Waters of Georgetown: Staffing Failures Cited Four Times - IN
There are 64 residents at Waters of Georgetown. Federal inspectors had already cited the facility for insufficient staffing three times before they walked in the door on September 26.
The first citation came from a complaint inspection on December 31, 2024. The second from another complaint inspection on March 27, 2025. The third from the facility's annual survey on June 17, 2025. Each time, inspectors documented the same problem. Each time, the facility was required to fix it.
Nothing systemic changed.
The quality assurance records inspectors reviewed told the story in their own way. January 2025: the facility documented terminations and new hires. February: no documentation at all. March: open positions and more terminations. April: open positions carried over from the previous month. May: nothing. June: nothing. July: open positions again. August and September showed new hires and open positions listed, but no record of any intervention actually implemented, no evidence of any structural change made.
The facility's QAPI workbook, the document meant to capture how the organization identifies problems and drives improvement, contained no documentation of interventions or systemic changes for the staffing deficiency that had now been cited on four consecutive surveys.
What the workbook did contain was a general outline of how to set up a quality committee and what that committee should do. That is not a corrective plan. That is a description of one.
The Regional Director of Operations, interviewed on September 25, explained the facility's approach. Aides had complained that nurses weren't helping them, so management restructured assignments: one nurse for two villas instead of one, one aide per villa, with floats added to assist when needed. The staffing sheets show that change was made official on August 20.
But the sheets also show what happened before and after that date. Between August 1 and August 4, the facility ran one nurse and one aide per villa. August 5 and 6, the configuration shifted. August 7 through August 19, it shifted back to one nurse and one aide per villa. The August 20 restructuring, with floats added, lasted on paper. In practice, on August 23, one nurse still covered all four villas through the night. On September 8, a nurse in Villa 3 worked the shift as both the nurse and the aide after a call-in left the position vacant. On September 13, after 10:46 p.m., one nurse again.
The Performance and Peer Review document, dated August 1 and updated September 1, listed the problem as staffing. The corrective actions included adjusting staffing to ensure aides have assistance, monthly rounding, staff interviews every other month, and a staffing assignment review. No supporting documentation accompanied the plan. No evidence that any of those actions produced a measurable result.
Inspectors noted the deficiency had the potential to affect all 64 residents.
The facility's own quality improvement framework, as described in its QAPI plan, calls for identifying gaps in systems, developing corrective plans, implementing them, and monitoring continuously. The inspection record shows nine months of meetings in which open positions were logged and new hires were noted, with nothing in between that would explain why the same violation keeps appearing on the same facility's record.
On the night of September 13, after 10:46 p.m., one nurse held responsibility for everyone inside.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Georgetown, The from 2025-09-26 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
WATERS OF GEORGETOWN, THE in GEORGETOWN, IN was cited for violations during a health inspection on September 26, 2025.
There are 64 residents at Waters of 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.