C73

WATERS OF LEBANON, THE

Grade C 73/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
2/5
Health Insp.
2/5
Quality
3/5
Staffing
2/5
RN Staffing
Not rated

Certified Beds

64

Ownership

For profit - Corporation

Total Fines

None

Last Survey

N/A

1585 PERRY WORTH RD, LEBANON, IN 46052
7654826391

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.48h
LPN
0.62h
CNA
1.59h
Total
2.69h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

HENDRICKS COUNTY HOSPITAL

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Jul 2017

100%

THE WATERS OF LEBANON LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jul 2017

ENGELS, ERIN

IndividualCORPORATE DIRECTORSince Jul 2017

GENTRY, MARK

IndividualCORPORATE DIRECTORSince Jan 2022

STARKEY, TYLER

IndividualCORPORATE DIRECTORSince Aug 2020

WAITE, JOHN

IndividualCORPORATE DIRECTORSince Aug 2020

WHICKER, TIMOTHY

IndividualCORPORATE DIRECTORSince Jan 2022

FENOUGHTY, DEANNA

IndividualCORPORATE OFFICERSince Jul 2023

JONES, DONNA

IndividualCONTRACTED MANAGING EMPLOYEESince Dec 2022

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (37)

July 31, 2025Health1 deficiency
0689DMinimal harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Aug 25, 2025
September 12, 2024Health7 deficiencies
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Oct 15, 2024
0688DMinimal harm, Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Oct 15, 2024
0761DMinimal harm, Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Oct 15, 2024
0812DMinimal harm, Isolated

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 15, 2024
0641DMinimal harm, Isolated

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 15, 2024
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Oct 15, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Oct 15, 2024
March 7, 2024Health1 deficiency
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Mar 25, 2024
July 14, 2023Health13 deficiencies
0578DMinimal harm, Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Corrected Aug 22, 2023
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Aug 22, 2023
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Aug 22, 2023
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Aug 22, 2023
0690DMinimal harm, Isolated

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

Quality of Life and Care Deficiencies

Corrected Aug 22, 2023
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Aug 22, 2023
0697DMinimal harm, Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Aug 22, 2023
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Aug 22, 2023
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Aug 22, 2023
0761EMinimal harm, Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Aug 22, 2023
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Aug 22, 2023
0883DMinimal harm, Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Corrected Aug 22, 2023
0921FMinimal harm, Widespread

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Aug 22, 2023
April 14, 2023Health2 deficiencies
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected May 18, 2023
0919EMinimal harm, Pattern

Make sure that a working call system is available in each resident's bathroom and bathing area.

Environmental Deficiencies

Corrected May 18, 2023
March 25, 2022Health13 deficiencies
0558DMinimal harm, Isolated

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

Corrected Apr 20, 2022
0584DMinimal harm, Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Corrected Apr 20, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Apr 20, 2022
0685DMinimal harm, Isolated

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Corrected Apr 20, 2022
0686DMinimal harm, Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Apr 20, 2022
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Apr 20, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Apr 20, 2022
0698DMinimal harm, Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Apr 20, 2022
0759DMinimal harm, Isolated

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Corrected Apr 20, 2022
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Apr 20, 2022
0761EMinimal harm, Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Apr 20, 2022
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Apr 20, 2022
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Apr 20, 2022

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Frequently Asked Questions

What is the CareGrader rating for WATERS OF LEBANON, THE?

WATERS OF LEBANON, THE in LEBANON, Indiana has a CareGrader grade of C (Average), with a composite score of 72.8 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for WATERS OF LEBANON, THE?

WATERS OF LEBANON, THE has an overall CMS star rating of 2 out of 5, a health inspection rating of 2/5, and a staffing rating of 2/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does WATERS OF LEBANON, THE have?

WATERS OF LEBANON, THE has 37 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does WATERS OF LEBANON, THE have?

WATERS OF LEBANON, THE has 64 certified beds with approximately 41 current residents (64% occupancy). The facility is located at 1585 PERRY WORTH RD, LEBANON, Indiana 46052. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.