WATERS OF LEBANON, THE
1585 PERRY WORTH RD
LEBANON, IN, 46052
7654826391
CCN: 155211
2
Overall2
Health2
Staffing3
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| HENDRICKS COUNTY HOSPITAL | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| JONES, DONNA | CONTRACTED MANAGING EMPLOYEE | NOT APPLICABLE |
| ENGELS, ERIN | CORPORATE DIRECTOR | NOT APPLICABLE |
| GENTRY, MARK | CORPORATE DIRECTOR | NOT APPLICABLE |
| STARKEY, TYLER | CORPORATE DIRECTOR | NOT APPLICABLE |
| WAITE, JOHN | CORPORATE DIRECTOR | NOT APPLICABLE |
| WHICKER, TIMOTHY | CORPORATE DIRECTOR | NOT APPLICABLE |
| FENOUGHTY, DEANNA | CORPORATE OFFICER | NOT APPLICABLE |
| THE WATERS OF LEBANON LLC | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Health Deficiencies (33)
2025-09-11 · Health
D
F842 · Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
D
F726 · Nursing and Physician Services Deficiencies
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F628 · Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
F
F585 · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
2025-07-31 · Health
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
2024-09-12 · Health
D
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F761 · Pharmacy Service Deficiencies
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.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F688 · Quality of Life and Care Deficiencies
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.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
2024-03-07 · Health
D
F583 · Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
2023-07-14 · Health
F
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
D
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
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.
D
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F578 · Resident Rights Deficiencies
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.
2023-04-14 · Health
E
F919 · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.26
RN Hrs/Resident/Day0.54
0.58
LPN Hrs/Resident/Day0.81
0.75
CNA Hrs/Resident/Day2.33
1.93
PT Hrs/Resident/Day0.12
0.04
Data as of 2026-03-01