Waters Of Georgetown, The

Based on interview and record review, the facility failed to ensure a resident's (Resident D) urine output was documented, as ordered, for 1 of 3 residents reviewed for Indwelling catheters.

Findings include: The clinical record for Resident D was reviewed on 9/23/25 at 1:50 p.m.

The resident's diagnosis included, but was not limited to, neuromuscular dysfunction of the bladder.

The physician's order, dated 5/3/25, indicated staff were to monitor the resident's Indwelling catheter output every shift.

The August 2025 and September 2025 medication administration records indicated the resident's urine output was not documented on the following dates and shifts:-On 8/07/25 on day shift,-On 8/12/25 on day shift,-On 9/08/25 on night shift,-On 9/16/25 on night shift, and-On 9/18/25 on night shift.

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)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Georgetown, The

1002 Sister Barbara Way Georgetown, IN 47122

SUMMARY STATEMENT OF DEFICIENCIES

p.m. dose was administered on 8/14/25 12:50 a.m.-On 8/14/25, the resident's 8:00 p.m. dose was administered at 9:38 p.m.-On 8/15/25, the resident's 8:00 p.m. dose was administered at 11:32 p.m.-On 8/18/25, the resident's 8:00 p.m. dose was administered on 8/19/25 at 2:55 a.m.-On 8/19/25, the resident's 8:00 p.m. dose was administered on 8/20/25 at 1:09 a.m.-On 8/20/25, the resident's 8:00 p.m. dose was administered at 11:42 p.m.-On 8/22/25, the resident's 8:00 p.m. dose was administered at 9:51 p.m.-On 8/25/25, the resident's 8:00 p.m. dose was administered at 10:55 p.m.-On 8/26/25, the resident's 8:00 p.m. dose was administered on 8/27/25 at 12:03 a.m.-On 8/27/25, the resident's 8:00 p.m. dose was administered at 11:31 p.m. -On 9/01/25, the resident's 8:00 p.m. dose was administered on 9/2/25 at 12:57 a.m.-On 9/02/25, the resident's 8:00 p.m. dose was administered at 11:28 p.m.-On 9/03/25, the resident's 8:00 p.m. dose was administered at 11:25 p.m.-On 9/04/25, the resident's 8:00 p.m. dose was administered at 11:19 p.m.-On 9/05/25, the resident's 8:00 p.m. dose was administered at 10:56 p.m.-On 9/06/25, the resident's 8:00 p.m. dose was administered at 11:32 p.m.-On 9/08/25, the resident's 8:00 p.m. dose was administered on 9/9/25 at 12:58 a.m.-On 9/09/25, the resident's 8:00 p.m. dose was administered on 9/9/25 at 12:04 a.m.-On 9/10/25, the resident's 8:00 p.m. dose was administered at 11:53 p.m.-On 9/11/25, the resident's 8:00 p.m. dose was administered at 9:23 p.m.-On 9/12/25, the resident's 8:00 p.m. dose was administered at 9:51 p.m.-On 9/14/25, the resident's 8:00 p.m. dose was administered at 9:24 p.m.-On 9/15/25, the resident's 8:00 p.m. dose was administered on 9/16/25 at 12:02 a.m.-On 9/16/25, the resident's 8:00 p.m. dose was administered on 9/17/25 at 1:47 a.m.-On 9/17/25, the resident's 8:00 p.m. dose was administered at 11:21 p.m.-On 9/18/25, the resident's 8:00 p.m. dose was administered at 11:51 p.m.-On 9/19/25, the resident's 8:00 p.m. dose was administered at 11:02 p.m.-On 9/20/25, the resident's 8:00 p.m. dose was administered on 9/21/25 at 12:56 a.m.-On 9/21/25 the resident's 8:00 p.m. dose was administered on 9/22/25 at 4:59 a.m.-On 9/22/25, the resident's 8:00 p.m. dose was administered on 9/23/25 at 12:11 a.m.-On 9/23/25, the resident's 8:00 p.m. dose was administered at 9:59 p.m.

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 1to 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 This Citation relates to Intakes 2583741, 2597221, 2599540, 2608512 and 2613322 3.1-17(a)

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/26/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Georgetown, The

1002 Sister Barbara Way Georgetown, IN 47122

SUMMARY STATEMENT OF DEFICIENCIES

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)

Facility ID: