Waters Of Georgetown, The

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

to and after administration. The nurse should be monitoring the site for signs and symptoms of infection and infiltration every shift. 3. The clinical record for Resident G was reviewed on 9/23/25 at 3:22 p.m. The resident's diagnoses included, but were not limited to, encephalopathy, diabetes and a urinary tract infection. The September 2025 medication administration record indicated on 9/23/25, the resident was to have a midline placed for intravenous antibiotic therapy for a urinary tract infection. On 9/23/25 at 1:10 p.m.,

the resident was observed with a midline to his right upper arm, dated 9/23/25. The physician's order, dated 9/23/25, indicated the resident was to receive Meropenem, one gram intravenously for a urinary tract infection every 8 hours at 12:00 a.m., 8:00 a.m. and 4:00 p.m. On 9/25/25 at 10:30 a.m., the September 2025 medication administration record indicated the resident had been administered the following doses of

the antibiotic medication:-9/24/25 at 12:00 a.m., 8:00 a.m. and 4:00 p.m.-9/25/25 at 12:00 a.m. and 8:00 a.m. The clinical record lacked documentation of the midline flush orders before/after medication administration, monitoring the midline site for infiltration and signs/symptoms of infection from 9/24/25 at 12:00 a.m. through 9/25/25 at 8:00 a.m. 4. The clinical record for Resident L was reviewed on 9/23/25 at 4:18 p.m. The resident's diagnosis included, but was not limited to, hypertension. The current care plan, dated 11/18/21, indicated the resident had a diagnosis of hypertension and to administer medications as ordered. The August 2025 and September 2025 medication administration record indicated the resident was to receive Succinate (medication for high blood pressure) extended release, 50 mg daily. The medication was to be held if the resident's pulse was less than 60.Review of the August 2025 and September 2025 vital signs report lacked documentation of an obtained pulse for the resident on the following dates: 8/12/25 through 8/14/25, 8/16/25, 8/17/25, 8/26/25, 8/30/2, 9/11/25 through 9/13/25, 9/18/25, and 9/22/25. 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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Georgetown, The

1002 Sister Barbara Way Georgetown, IN 47122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Georgetown, The

1002 Sister Barbara Way Georgetown, IN 47122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Georgetown, The

1002 Sister Barbara Way Georgetown, IN 47122

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview, the facility failed to identify an unresolved quality deficiency which had been cited on previous surveys, and ensure actions were developed and implemented to attempt to correct the deficiency through the quality assessment and assurance (QAA) process, as evidenced by a repeated deficiency for sufficient staffing. This deficient practice had the potential to affect 64 of 64 residents residing

in the facility. Findings include:The Quality Assurance and Performance Improvement (QAPI) plan was a general outline of how to set up a QAPI committee and what the committee should do. The QAPI plan was

a data driven, proactive approach for improving the quality of life, care and services in long term care. The activities of QAPI involved members at all levels of the organization to identify opportunities for improvement, address gaps in systems or processes, develop and implement and improvement or corrective plan and continuous monitoring of interventions. The following deficiency was cited on this survey and had been cited previously: -F-F725 Sufficient Staffing was previously cited on Complaint survey completed on 12/31/24.-F-F725 Sufficient Staffing was previously cited on Complaint survey completed on 3/27/25.-F-F725 Sufficient Staffing was previously cited on the Annual Survey completed on 6/17/25. 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)

Event ID:

Facility ID:

If continuation sheet