Nursing homeActive
Waters Of Lebanon, The
1585 Perry Worth Rd, Lebanon, IN 46052765482639164 certified beds · 42 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
5
since 2023
Deficiencies
31
● 0● 31● 0
Penalties · 3 yrs
—
none on file
Last survey
2025-09-11
Standard
CMS overall
1 / 5
stars as published by CMS
CMS overall 1/5
Health 2
Staffing 1
Quality 4
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Indiana Department of Health · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-09-11 | Standard | 090 | CMS-2567 (Care Compare) | — |
| 2025-07-31 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2024-09-12 | Standard | 070 | CMS-2567 (Care Compare) | — |
| 2024-03-07 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-07-14 | Standard | 0130 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Indiana Department of Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F585Honor 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.Scope/severity FStandard
Dignity & rights
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F585
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F628
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F641
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F689
F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F698
F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Scope/severity FStandard
Staffing
Widespread; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F725
F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Scope/severity DStandard
Staffing
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F726
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F761
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-10-24Record 155211-20250911-F842
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity DStandard
Care planningFalls
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-08-25Record 155211-20250731-F689
F554Allow residents to self-administer drugs if determined clinically appropriate.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 155211-20240912-F554
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 155211-20240912-F641
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 155211-20240912-F686
F688Provide 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.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 155211-20240912-F688
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 155211-20240912-F695
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 155211-20240912-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity DStandard
Food & nutrition
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-10-15Record 155211-20240912-F812
F583Keep residents' personal and medical records private and confidential.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-25Record 155211-20240307-F583
F578Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F578
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F609
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F684
F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F686
F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F690
F692Provide enough food/fluids to maintain a resident's health.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F692
F697Provide safe, appropriate pain management for a resident who requires such services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F697
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F755
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F760
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F761
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F812
F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F883
F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Scope/severity FStandard
Environment
Widespread; no actual harm, potential for more than minimal harm.Corrected 2023-08-22Record 155211-20230714-F921
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.43
Facility
Indiana
National
Indiana 0.67 · National 0.69
Total nurse hours per resident day3.19
Facility
Indiana
National
Indiana 3.68 · National 3.86
Weekend total nurse hours2.87
Facility
Indiana
National
Indiana 3.24 · National 3.42
Total nursing staff turnover66%
Facility
Indiana
National
Indiana 46% · National 46%
Registered nurse turnover60%
Facility
Indiana
National
Indiana 40% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Indiana | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 5.1% | 3.6% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 2.8% | 3.9% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 18.6% | 13.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.7% | 1.1% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 9.4% | 11.0% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 0.7% | 5.5% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 32.4% | 23.5% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| The Waters Of Lebanon LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Engels, Erin Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Fenoughty, Deanna Individual | CORPORATE OFFICER | NOT APPLICABLE | — | — |
| Gentry, Mark Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Jones, Donna Individual | CONTRACTED MANAGING EMPLOYEE | NOT APPLICABLE | — | — |
| Starkey, Tyler Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Waite, John Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
| Whicker, Timothy Individual | CORPORATE DIRECTOR | NOT APPLICABLE | — | — |
Part of a chain
Infinity Healthcare Consulting — 69 facilities
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Indiana.
No county cost figures on file for Boone.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Signature Healthcare At Parkwood Lebanon | 3.0 mi | 2026-03-06 | 0201 |
| Homewood Health Campus Lebanon | 4.5 mi | 2026-06-16 | 0280 |
| Restoracy Of Whitestown, The Whitestown | 5.1 mi | 2026-02-13 | 080 |
| Zionsville Meadows Zionsville | 9.5 mi | 2026-01-28 | 0180 |
| Brownsburg Meadows Brownsburg | 12.6 mi | 2026-04-16 | 0181 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |