Cycle 1
Health 2025-01-13 · Fire 2025-01-13
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Chesterfield, IN
Waters Of Chesterfield Skilled Nursing Facility
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
524 Anderson Rd, Chesterfield, IN
(765) 378-0213
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
38
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1996-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
70 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
1.29
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
1.68
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.99
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,119
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.76
Baseline 65.85% · Performance 52.50% · Measure score 2.76 · Achievement 2.74 · Improvement 2.76
Adjusted total nurse staffing
0
Baseline 2.84 hours · Performance 2.50 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.31% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 6.41% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 2.56% |
42%
39.4 pts worse
|
Numerator 2 · Denominator 78 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.6
1.1 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.4%
4.6 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.8%
3.8 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 40.1% |
24.6%
15.5 pts worse
|
11.4%
28.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.4% · Q2 47.1% · Q3 27.8% · Q4 37.9% · 4Q avg 40.1% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.6%
1 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.7% · Q3 3.4% · Q4 0.0% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
23.5%
4.1 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 23.1% · Q3 20.7% · Q4 19.0% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.2% |
14.8%
5.6 pts better
|
16.7%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 15.0% · Q3 4.2% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.2% |
13.3%
9.1 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.8% |
11.7%
8.9 pts better
|
14.9%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 6.9% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
24.2%
3.2 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 9.0% · Q3 19.1% · Q4 20.0% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.1%
2 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 3.0% · Q4 3.1% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
81.6%
16.8 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 94.3% · 4Q avg 98.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.3%
About the same
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 4.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.0%
21 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-22 · Fire 2024-01-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2023-01-13 · Fire 2023-01-13
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
13 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-01-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-03-07
F · Potential for more than minimal harm
2024-10-30
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-10-30
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-16
F · Potential for more than minimal harm
2024-01-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-14
F · Potential for more than minimal harm
2024-01-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-14
F · Potential for more than minimal harm
2024-01-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-01-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-01-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-14
F · Potential for more than minimal harm
2023-01-13
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-02-23
F · Potential for more than minimal harm
2023-01-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-02-23
F · Potential for more than minimal harm
2023-01-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-02-23
F · Potential for more than minimal harm
2023-01-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-02-23
E · Potential for more than minimal harm
2023-01-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-23
E · Potential for more than minimal harm
2023-01-13
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-02-23
E · Potential for more than minimal harm
2023-01-13
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-13
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-13
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-02-23
D · Potential for more than minimal harm
2023-01-13
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-02-23
C · Minimal harm
2023-01-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-05-01
F · Potential for more than minimal harm
2025-01-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-14
D · Potential for more than minimal harm
2025-01-13
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-01-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-22
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-20
D · Potential for more than minimal harm
2024-01-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-20
D · Potential for more than minimal harm
2023-11-21
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-03
D · Potential for more than minimal harm
2023-01-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-29
D · Potential for more than minimal harm
2023-01-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-29
D · Potential for more than minimal harm
2023-01-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-01-29
D · Potential for more than minimal harm
2023-01-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-29
B · Minimal harm
2023-01-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-01-29
Penalties and ownership
What sits behind the stars
Ownership
Johnson Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Berkhouse, Steven
Corporate Director · Individual
Berkhouse, Steven
Corporate Officer · Individual
Decola, Robert
W-2 Managing Employee · Individual
Dunkle, David
Operational/Managerial Control · Individual
Dunkle, David
Corporate Director · Individual
Dunkle, David
Corporate Officer · Individual
Locke, Kimberly
Contracted Managing Employee · Individual
Schneider, Maggie
Contracted Managing Employee · Individual
The Waters Of Chesterfield Skilled Nursing Facility, LLC
Operational/Managerial Control · Organization
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#2
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3-star overall rating with 3-star inspections with $8,390 in total fines with 5 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Countryside Manor Health & Living Community
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