Report
TheVardellReport
Waters of Georgetown, the
Skilled nursing facility and nursing facility
1002 Sister Barbara Way
Georgetown, IN 47122
Report
← Waters of Georgetown, the, free profile
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The Vardell Report.Waters of Georgetown, the
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
- Provider Category
- Nursing home
- Location
- Georgetown, IN
- Record Period
- 2023–2026
- Source Documents
- 13
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Summary
Across 12 inspections from April 2023 to August 2026, state surveyors documented 41 findings at Waters of Georgetown, the; 41 have a recorded correction; CMS lists no enforcement action in the window.
- Inspections
- 12
- 2023–2026, complaint, standard and infection control
- Findings
- 41
- Deficiencies cited by state inspectors
- Corrected
- 41
- Of 41 findings, with a recorded correction date
- Penalties
- 0
- No fines or payment denials in the window
Findings by Year
- Findings
- Of which, actual harm (level G or above)
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 3 | 7 | 0 |
| 2024 | 3 | 6 | 0 |
| 2025 | 4 | 22 | 0 |
| 2026 | 2 | 6 | 0 |
What the Record Shows
- 41 of 41 findings have a recorded correction date.
- CMS lists no fines or payment denials in this window.
- 9 visits in this window included a complaint investigation. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- The latest standard inspection, June 16, 2025, recorded 10 findings (most serious: Level F).
What to Ask About
- Nursing Staff Levels, Cited in Five Inspections
- Quality of Care, Cited in Four Inspections
- Help With Daily Living, Cited in Three Inspections
- Provide activities to meet all resident's needs, Cited in Three Inspections
- Accident Hazards and Supervision, Cited in Three Inspections
- Pharmacy Services, Cited in Three Inspections
- Medical Records, Cited in Three Inspections
- Telling Families About Changes, Cited in Two Inspections
- Continence and Catheter Care, Cited in Two Inspections
Report at a Glance
- Facility
- Waters of Georgetown, the
- Address
- 1002 Sister Barbara Way, Georgetown, IN 47122
- CMS Certification Number
- 155770
- Provider Type
- Skilled nursing facility and nursing facility
- Certified Beds
- 68
- Ownership
- Non profit - Corporation
- Record Window
- April 26, 2023 to October 1, 2026
Chronology
Inspection History
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
- 2026
Complaint investigation
1 finding
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Level ENo actual harm, potential for moreCorrected Aug 27, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2026
Complaint investigation
5 findings
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected May 6, 2026
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected May 6, 2026
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected May 6, 2026
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected May 6, 2026
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected May 6, 2026
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
4 findings
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Dec 3, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Dec 3, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Dec 3, 2025
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level DNo actual harm, potential for moreCorrected Dec 3, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Standard health inspection
10 findings
The same visit included a complaint investigation.
- F679Provide activities to meet all resident's needs.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Level FNo actual harm, potential for moreCorrected Jul 24, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level ENo actual harm, potential for moreCorrected Jul 24, 2025
- F695Provide safe and appropriate respiratory care for a resident when needed.Level ENo actual harm, potential for moreCorrected Jul 24, 2025
- F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Jul 24, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 24, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
1 finding
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected May 20, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2025
Complaint investigation
7 findings
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level FNo actual harm, potential for moreCorrected Apr 22, 2025
- F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Apr 22, 2025
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level ENo actual harm, potential for moreCorrected Apr 22, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
- F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
- F691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
- F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 22, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
4 findings
- F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Feb 4, 2025
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Level ENo actual harm, potential for moreCorrected Feb 4, 2025
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Level DNo actual harm, potential for moreCorrected Feb 4, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Feb 4, 2025
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Standard health inspection
1 finding
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Level DNo actual harm, potential for moreCorrected Jul 23, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2024
Complaint investigation
1 finding
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Level DNo actual harm, potential for moreCorrected May 3, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Complaint investigation
1 finding
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Jan 19, 2024
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Infection control inspection
No findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
- 2023
Standard health inspection
6 findings
- F679Provide activities to meet all resident's needs.Level ENo actual harm, potential for moreCorrected Jun 1, 2023
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Level ENo actual harm, potential for moreCorrected Jun 1, 2023
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Jun 1, 2023
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Level DNo actual harm, potential for moreCorrected Jun 1, 2023
- F760Ensure that residents are free from significant medication errors.Level DNo actual harm, potential for moreCorrected Jun 1, 2023
