Waters Of Georgetown, The
WATERS OF GEORGETOWN, THE in GEORGETOWN, IN — inspection on March 30, 2026.
Found 5 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, Staff Member 7 indicated two nurses had to verify the death of a resident with a DNR status.
- The clinical record for Resident D was reviewed on [DATE] at 1:40 p.m.
The resident's diagnoses included, but were not limited to, macular degeneration (common eye disease and leading cause of vision loss in people aged 50 and older) and glaucoma (a group of eye diseases that damage the optic nerve often due to high fluid pressure inside the eye).
The optometrist note, dated [DATE] at 11:35 a.m., indicated Resident D was seen on [DATE] with the following medications prescribed on the visit:- Artificial Tears 0.1-0.3% 1 drop in both eyes three times a day for dry eyes-Preservision, AREDS 2 250 mg (milligrams) 90mg-40mg 1 capsule twice daily for macular degeneration-Discontinue Latanoprost eye drops-Start Brimonidine, 0.1% - dorzolamide 2% eye drops, 1 drop to both eyes twice daily for glaucoma.
The clinical record lacked documentation of the physician's orders prescribed on [DATE] and not documented until [DATE].
During the survey period, Staff Member 6 indicated orders should be transcribed on the day the physician wrote/ordered them. On [DATE] at 4:05 p.m., the Regional Director of Operations provided a current copy of the document titled Guidelines for Physician Orders-(Following Physician Orders) dated [DATE]. It included, but was not limited to, Policy .It is the policy of the facility to follow the orders of the physician .Procedure .All physician orders received pertaining to the resident will be implemented and followed throughout the course of the resident's stay in the facility as the orders are received This citation relates to Intakes 2743599, 2960736 and 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-37 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
155770 03/30/2026
Waters of Georgetown, The 1002 Sister Barbara Way Georgetown, IN 47122
During an interview, on 3/30/26 at 10:37 a.m., the Regional Director of Operations (RDO) indicated the chime on/chime off switch was set in the middle and not all the way up to the on position.
The clinical record lacked documentation of a physician's order for the alarm and family notification related to the placement of the alarm.
During an interview, during the survey period, Staff Member 9 indicated the motion sensor chime should be on when residents', considered at risk for falls, were in their rooms alone to alert staff of attempted self-transfers.
During an interview, during the survey period, Staff Member 6 indicated residents' motion sensors could not be put in place without a physician's order.
During an interview, on 3/30/26 at 5:17 p.m., the RDO indicated the resident had been attempting to transfer without assistance and a staff member had placed the motion sensor for the resident's safety.
They were currently getting an order for the resident's motion sensor. On 3/30/26 at 2:40 p.m., the RDO provided a current, undated copy of the document titled SAFETY ALARM DEVICES. It included, but was not limited to, Purpose.Safety alarms/devices are utilized when deemed appropriate.Policy.The use of a personal alarm will be on the order of a physician.The resident's family/representative must be informed of and agree to the placement of an alarm.The personal alarm should sound at he Nurse's station if at all possible. 2.
The clinical record for Resident G was reviewed on 3/30/26 at 3:43 p.m.
The resident's diagnoses included, but were not limited to, dementia, chronic pain, anxiety and lack of coordination.
The physician's order, dated 9/5/25, indicated the resident was to have a motion sensor alarm for safety every shift.
The physician's order, dated 12/10/25 indicated staff were to check for proper functioning of the resident's motion sensor alarm every shift.
The care plan, dated 11/24/25, indicated the resident was at risk for fall and was to have a motion sensor alarm as ordered for safety.
During an observation, on 3/30/26 at 10:32 a.m., there was an alarm box sitting on the handrail just outside and to the left of the resident's door entrance.
Resident G was observed resting in her bed with her eyes open and she was confused. observed on the floor, to the right of the resident's dresser was a small box. A yellow light was observed to come on with motion in front of the box, however the alarm box outside of the resident's room did not chime.
During an interview, on 3/30/26 at 10:37 a.m., the Regional Director of Operations (RDO) indicated the chime on/chime off switch was not on.
This citation relates to Intake 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-45(a)(2)
155770 03/30/2026
Waters of Georgetown, The 1002 Sister Barbara Way Georgetown, IN 47122
a.m.-3/17/26 at 10:20 a.m.-3/19/26 at 10:57 a.m.-3/21/26 at 10:18 a.m.-3/23/26 at 11:13
4:30 p.m. and 10:00 p.m.
The March 2026 MAR indicated the resident received the insulin late on the
dose was administered at 12:40 p.m.-3/03/26, 11:30 a.m. dose was administered at 12:57 p.m.-3/04/26, 10:00 p.m. dose was administered at 11:52 p.m.-3/07/26, 10:00 p.m. dose was administered on 3/8/26 at 12:25 a.m.-3/09/26, 7:30 a.m. dose was administered at 10:50 a.m. and 11:30 a.m. dose was administered at 12:53 p.m.-3/10/26, 11:30 a.m. dose was administered at 1:02 p.m.-3/12/26, 7:30 a.m. dose was administered at 10:56 a.m.-3/15/25, 10:00 p.m. dose was administered on 3/16/26 at 12:28 a.m.-3/16/26, 11:30 a.m. dose was administered at 12:46 p.m.-3/19/26, 4:30 p.m. dose was administered at 5:45 p.m.-3/21/26, 4:30 p.m. dose was administered at 6:23 p.m.-3/24/26, 11:30 a.m. dose was administered at 1:07 p.m.-3/25/26, 4:30 p.m. dose was administered at 6:40 p.m. On 3/30/26 at 2:21 p.m., the Regional Director of Operations provided a current copy of the document titled Standard Supervision and Monitoring dated 11/25/11.
