Lebanon, IN

Waters Of Lebanon, The

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

1585 Perry Worth Rd, Lebanon, IN

(765) 482-6391

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinity Healthcare Consulting

Operator or chain grouping

Approved since

1983-02-22

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

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

0.58

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.75

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

1.93

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.26

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.33

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.93

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.33

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.48

CMS adjusted RN staffing hours

Adjusted total hours

2.69

CMS adjusted total nurse staffing hours

Case-mix index

1.66

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,016

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

31.03

Composite VBP score used to determine payment impact.

Payment multiplier

0.9863

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

5.51

Baseline 87.81% · Performance 50.00% · Measure score 5.51 · Achievement 3.35 · Improvement 5.51

Adjusted total nurse staffing

0.7

Baseline 2.26 hours · Performance 2.69 hours · Measure score 0.7 · Achievement 0 · Improvement 0.7

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 7 · 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 9 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	5.08%	8.2% 3.1 pts worse	Numerator 3 · Denominator 59
Staff flu vaccination coverage	3.33%	42% 38.7 pts worse	Numerator 3 · Denominator 90
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.3%	93.6% 5.7 pts better	93.4% 5.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.1% · 4Q avg 99.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.5%	95.4% 4.9 pts worse	95.5% 5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 90.5%
Percentage of long-stay residents experiencing one or more falls with major injury	3.4%	3.8% 0.4 pts better	3.3% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.3% · Q3 2.9% · Q4 2.9% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	94.6%	24.6% 70 pts worse	11.4% 83.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 97.1% · Q3 93.1% · Q4 93.5% · 4Q avg 94.6%
Percentage of long-stay residents who lose too much weight	2.2%	5.6% 3.4 pts better	5.4% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.5%	23.5% 6 pts worse	19.6% 9.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 25.0% · Q3 27.3% · Q4 39.4% · 4Q avg 29.5%
Percentage of long-stay residents who received an antipsychotic medication	17.9%	14.8% 3.1 pts worse	16.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 20.0% · Q3 16.7% · Q4 17.4% · 4Q avg 17.9% · 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	32.1%	13.3% 18.8 pts worse	16.3% 15.8 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 32.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.2%	11.7% 10.5 pts worse	14.9% 7.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 35.3% · Q3 25.0% · Q4 15.6% · 4Q avg 22.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.8%	0.4% 0.4 pts worse	1.0% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
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 · 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 new or worsened bowel or bladder incontinence	29.1%	24.2% 4.9 pts worse	19.8% 9.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 37.9% · Q2 30.7% · Q3 33.8% · Q4 12.2% · 4Q avg 29.1%
Percentage of long-stay residents with pressure ulcers	1.9%	4.1% 2.2 pts better	5.1% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.8% · Q4 2.7% · 4Q avg 1.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.9%	81.6% 16.3 pts better	81.7% 16.2 pts better	Short Stay · 2024Q4-2025Q3 · Q3 100.0% · Q4 93.9% · 4Q avg 97.9%
Percentage of short-stay residents who newly received an antipsychotic medication	13.9%	1.3% 12.6 pts worse	1.6% 12.3 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 13.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-11 · Fire 2025-09-11

10 health deficiencies

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

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-09-12 · Fire 2024-09-12

8 health deficiencies

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

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-07-14 · Fire 2023-07-14

15 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-09-11

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 2025-11-25

E · Potential for more than minimal harm 2025-09-11

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-11-25

E · Potential for more than minimal harm 2024-09-12

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 2024-10-08

E · Potential for more than minimal harm 2024-09-12

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-10-29

E · Potential for more than minimal harm 2023-07-14

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2023-08-30

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-11

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 2025-10-24

F · Potential for more than minimal harm 2025-09-11

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-11

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-11

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-11

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 2025-10-24

D · Potential for more than minimal harm 2025-09-11

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-11

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2025-10-24

D · Potential for more than minimal harm 2025-09-11

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 2025-10-24

D · Potential for more than minimal harm 2025-09-11

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 2025-10-24

D · Potential for more than minimal harm 2025-07-31

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 2025-08-25

D · Potential for more than minimal harm 2024-09-12

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-10-15

D · Potential for more than minimal harm 2024-09-12

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-10-15

D · Potential for more than minimal harm 2024-09-12

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-10-15

D · Potential for more than minimal harm 2024-09-12

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 2024-10-15

D · Potential for more than minimal harm 2024-09-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-10-15

D · Potential for more than minimal harm 2024-09-12

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-10-15

D · Potential for more than minimal harm 2024-09-12

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 2024-10-15

D · Potential for more than minimal harm 2024-03-07

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-03-25

F · Potential for more than minimal harm 2023-07-14

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 2023-08-22

E · Potential for more than minimal harm 2023-07-14

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-08-22

E · Potential for more than minimal harm 2023-07-14

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 2023-08-22