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)
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
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
64
Certified beds
Average residents
41
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
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing
LPN hours / resident day
0.75
Licensed practical nurse staffing
Aide hours / resident day
1.93
Nurse aide staffing
Weekend hours
2.93
Weekend nurse staffing
RN turnover
29%
Annual RN turnover
Total nurse turnover
51%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 32.1% |
13.3%
18.8 pts worse
|
16.3%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 | 29.1% |
24.2%
4.9 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
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 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
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 2023-08-22
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
D · Potential for more than minimal harm
2023-07-14
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-22
E · Potential for more than minimal harm
2023-04-14
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-05-18
D · Potential for more than minimal harm
2023-04-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-18
Penalties and ownership
What sits behind the stars
Ownership
Hendricks County Hospital
5% Or Greater Direct Ownership Interest · Organization
Engels, Erin
Corporate Director · Individual
Fenoughty, Deanna
Corporate Officer · Individual
Gentry, Mark
Corporate Director · Individual
Jones, Donna
Contracted Managing Employee · Individual
Starkey, Tyler
Corporate Director · Individual
The Waters Of Lebanon LLC
Operational/Managerial Control · Organization
Waite, John
Corporate Director · Individual
Whicker, Timothy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Signature Healthcare At Parkwood
Lebanon, IN
4-star overall rating with 3-star inspections with $8,018 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Homewood Health Campus
Lebanon, IN
2-star overall rating with 2-star inspections with 14 recent health deficiencies
#3
Restoracy Of Whitestown, The
Whitestown, IN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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