Waters Of Rising Sun, The
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
12:22 A.M., the Maintenance Director indicated he was the weekend manager on Sunday, 11/16/2025.
When he came in the staff informed him that the van lift had broken the previous day and a resident had fell to the ground. He was told that Activities/Transport Driver 3 was pushing Resident D out of the van onto the lift when the lift suddenly went to the ground, causing both the resident and staff member to fall to the ground. The safety belt on the lift was not in place at the time of the transfer and should be in place before
the lift was even folded down. He performed monthly inspections of the van and lift without any concerns from the last two months. The only documented inspections for the van lift provided were dated 10/15/25 and dated 11/12/25. During an interview, on 11/20/2025 at 1:04 P.M., RN 4 indicated she was the nurse on duty on 11/15/2025 when Activities/Transport Driver 3 came into the facility for help because Resident D was on the ground outside. When she went outside Resident D was lying on the ground on her right side.
The resident's wheelchair was sitting on the van lift on its back with the lift all the way on the ground and
the lift strap not in place. Activities/Transport Driver 3 had told her she didn't have time to put the strap in place before the lift went to the ground. The resident was complaining of back and right elbow pain at the time. She assessed the resident and started neurological assessments. She made the resident comfortable and someone called 911. The resident was transported to the local hospital. The resident had no abnormal findings and was sent back to the facility. The clinical record for Resident D was reviewed on 11/20/2025 at 10:35 A.M. A Quarterly Minimum Data Set assessment, dated 10/20/2025, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, anemia, heart failure, hypertension, renal insufficiency, anxiety, and depression.A Progress Note, dated 11/15/2025 at 3:21 P.M., indicated the writer was notified by the facility's transporter that Resident D was on the ground outside. The writer went to the parking lot, and the resident was lying on her right side on the ground at the back of the van. The staff member was transferring the resident and when she was putting the resident onto the lift from the van the hydraulics failed causing the lift, staff member, and the resident to quickly lower to the ground and they both fell off the lift. A head-to-toe assessment was completed; neurological assessments were completed. The resident was alert and complained of back and head pain. An ambulance was called, and the resident was sent to the local emergency room for evaluation and treatment. A Progress Note, dated 11/16/2026 at 2:04 A.M., indicted the resident returned from the hospital and the x-rays were negative. The hospital records for the resident lacked abnormal findings related to the fall. The current, undated, facility policy titled, Vehicle Lift Safety, was provided by the Regional Director of Operations on 11/20/2025 at 12:57 P.M. The policy indicated, .Resident will be secure and safe during use of transport vehicle lift.Secure seat belt.The current facility policy titled, GUIDELINES FOR INCIDENTS/ACCIDENTS/FALLS, dated 06/30/2023, was provided by the Regional Director of Operations
on 11/20/2025 at 12:57 P.M. The policy indicated, .The facility will ensure that incidents and accidents that occur involving residents are identified, reported, and resolved.3.1-45(a)(1)3.1-45(a)(2)
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If continuation sheet
WATERS OF RISING SUN, THE in RISING SUN, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 RISING SUN, 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 RISING SUN, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.