Waters of Georgetown: Death Verification Failure - IN
That was the central finding of a March 30 complaint inspection at the facility, located at 1002 Sister Barbara Way in Georgetown. Inspectors identified two violations: one involving the death of a resident identified in inspection records as Resident C, and a second involving medication orders for a resident with serious eye disease that went unrecorded for multiple days.
Neither violation rose to the level of immediate jeopardy under federal classification. But together they describe a facility where basic procedural requirements, the kind designed as a check against error and neglect, were not being followed.
Resident C had been living with nontraumatic chronic subdural hemorrhage, a condition in which blood and its breakdown products accumulate slowly between the membranes surrounding the brain, sometimes triggered by nothing more significant than minor trauma or the gradual effects of blood thinners. The resident also had heart failure and dementia. A do-not-resuscitate order was in place.
A nursing aide found the resident had died and informed a nurse. The nurse entered the room and documented what she found: the resident was unresponsive, pale, cold, and not breathing. The time of death was recorded as 10:22 p.m. The physician was called. The family was notified.
What the clinical record did not contain was any documentation that a second nurse had assessed the deceased resident. According to a staff member interviewed during the inspection, the facility's own protocol required two nurses to verify the death of a resident with DNR status. One nurse had done it. The record showed no evidence a second nurse ever came.
It is a small procedural requirement in the context of a death, easy to dismiss as paperwork. But the requirement exists precisely because the moment of death carries consequences: for the family, for the legal record, for the integrity of what the facility says happened and when. A second nurse's assessment is not redundant. It is a witness.
The inspection report does not explain why the second verification never happened, or whether a second nurse was even present in the building at the time. It does not say whether anyone at the facility noticed the gap before inspectors arrived. The record simply lacked the documentation. Nobody had filled it in.
The second finding involved Resident D, a resident being treated for two serious eye conditions: macular degeneration, one of the leading causes of vision loss in older adults, and glaucoma, which damages the optic nerve and can lead to irreversible blindness if not properly managed.
An optometrist examined Resident D and issued a detailed set of medication changes. Artificial tears, one drop in both eyes three times daily for dry eyes. A vitamin supplement called Preservision for the macular degeneration. The existing glaucoma medication, Latanoprost eye drops, was to be discontinued. In its place, the optometrist ordered Brimonidine 0.1% combined with dorzolamide 2%, one drop in both eyes twice daily, to manage the glaucoma going forward.
The optometrist's note documenting these orders was dated at 11:35 a.m. on the day of the visit. According to a staff member interviewed during the inspection, orders are supposed to be transcribed the same day a physician or specialist writes them.
They were not. The orders from that visit were not documented in Resident D's clinical record until multiple days later.
During those days, Resident D's medication regimen was in a state the record did not reflect. The old glaucoma medication had been ordered discontinued. The new one had been ordered started. Whether either instruction was actually carried out during the gap, the inspection report does not say. What it does say is that the record, the document that guides what nurses and aides do when they enter a resident's room and administer medications, did not contain those orders when it should have.
Glaucoma is not a condition that waits. Elevated pressure inside the eye, left unmanaged, causes progressive and permanent damage to the optic nerve. The difference between the discontinued medication and the newly ordered one was not incidental. The optometrist had made a clinical decision to change the treatment. That decision sat unrecorded.
The Regional Director of Operations provided inspectors with a copy of the facility's own written policy on physician orders. The policy stated that all orders received pertaining to a resident would be implemented and followed as the orders are received. The policy did not match what the record showed had happened.
Staff Member 6, interviewed during the survey, confirmed that orders should be transcribed on the day they are written. Staff Member 7 confirmed that two nurses are required to verify a death in a resident with DNR status. Both staff members described requirements the facility had not met.
Waters of Georgetown is a nursing facility in a small community in Floyd County, in southern Indiana near the Kentucky border. The inspection was conducted as a complaint survey, meaning it was triggered by concerns reported to regulators rather than as part of a routine inspection cycle. The complaint intakes referenced in the inspection report are numbered 2743599, 2960736, and 2964825.
The violations were cited under Indiana Administrative Code 16.2-3.1-37 and classified at a level of minimal harm or potential for actual harm, affecting few residents.
Minimal harm is a regulatory designation. It describes the category into which inspectors place a finding based on what they can document. It does not describe what Resident D experienced during the days her new glaucoma medication went unrecorded, or whether the discontinued drops were given anyway, or whether the new ones were started on time. It does not describe what it means for a family to learn, after the fact, that only one nurse confirmed their relative had died.
Resident C's family was notified of the death the night it happened. Whether they were ever told that the second verification their facility required never took place, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Georgetown, The from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
WATERS OF GEORGETOWN, THE in GEORGETOWN, IN was cited for immediate jeopardy violations during a health inspection on March 30, 2026.
That was the central finding of a March 30 complaint inspection at the facility, located at 1002 Sister Barbara Way in Georgetown.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.