- F886Perform COVID19 testing on residents and staff.Level DNo actual harm, potential for moreCorrected Jun 1, 2023
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
Patterns Worth Examining
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
- 1
Nursing Staff Levels, Cited in Five Inspections
Inspectors cited F725 in December 2024, March 2025, June 2025, September 2025 and March 2026. This citation covers whether there are enough nurses and aides to meet residents’ needs, with a licensed nurse in charge on each shift. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F725 across all 12 inspections, oldest to newest - 2
Quality of Care, Cited in Four Inspections
Inspectors cited F684 in March 2025, June 2025, September 2025 and March 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F684 across all 12 inspections, oldest to newest - 3
Help With Daily Living, Cited in Three Inspections
Inspectors cited F677 in December 2023, December 2024 and June 2025. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F677 across all 12 inspections, oldest to newest - 4
Provide activities to meet all resident's needs, Cited in Three Inspections
Inspectors cited F679 in April 2023, December 2024 and June 2025. The agency describes it this way: Provide activities to meet all resident's needs. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F679 across all 12 inspections, oldest to newest - 5
Accident Hazards and Supervision, Cited in Three Inspections
Inspectors cited F689 in June 2024, June 2025 and March 2026. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F689 across all 12 inspections, oldest to newest - 6
Pharmacy Services, Cited in Three Inspections
Inspectors cited F755 in April 2023, June 2025 and March 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F755 across all 12 inspections, oldest to newest - 7
Medical Records, Cited in Three Inspections
Inspectors cited F842 in March 2025, May 2025 and March 2026. This citation covers whether resident records are complete, accurate and kept confidential. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F842 across all 12 inspections, oldest to newest - 8
Telling Families About Changes, Cited in Two Inspections
Inspectors cited F580 in April 2023 and June 2025. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F580 across all 12 inspections, oldest to newest - 9
Continence and Catheter Care, Cited in Two Inspections
Inspectors cited F690 in March 2025 and September 2025. This citation covers continence care, catheter care and preventing urinary tract infections. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
232323242424252525252626F690 across all 12 inspections, oldest to newest
For Your Next Visit
Questions to Ask on Your Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
- 01
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
Nursing Staff Levels: cited in five inspections, most seriously at level F.
- 02
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in four inspections, most seriously at level E.
- 03
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in three inspections, most seriously at level E.
- 04
What changed after F679 was cited, and how do you check it now?
Provide activities to meet all resident's needs: cited in three inspections, most seriously at level F.
- 05
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in three inspections, most seriously at level D.
- 06
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in three inspections, most seriously at level E.
- 07
How can a family request a resident’s records, and how are they kept accurate?
Medical Records: cited in three inspections, most seriously at level E.
- 08
How quickly will we hear about a fall, an injury or a change in condition, and from whom?
Telling Families About Changes: cited in two inspections, most seriously at level D.
- 09
How is continence care scheduled, and how do you prevent urinary infections?
Continence and Catheter Care: cited in two inspections, most seriously at level D.
- 10
Has the home been fined or had payments denied before this record begins?
CMS lists no fines or payment denials in this window. The record starts April 26, 2023; anything earlier is not in it.
The Evidence
Sources and Coverage
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Indiana state survey agency.
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Apr 26, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Oct 10, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Dec 28, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Apr 16, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Jun 28, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Dec 31, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Mar 27, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection May 15, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Jun 16, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Sep 26, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Mar 30, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Indiana state survey agency
Inspection Aug 5, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
- Provider Information, Provider Data CatalogView Dataset ↗
Centers for Medicare & Medicaid Services · 155770
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Coverage
Record windowApril 26, 2023 – October 1, 2026
- CMS publishes about three inspection cycles; inspections before April 2023 are not in this release.
- CMS refreshes these files monthly, after statements of deficiencies are processed, so an inspection from the last two months may not appear yet.
What This Report Cannot Tell You
- Complaints not investigated onsite
- Allegations screened out by the state before an onsite visit are not published.
- Complaint allegations
- CMS publishes the deficiencies a complaint survey cited, not the allegation itself.
- Facility-reported incidents
- Self-reported incidents appear only if they led to an inspection.
- Follow-up visits
- CMS's files list standard, complaint and infection control surveys, not revisits; a correction date is the one CMS records.
- Fire safety inspections
- Published by CMS separately and not included in this record yet.
- Staffing levels and ownership history
- Published by CMS separately and not included in this record.
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
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