Waters of Syracuse Skilled Nursing Facility, the
500 E Pickwick Dr, Syracuse, IN 46567 · Kosciusko County · 66 certified beds · avg 41 residents/day · certified since Oct 1, 1996
Part of chain: INFINITY HEALTHCARE CONSULTING (69 facilities, chain avg rating 2.0★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 21, 2026 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 5, 2026 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 10, 2025 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 11, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (34)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 21, 2026 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 21, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| May 21, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 21, 2026 | D · Potential for harm, one-off | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Jan 10, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 10, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate pain management for a resident who needed it. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Jan 10, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 9, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (17 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 8 | 0 | D |
| 2025 | 17 | 1 | G ▲ |
| 2026 | 9 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
0 fines totaling $0, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Jan 10, 2025 | Payment Denial | 13 days from Feb 14, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Indiana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 2.71 | 3.42 | 3.95 | bottom 10% in Indiana; bottom 6% in the U.S. |
| Registered Nurse hours | 0.42 | 0.62 | 0.69 | bottom 23% in Indiana; bottom 26% in the U.S. |
| Weekend total nurse staffing | 2.42 | 3.01 | 3.50 | bottom 12% in Indiana; bottom 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.47 | 0.48 | bottom 22% in Indiana; bottom 31% in the U.S. |
| Total nursing staff turnover (%) | 61.8 | 45.9 | 45.8 | bottom 10% in Indiana; bottom 14% in the U.S. |
| RN turnover (%) | 83.3 | 40.4 | 42.9 | bottom 1% in Indiana; bottom 4% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.33, RN 0.52, weekend 2.97. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Johnson Memorial Hospital | Organization | 5% or Greater Direct Ownership Interest | 100% | 03/01/2013 |
| Berkhouse, Steven | Individual | Corporate Director | NOT APPLICABLE | 10/18/2021 |
| Berkhouse, Steven | Individual | Corporate Officer | NOT APPLICABLE | 10/18/2021 |
| Decola, Robert | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/16/2019 |
| Dunkle, David | Individual | Corporate Director | NOT APPLICABLE | 03/01/2019 |
| Dunkle, David | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2019 |
| Dunkle, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/01/2019 |
| Jackson, Nathan | Individual | Contracted Managing Employee | NOT APPLICABLE | 06/21/2021 |
| The Waters of Syracuse Skilled Nursing Facility LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2022 |
| Vance, Carolyn | Individual | Contracted Managing Employee | NOT APPLICABLE | 11/01/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avalon Village | 7.6 mi | Ligonier, IN | ★★★★★ | 5/5 | |
| Waterford Crossing | 9.6 mi | Goshen, IN | ★★★★★ | 4/5 | |
| Greencroft Healthcare | 10.8 mi | Goshen, IN | ★★☆☆☆ | 1/5 | |
| Majestic Care of Goshen | 10.8 mi | Goshen, IN | ★☆☆☆☆ | 1/5 | abuse |
| Restoracy of Goshen, the | 12.1 mi | Goshen, IN | ★★★★☆ | 3/5 | |
| Mason Health Care Center | 12.4 mi | Warsaw, IN | ★☆☆☆☆ | 1/5 | |
| Paddock Springs | 13.6 mi | Warsaw, IN | ★★★★★ | 4/5 | |
| Grace Village Health Care Facility | 13.6 mi | Winona Lake, IN | ★★★★★ | 5/5 | |
| Warsaw Meadows | 13.9 mi | Warsaw, IN | ★☆☆☆☆ | 1/5 | abuse |
| Miller's Merry Manor | 14.9 mi | Warsaw, IN | ★★★★☆ | 4/5 | |
| Waters of Wakarusa Skilled Nursing Facility, the | 17.0 mi | Wakarusa, IN | ★☆☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 155581.