Cycle 1
Health 2025-01-10 · Fire 2025-01-10
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Syracuse, IN
Waters Of Syracuse Skilled Nursing Facility, The
1-star overall rating with 1-star inspections with 17 recent health deficiencies
500 E Pickwick Dr, Syracuse, IN
(574) 457-4401
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
66
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Infinity Healthcare Consulting
Operator or chain grouping
Approved since
1996-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing
LPN hours / resident day
0.33
Licensed practical nurse staffing
Aide hours / resident day
2.29
Nurse aide staffing
Weekend hours
2.81
Weekend nurse staffing
RN turnover
75%
Annual RN turnover
Total nurse turnover
62%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.5
0.8 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
93.6%
0.3 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.8%
3.1 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 55.8% |
24.6%
31.2 pts worse
|
11.4%
44.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 11.6% |
5.6%
6 pts worse
|
5.4%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
23.5%
0.7 pts worse
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 20.8% |
14.8%
6 pts worse
|
16.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.8% |
13.3%
6.5 pts better
|
16.3%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.8% |
11.7%
4.9 pts better
|
14.9%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
24.2%
3.9 pts better
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
4.1%
0.1 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.7% |
81.6%
0.9 pts worse
|
81.7%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
10.5%
3.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.8% |
79.0%
12.8 pts better
|
79.7%
12.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.4% |
22.4%
8 pts better
|
23.9%
9.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-01-03 · Fire 2023-01-03
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-09
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-09
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 2024-03-22
E · Potential for more than minimal harm
2024-02-09
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 2024-03-22
F · Potential for more than minimal harm
2023-01-03
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 2023-02-20
F · Potential for more than minimal harm
2023-01-03
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-20
E · Potential for more than minimal harm
2023-01-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-20
Inspection history
Recent health citations
G · Actual harm
2025-01-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-11
E · Potential for more than minimal harm
2025-01-10
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 2025-02-11
D · Potential for more than minimal harm
2025-01-10
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 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
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 2025-02-27
D · Potential for more than minimal harm
2025-01-10
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 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-27
D · Potential for more than minimal harm
2025-01-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-02-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-09
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 2024-03-05
D · Potential for more than minimal harm
2024-02-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-09
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-09
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-02-09
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 2024-03-05
D · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-05
D · Potential for more than minimal harm
2023-01-03
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-03
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-03
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 2023-01-26
D · Potential for more than minimal harm
2023-01-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-03
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-03
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-26
D · Potential for more than minimal harm
2023-01-03
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 2023-01-26
D · Potential for more than minimal harm
2023-01-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-01-26
Penalties and ownership
What sits behind the stars
$0
2025-01-10
Payment Denial
Payment Denial · denial start 2025-02-14 · 13 days
13 day denial
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
Jackson, Nathan
Contracted Managing Employee · Individual
The Waters Of Syracuse Skilled Nursing Facility LLC
Operational/Managerial Control · Organization
Vance, Carolyn
Contracted Managing Employee · Individual
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#3
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