WATERS OF GEORGETOWN, THE
1002 SISTER BARBARA WAY, GEORGETOWN, IN 47122
Below the repealed 0.55 hr RN benchmark — review inspection history before visiting.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.36 — Below the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
35
Outstanding
0
Actual harm or worse (G–L)
0
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★☆☆ (3/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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29/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
35 deficiencies found. 35 corrected. None involved actual harm.
Most recent inspection (September 26, 2025)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Administration Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2025
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2025
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.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected December 3, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 24, 2025
Inspection cycle 2 (March 27, 2025)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2025
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2025
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 23, 2024
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected April 22, 2025
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 4, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 3, 2024
Inspection cycle 3 (April 26, 2023)
Perform COVID19 testing on residents and staff.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 1, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 1, 2023
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 1, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected January 19, 2024
Provide activities to meet all resident's needs.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 1, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 1, 2023
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 1, 2023
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