Waters Of Martinsville, The

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to ensure food was served in a safe and sanitary manner for 2 of 2 kitchen observations. Hairnets were not worn while preparing food, the dishwashing room was dirty, and expired foods were not discarded. Findings include:1. During a tour of the kitchen on 1/29/26 from 7:40 a.m. until 8:05 a.m., the following was observed.- The Activity Director and the Social Service Director were working in the kitchen, preparing meal trays, without wearing a hair net. At that time, the Social Service Director indicated they should have put on hair nets before working in the kitchen. - Inside

the walk-in refrigerator observed a plastic one-gallon jug of [NAME] Chere Old Fashion Ranch Dressing with an open date of 12/29/25, and an expiration of on 12/12/25 (The dressing was opened after the expiration date). At that time, the Dietary Manager indicated the expired ranch dressing should have been removed from the refrigerator.- A buildup of debris and food particles were observed on the top of the dishwasher and along the floor underneath the metal dishwasher tables. At that time, the Dietary Manager indicated the dishwasher and dish room floors should have been cleaned thoroughly.2. On 1/30/26 at 8:24 a.m., inside the walk-in refrigerator observed two full plastic, one-gallon jugs of [NAME] two percent milk.

The expiration date on both of the milk jugs was 1/29/26. At that time, the Regional Dietary Director indicated the expired milk should have been removed from the refrigerator. On 1/30/26 at 9:00 a.m., the Administrator provided a copy of a facility policy, titled Food Storage, dated 11/29/19, and indicated this was

the current policy used by the facility. A review of the policy indicated food should be storage and prepared

in a clean, safe, and sanitary manner.This citation relates to Intakes 2725718 and 2700986.3.1-21(i)(2)3.1-21(i)(3)

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 REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/30/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Martinsville, The

2055 Heritage Dr Martinsville, IN 46151

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and interview, the facility failed to ensure a sanitary and safe environment for 2 of 2 random

observations. Linens were not clean, soiled briefs were left in garbage cans, and odors were present. (room [ROOM NUMBER], room [ROOM NUMBER])1. On 1/29/26 at 8:25 a.m., inside room [ROOM NUMBER] observed a large orange/brown stain on the fitted sheet on Bed B (window bed) and one urine soiled brief

in the garbage can inside the bathroom. The bathroom had a strong urine odor. The bathroom was shared between room [ROOM NUMBER] and room [ROOM NUMBER]. At that time, Resident B indicated she couldn't remember when her sheets had been changed last and when she changed her own briefs, she threw her used soiled briefs in the garbage can in the bathroom.During an interview on 1/29/26 at 8:42 a.m., Resident C indicated her room had a shared bathroom with Resident B's room. Resident C had taken herself to the bathroom because she liked doing things for herself and had placed her own soiled briefs in

the garbage can. On several occasions, Resident C noticed soiled briefs in the garbage can that she did not put in there. During an interview on 1/29/26 at 8:44 a.m., CNA 1 indicated soiled briefs should not have been left in Resident B and Resident C's bathroom garbage can. The staff should have checked the garbage cans and removed the garbage bags and soiled briefs.2. On 1/29/26 at 9:05 a.m., there was a strong urine odor in room [ROOM NUMBER]. Resident D was lying on Bed B without any sheets on her bed. Resident D was covered with a small fleece blanket. At that time, Resident D indicated she was not sure where the urine odor was coming from. Resident D couldn't remember when she had sheets on her mattress last. On 1/30/26 at 8:44 a.m., observed Resident D sitting up in her wheelchair inside her room. A fleece blanket had been thrown on top of Bed B and did not have any linens. The fleece blanket was saturated with urine and the mattress was wet. At that time, Resident D indicated the staff had not put any linens on her mattress yesterday nor today. Resident D couldn't remember the last time her blanket had been cleaned. On 1/30/26 at 2:45 p.m., the facility was unable to provide a policy.This citation relates to Intake 2711983.3.1-19(f)

Event ID:

Facility ID:

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