Waters of Muncie, The

In the surveyor’s words

From the most serious findings on record at Waters of Muncie, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Aug 10, 2022

  Based on interview and record review the facility failed to ensure an abnormal blood pressure was reported to the physician for possible life saving interventions. This deficient practice resulted in the death of a resident (Resident C). The immediate jeopardy began on [DATE], when a QMA failed to seek an assessment of a resident who presented with a blood pressure of ,d+[DATE]. The resident was not assessed, the physician was not called for possible treatment guidelines. Approximately 3 hours later the resident collapsed and expired in the facility (Resident C). The Administrator and DON (Director of Nursing) were notified of the immediate jeopardy on [DATE] at 11:45 a.m. […]

• Immediate jeopardy, isolatedF600Apr 26, 2022

  The facility failed to ensure a resident with history of maladaptive aggressive behaviors towards others (Resident F) was not supervised in a manner to prevent sexual abuse of a cognitively impaired resident (Resident J). The resident also had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failed to initiate behavioral care plans and interventions. The immediate jeopardy began on 4/5/2022, when the facility failed to ensure the identification, monitoring and prevention of maladaptive aggressive behaviors that resulted in sexual harassment of a cognitively impaired resident and inappropriate photography and distribution on social media. The Administrator and DON were notified of the immediate jeopardy on 4/26/22 at 5:26 p.m. […]

• Actual harm, isolatedF600Jan 27, 2023

  Based on interview and record review, the facility failed to prevent the alleged sexual assault of a resident with severe cognitive impairment (Resident B) by another resident (Resident C), which resulted in Resident B being sent to the hospital for a sexual assault evaluation. Using the reasonable person concept, it is likely this would lead to chronic or recurrent fear and anxiety. Findings include: The clinical record of Resident B was reviewed on 1/27/2023 at 10:00 a.m. Diagnoses included chronic obstructive pulmonary disease, dementia with behaviors, depressive disorder and high risk heterosexual behaviors. A 1/3/23, quarterly, Minimum Data Set (MDS) assessment indicated Resident B's cognitive state and mood was unable to be assessed due to rarely/never being understood. […]

• No harm, potential for more than minimal, widespreadF755Jun 30, 2023

  Based on observation, interview, and record review, the facility failed to ensure narcotics were reconciled per facility policy for 2 of 3 nursing unit's medication carts reviewed for medication storage. (300 Hall cart and 400 Hall cart) Findings include: 1. During a medication storage observation on 6/28/23 at 11:57 a.m. with LPN 5, the narcotic book on the 300 Hall medication cart lacked any shift-to-shift sign-in/out sheets or narcotic count reconciliation documentation. LPN 5 indicated there were no sheets to document the narcotic counts that she was aware of, and the nurses counted the narcotics in the drawer during shift change, but did not document this anywhere. 2. […]

• No harm, potential for more than minimal, patternF602Mar 31, 2025

  Based on record review and interview, the facility failed to prevent the misappropriation of residents' medications for 4 of 7 residents reviewed for misappropriation. (Residents J, F, H, and G) This deficiency had the potential to affect 16 of 46 residents who had controlled medications stored in facility's the medication carts. Findings include: Review of an Indiana State Department of Health facility reported incident, dated 3/16/25 at 12:16 p.m., indicated the facility initiated an investigation of misappropriation of Resident J's medications. The incident was identified on 3/16/25 at 10:25 a.m. LPN 9 was the staff member involved and suspended until further notice. The police were notified on 3/16/25. […]