Greencastle, IN

Waters Of Greencastle, The

2-star overall rating with 2-star inspections with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1601 Hospital Dr, Greencastle, IN

(765) 653-2602

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 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

100

Certified beds

Average residents

67

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

Infinity Healthcare Consulting

Operator or chain grouping

Approved since

1981-10-21

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.41

Registered nurse staffing

LPN hours / resident day

0.75

Licensed practical nurse staffing

Aide hours / resident day

2.21

Nurse aide staffing

Weekend hours

2.98

Weekend nurse staffing

RN turnover

50%

Annual RN turnover

Total nurse turnover

41%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 0.8
1.6
0.8 pts better
1.9
1.1 pts better
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 0.8
1.5
0.7 pts better
1.8
1 pts better
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 99.2%
93.6%
5.6 pts better
93.4%
5.8 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 7.0%
3.8%
3.2 pts worse
3.3%
3.7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who have depressive symptoms 32.6%
24.6%
8 pts worse
11.4%
21.2 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who lose too much weight 3.7%
5.6%
1.9 pts better
5.4%
1.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 13.4%
23.5%
10.1 pts better
19.6%
6.2 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 29.6%
14.8%
14.8 pts worse
16.7%
12.9 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 7.7%
13.3%
5.6 pts better
16.3%
8.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 1.1%
11.7%
10.6 pts better
14.9%
13.8 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.4%
0.4%
About the same
1.0%
0.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 0.0%
1.2%
1.2 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 26.8%
24.2%
2.6 pts worse
19.8%
7 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 6.2%
4.1%
2.1 pts worse
5.1%
1.1 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.3%
81.6%
17.7 pts better
81.7%
17.6 pts better
Short Stay · 2024Q4-2025Q3
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 97.3%
79.0%
18.3 pts better
79.7%
17.6 pts better
Short Stay · 2024Q3-2025Q2

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-12-05 · Fire 2025-12-05

10 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2024-09-30 · Fire 2024-09-30

3 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2023-08-15 · Fire 2023-08-15

10 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

6 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-12-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2026-01-16

E · Potential for more than minimal harm 2025-12-05

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 2026-01-09

E · Potential for more than minimal harm 2025-12-05

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2026-01-09

F · Potential for more than minimal harm 2024-09-30

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-10-25

E · Potential for more than minimal harm 2024-09-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-10-25

E · Potential for more than minimal harm 2024-09-30

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-10-25

F · Potential for more than minimal harm 2023-08-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-10-10

E · Potential for more than minimal harm 2023-08-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-09-07

D · Potential for more than minimal harm 2023-08-15

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-09-07

C · Minimal harm 2023-08-15

E41 · Emergency Preparedness Deficiencies

Fire Safety

Implement emergency and standby power systems.

Corrected 2023-09-09

C · Minimal harm 2023-08-15

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2023-09-16

C · Minimal harm 2023-08-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-09-09

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-12-05

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 2026-01-16

E · Potential for more than minimal harm 2025-12-05

F552 · Resident Rights Deficiencies

Health

Ensure that residents are fully informed and understand their health status, care and treatments.

Corrected 2026-01-16

E · Potential for more than minimal harm 2025-12-05

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-12-05

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-12-05

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-12-05

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 2026-01-16

D · Potential for more than minimal harm 2025-12-05

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-12-05

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-12-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2026-01-16

D · Potential for more than minimal harm 2025-05-15

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 2025-05-29

D · Potential for more than minimal harm 2024-09-30

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-30

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2024-10-18

D · Potential for more than minimal harm 2024-09-30

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 2024-10-18

E · Potential for more than minimal harm 2023-08-15

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 2023-09-12

E · Potential for more than minimal harm 2023-08-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-09-12

D · Potential for more than minimal harm 2023-08-15

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 2023-09-12

D · Potential for more than minimal harm 2023-08-15

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-08-16

D · Potential for more than minimal harm 2023-08-15

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 2023-09-12

D · Potential for more than minimal harm 2023-08-15

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 2023-09-12

D · Potential for more than minimal harm 2023-08-15

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 2023-09-12

D · Potential for more than minimal harm 2023-08-15

F826 · Quality of Life and Care Deficiencies

Health

Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor.

Corrected 2023-09-12

D · Potential for more than minimal harm 2023-08-15

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2023-04-01

D · Potential for more than minimal harm 2023-03-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-04-03

Penalties and ownership

What sits behind the stars

Ownership

Putnam County Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 19 facilities 2014-05-23
Bray, Arnold

Corporate Director · Individual

0% 10 facilities 2014-05-23
County Hospital Manager LLC

Operational/Managerial Control · Organization

0% 5 facilities 2014-05-23
Etienne, Jennifer

Contracted Managing Employee · Individual

0% 2 facilities 2022-04-11
Fry, Janice

Corporate Director · Individual

0% 10 facilities 2014-05-23
Headley, Matthew

Corporate Director · Individual

0% 10 facilities 2014-05-23
Landry, Keith

Corporate Director · Individual

0% 9 facilities 2020-09-01
Lewis, Katrina

Corporate Director · Individual

0% 10 facilities 2022-12-21
Mann, Robert

Corporate Director · Individual

0% 6 facilities 2016-01-01
O'hair, Dennis

Corporate Director · Individual

0% 7 facilities 2014-05-23
Weatherford, Dennis

Corporate Officer · Individual

0% 19 facilities 2014-05-23
Weatherford, Dennis

W-2 Managing Employee · Individual

0% 19 facilities 2014-05-23

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Staffing
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#2

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Overall
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Health
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Staffing
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Fines
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#3

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Greencastle, IN

5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

Overall
5 / 5
Health
4 / 5
Staffing
5 / 5
Fines
$0

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