Waters Of Georgetown, The
WATERS OF GEORGETOWN, THE in GEORGETOWN, IN — inspection on September 26, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the survey period, between 9/22/25 and 9/26/25, Staff Member 18 indicated all physician's orders should be followed.
This Citation relates to Intakes 2597221, 2608512 and 2613322 3.1-37
155770 09/26/2025
Waters of Georgetown, The 1002 Sister Barbara Way Georgetown, IN 47122
During the survey period, between 9/22/25 and 9/26/25, Staff Member 18 indicated physician orders must be followed. On 9/26/25 at 10:39 a.m., the Regional Director of Operations provided a current, undated copy of the document titled Physician Orders. It included, but was not limited to, Policy .It is the policy of the facility to follow the orders of the physician .The facility will follow physician orders to provide essential care to the resident, consistent with the resident's .physical status This Citation relates to Intake 2599540 3.1-41(a)(2)
155770 09/26/2025
Waters of Georgetown, The 1002 Sister Barbara Way Georgetown, IN 47122
with 2 aides per villaBetween 8/7/25 through 8/19/25, the facility scheduled one nurse and one aide
for [NAME] 1, 2, 3 and 4 On 8/23/25, during night shift, there was only one nurse for [NAME] 1, 2, 3
night shift, there was one nurse for Villa 1 and 3 and the nurse also worked as the aide in Villa 3 due to a call in. On 9/13/25, during night shift, after 10:46 p.m., there was only one nurse for Villa 1, 2, 3 and 4 This Citation relates to Intakes 2583741, 2597221, 2599540, 2608512 and 2613322 3.1-17(a)
155770 09/26/2025
Waters of Georgetown, The 1002 Sister Barbara Way Georgetown, IN 47122
Review of the facility QAPI meetings for January 2025 and September 1025 included the following:January 2025 - documented terminations and new hiresFebruary 2025 - no documentationMarch 2025 - documented open positions and terminationsApril 2025 - documented open positions from the previous monthMay 2025 - no documentationJune 2025 - no documentationJuly 2025 - open positions documentedAugust 2025 - documented open positions and new hiresSeptember 2025 - documented open positions and new hires The QAPI workbook provided lacked documentation of interventions implemented or systemic changes for the continued deficient practice.The QAPI Performance/Peer Review, dated 8/1/25 and updated 9/1/25, indicated the problem was staffing.
The corrective actions included, but were not limited to, adjust staffing to ensure CNAs have assistance, monthly rounding, every other month staff interviews, and staffing assignment review. No other information was provided except for the Performance/Peer review Plan document.
During an interview, on 9/25/25 at 3:07 p.m., the Regional Director of Operations indicated they had been utilizing one nurse and one aide in each villa.
The aides complained that the nurses were not helping them.
They then utilized one nurse per 2 [NAME], one aide per villa, and added floats to assist the aides when needed.
Review of the staffing sheets indicated the following: Between 8/1/25 through 8/4/25, the facility scheduled one nurse and one aide for each villa.Between 8/5/25 through 8/6/25, the facility scheduled one nurse for 2 [NAME] with 2 aides per villaBetween 8/7/25 through 8/19/25, the facility scheduled one nurse and one aide per villa On 8/20/25, the facility schedule changed to one nurse for 2 [NAME], one aide per villa with 1 to 3 floats scheduled On 8/8/25, during night shift starting at 10:00 p.m., there was only one nurse for [NAME] 1, 2, 3 and 4 On 8/23/25, during night shift, there was only one nurse for [NAME] 1, 2, 3 and 4 after the QMA completed the evening medication pass in [NAME] 2 and 4 On 9/8/25, during night shift, there was one nurse for Villa 1 and 3 and the nurse also worked as the aide in Villa 3 due to a call in. On 9/13/25, during night shift, after 10:46 p.m., there was only one nurse for Villa 1, 2, 3 and 4 3.1-52(b)(2)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.