Federal inspection record · CMS data as of October 1, 2026
Waters Of Lebanon, The
1585 Perry Worth Rd, Lebanon, IN · (765) 482-6391
- Certified beds
- 64
- Residents per day
- 42
- Ownership
- For-Profit
- Chain
- Infinity Healthcare Consulting
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 22, 1983
1
How this home got 3 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Indiana.
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Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★3 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Indiana homes
Waters Of Lebanon, The carries 54 inspection points. That is fewer than 29% of Indiana's 504 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Indiana: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–9 pts
- 4★ 9–24 pts
- 3★ 24–42 pts
- 2★ 42–72 pts
- 1★ over 72 pts
Bars show every rated home in Indiana by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
31 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
No citation on record at the harm or immediate-jeopardy level.
Everything else, by area of care
Quality of Life and Care11D
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
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.
- D
Provide safe and appropriate respiratory care for a resident when needed.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide enough food/fluids to maintain a resident's health.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Resident Rights5F
- F
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.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
- D
Keep residents' personal and medical records private and confidential.
- D
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Pharmacy Service5E
- D
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.
- D
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.
- E
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure that residents are free from significant medication errors.
Resident Assessment and Care Planning3D
- D
Ensure each resident receives an accurate assessment.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- D
Ensure each resident receives an accurate assessment.
Nursing and Physician Services2F
- F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- D
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.
Nutrition and Dietary2E
- D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental1F
- F
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Freedom from Abuse, Neglect, and Exploitation1D
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Infection Control1D
- D
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspection history
2025-09-11
9 health deficiencies · 2 fire-safety deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
2024-09-12
8 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2023-07-14
14 health deficiencies · 1 fire-safety deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 5 h 1 min of nursing staff time a day, 55 min of it from a registered nurse.
This home
5 h 1 min
Indiana average
3 h 44 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine0.3 pts better | 94.0% | 93.7% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.9 pts better | 100.0% | 95.1% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury1.2 pts better | 2.6% | 3.8% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms59.2 pts worse | 84.7% | 25.5% | 13.5% |
| Percentage of long-stay residents who lose too much weight4.6 pts better | 0.7% | 5.3% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication10.1 pts worse | 33.6% | 23.5% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication4.2 pts worse | 17.9% | 13.7% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened8.4 pts better | 2.7% | 11.1% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.4 pts better | 3.4% | 10.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.1 pts worse | 0.4% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.4 pts better | 0.7% | 1.1% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence1.5 pts better | 20.9% | 22.4% | 18.3% |
| Percentage of long-stay residents with pressure ulcers1.6 pts worse | 5.1% | 3.5% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine3.1 pts worse | 78.8% | 81.9% | 82.3% |
| Percentage of short-stay residents who newly received an antipsychotic medication2.7 pts worse | 3.8% | 1.1% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine18.5 pts worse | 60.7% | 79.2% | 80.1% |
·
Who owns and runs it
8 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Engels, Erin | Corporate Director · Individual | 0% | 44 facilities |
| Fenoughty, Deanna | Corporate Officer · Individual | 0% | 45 facilities |
| Gentry, Mark | Corporate Director · Individual | 0% | 45 facilities |
| Jones, Donna | Contracted Managing Employee · Individual | 0% | 1 facilities |
| Starkey, Tyler | Corporate Director · Individual | 0% | 45 facilities |
| The Waters Of Lebanon LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Waite, John | Corporate Director · Individual | 0% | 45 facilities |
| Whicker, Timothy | Corporate Director · Individual | 0% | 45 facilities |
·
Fire safety
5 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke2E
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Provide properly protected cooking facilities.
Egress2E
- E
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.
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Miscellaneous1E
- E
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
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Other homes nearby
-
Signature Healthcare At Parkwood
Lebanon, IN · Signature Healthcare
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 32 min
- Fines
- $8,018
-
Homewood Health Campus
Lebanon, IN · Trilogy Health Services
★★★★★- Worst citation, 3 yrs
- F
- Nursing / resident / day
- 3 h 35 min
- Fines
- $0
-
Restoracy Of Whitestown, The
Whitestown, IN
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 5 h 14 min
- Fines
- $0