It included, but was not limited to, Purpose.This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being.
The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical.needs.Staff assignments are based on the resident needs as far as their acuity.and their person-centered care planning.
Therefore the requirement of meeting those needs to include physical.will be accomplished by provision of as much hands on care as necessary.
This Citation relates to Intakes 7243599, 2960736 and 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-17(a)410 IAC 16.2-3.1-17(b)
155770 03/30/2026
Waters of Georgetown, The 1002 Sister Barbara Way Georgetown, IN 47122
During an interview, on 3/30/26 at 11:55 a.m., Resident L indicated she was here at the facility for the management of her pain and management for her diabetes.
The facility did not do either because she cannot get her pain medication or diabetic medication on time.
During the survey period, from March 26 through March 30, Staff Member 6 indicated medications were administered late due to having to stop the medication pass to assist the aides with the full body mechanical lifts, two staff member assisted resident transfers, or cover two Villa's (separate free standing buildings with going outside to get from one Villa to another while trading places with the aid in the other Villa). On 3/30/26 at 4:22 p.m., the Regional Director of Operations provided a current copy of the document titled Medication Administration Policy Guideline dated 1/25/19. It included, but was not limited to, Policy.Medications are administered as prescribed, in accordance with good nursing principles and practices.Procedure.The resident's MAR is initialed by the person administering the medication.
This Citation relates to Intakes 7243599, 2960736 and 2964825 410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)
155770 03/30/2026
Waters of Georgetown, The 1002 Sister Barbara Way Georgetown, IN 47122
During the survey period, from March 26 through March 30, Staff Member 6 indicated when an as needed pain medication was administered, the medication administration record should be signed off by the nurse. On 3/30/26 at 4:22 p.m., the Regional Director of Operations provided a current copy of the document titled Medication Administration Policy Guideline dated 1/25/19. It included, but was not limited to, Policy.Medications are administered as prescribed, in accordance with good nursing principles and practices.Procedure.The resident's MAR is initialed by the person administering the medication. 2.
The clinical record for Resident H was reviewed on 3/30/26 at 3:58 p.m.
The resident's diagnoses included, but were not limited to, diabetes and depression.
The physician's order, dated 3/21/26, indicated the resident was to receive Tramadol (narcotic pain medication) 50 mg every 6 hours as needed for pain.
The March 2025 controlled drug record indicated the resident received the medication on the following dates and times: 3/23/26 at 9:00 a.m., 3/24/26 at 3:40 p.m. and 9:15 p.m., 3/26/26 at 8:00 p.m., 3/28/26 at 8:00 a.m., and 3/29/26 at 8:00 a.m.
The March 2026 MAR lacked documentation of the administration of the above narcotic pain medications. 3.
The clinical record for Resident L was reviewed on 3/30/26 at 4:24 p.m.
The resident's diagnoses included, but were not limited to, diabetes, depression and fibromyalgia (a chronic disorder characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and cognitive issues).
The physician's order, dated 5/21/25, indicated the resident was to receive Hydrocodone-5-325 mg every 4 hours as needed for pain.
The March 2026 controlled drug record indicated the resident received the medication on the following dates and times: 3/01/26 at 12:15 p.m., 4:30 p.m. and 8:42 p.m.; 3/02/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/03/26 at 10:00 a.m. and 2:00 p.m.; 3/05/26 at 11:40 a.m. and 9:00 p.m.; 3/06/26 at 12:00 a.m. and 9:00 p.m.; 3/07/26 at 8:00 a.m., 12:15 p.m. and 8:54 p.m.; 3/08/26 at 8:00 a.m., 1:00 p.m. and 8:00 p.m.; 3/09/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/10/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/11/26 at 5:15 p.m. and 10:15 p.m.; 3/12/26 at 10:00 a.m. and 2:00 p.m.; 3/13/26 at 10:00 a.m., 2:00 p.m. and 10:30 p.m.; 3/14/26 at 9:00 a.m., 1:00 p.m. and 5:00 p.m.; 3/15/26 at 9:27 p.m.; 3/16/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/17/26 at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m.; 3/18/26 at 5:45 p.m. at 10:40 p.m.; 3/19/26 at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 9:58 p.m.; 3/20/26 at 5:00 p.m. and 9:33 p.m.; 3/21/26 at 8:37 p.m.; 3/22/26 at 10:00 p.m.; 3/23/26 at 10:00 a.m., 2:00 p.m., 6:00 p.m. and 10:00 p.m.; 3/24/26 at 10:00 a.m., 2:00 p.m. and 6:00 p.m.; 3/25/26 at 12:33 p.m. and 11:15 p.m.; 3/26/26 at 9:00 a.m. and 2:00 p.m.; 3/27/26 at 8:30 p.m.; 3/28/26 at 4:00 a.m., and 4:30 p.m. and 10:00 p.m.
The March 2026 MAR lacked documentation of the administration of the above narcotic pain medications.
This citation relates to Intake 2743599 410 IAC (Indiana Administrative Code) 16.2-3.1-50(a)(2)
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GEORGETOWN, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WATERS OF GEORGETOWN, THE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.