy indicated, .The main purpose of proper indwelling foley catheter care is to prevent catheter associated urinary tract infections. 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
During an interview, on 03/24/2026 at 3:38 P.M., the Director of Nursing (DON) indicated all newly admitted residents were reviewed in SWAT (Skin and Weight Assessment Team) meetings each week for the first four weeks the resident was in the facility, and then longer if needed.
The meetings were held on Thursdays, and the Registered Dietician participated through video conferencing and completed the assessment.
The DON was unaware of the resident's 24 lb. weight gain between 03/01/2026 and 03/15/2026. A SWAT assessment, dated 03/06/2026, indicated the resident was on weekly weights.
The comments section of the assessment indicated the resident's weight was up 5 lbs. since admission and to monitor for further changes.
Lab tests obtained on 02/25/2026 indicated high cholesterol and triglycerides and low red blood cells and low hemoglobin and hematocrit levels.
The resident was not receiving any nutritional supplementation.
They would continue the current plan of care and continue to monitor the resident weekly on SWAT. A SWAT assessment, dated 03/14/2026, indicated the resident was on weekly weights.
The comments section in the assessment indicated the resident needed an updated weekly weight.
The resident's Electronic Health Record (EHR) lacked any further SWAT assessments and lacked documentation that indicated the resident refused to be weighed.
During an interview, on 03/24/2026 at 3:42 P.M., the DON indicated the resident's weight should have been obtained weekly as ordered and the significant weight gain should have been addressed.
The current facility policy, titled GUIDELINES FOR OBTAINING RESIDENTS' WEIGHTS, and dated 07/24/2023, was provided by the DON on 03/25/2026 at 11:43 A.M.
The policy indicated, .Weight is an indicator of nutritional and health status and changes in weight can often indicate other medical changes.Compare the obtained to the previous weight. If there is a significant variance (Ex: 5 lbs. more or less), be sure to reweigh the resident to verify the weight.If a weight is found to be incorrect-note this and initial the error-then notify the nurse for guidance.Weekly weights mean WEEKLY month to month-record and then report to physician per physician order and/or policy.
The current, undated facility policy, titled S.W.A.T. PROGRAM (SKIN AND WEIGHT ASSESSMENT TEAM, was provided by the DON on 03/25/2026 at 11:43 A.M.
The policy indicated, .It is the policy of this facility to assess the nutritional status of each resident. SWAT is designed to aggressively review and address those residents exhibiting significant weight change or skin breakdown.
These residents will be monitored through this team effort on a weekly basis, involving all applicable disciplines to best cater to the improvement of the resident's nutritional status.Indicators determining implementation of SWAT monitoring.new admission.SWAT will meet weekly. 410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
During an interview, on 03/25/2026 at 10:34 A.M., Licensed Practical Nurse (LPN) 10 indicated if a resident didn't have medications available to be given, then she would check their EDK. If the medications were not available there, then she would call the pharmacy to see if it could be sent as soon as possible from a local pharmacy. If they couldn't get it from a local pharmacy, she would have the facility pharmacy get it to the facility as fast as they could. In the EMAR she would mark that the medication was not available and call the physician.
She would document it in a progress note.
During an interview, on 03/25/2026 at 12:42 P.M., the Director of Nursing (DON) indicated if medications were not available for residents, the staff were the check the EDK. If they were not available in the EDK, then they needed to get it ordered from the pharmacy. If a resident missed a dose of medication, then the provider would be notified.
They typically would just verbally let the provider know and didn't document in the clinical record.
The current facility policy tilted, Out of Stock Medications, dated July 2024, was provided by the DON on 03/25/2026 at 1:11 A.M.
The policy indicated, .will maintain an inventory of medications available to meet resident's needs. In the event the facility orders a medication that the pharmacy does not currently stock:.
Alternative suppliers will be contacted to check availability and expected date and time of delivery.
The facility should call the patient's physician to let him/her know that the ordered medication is not available.
The physician can then decide whether to hold the medication until it is available or change the medication to one that is readily available in the emergency dispensing kit.
The original medication that was ordered will be sent as soon as it becomes available. If the resident requires the medication sooner.other area pharmacy sources will be contacted to supply the item. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
medications.Medication rooms, carts, and medication supplies are locked or attended by person with
are refrigerated unless otherwise directed on the label.Outdated, contaminated, or deteriorated drugs
withdrawn from stock by the facility.
They will be disposed of according to drug disposal procedures, and reordered from the pharmacy if a current order exists.Medication storage areas are kept clean, well lit, and free of clutter.the facility is required to keep the carts clean. A Novolog insert was provided by the DON on 03/25/2026 at 2:56 P.M.
The insert indicated, .Unpunctured Novolog FlexPen or Novolog FlexTouch and PenFill cartridges can be used until the expiration date printed on the label if they are stored in the refrigerator. A Lantus insert was provided by the DON on 03/25/2026 at 2:56 P.M.
The insert indicated, .Storage.single-patient-use SoloStar prefilled pen.Not in-use (unopened) Refrigerated.until expiration date.
Not in-use (unopened) Room Temperature.28 days. 410 IAC (Indiana Administrative Code) 16.2-3.1-25(o)
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
During an interview, on 03/25/2026 at 1:54 P.M., RN 8 indicated there should not be blanks in the EMAR.
When the medications were administered they should have been documented as given. If a medication was not administered, the nurse should indicate the medication was not given and document the reason why.
The resident's progress notes were reviewed and lacked documentation related to the medication that was not documented as administered.
The current facility policy, titled, Medication Administration, dated February 2017, was provided by the Director of Nursing on 03/25/2026 at 2:29 P.M.
The policy indicated .Circle initials on MAR if medication is not administered as ordered and record reason in the PRN/Omission Medication section of the MAR . 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)
155280 03/26/2026
Waters of Dillsboro-Ross Manor, The 12803 Lenover St Dillsboro, IN 47018
During an observation, on 03/23/2026 at 11:08 A.M., LPN 5 was preparing medications for Resident 7.
With her bare hands, the nurse unlocked the medication cart, pulled open the narcotic drawer, unlocked the narcotic drawer, popped two pills into her bare hands, and dropped them in a medication cup.
She then administered the medications to the resident.
During an interview, on 03/25/2026 at 2:41 P.M., the IP indicated staff should not touch resident medications with their bare hands during medication administration.
The current facility policy titled, Medication Administration dated February 2017, was provided by the Director of Nursing on 03/25/2026 at 2:29 P.M.
The policy indicated, .To administer all medications safely and appropriately. 410 IAC (Indiana Administrative Code) 16.2-3.1-18(b)(2)