Waters of Lebanon, the
1585 Perry Worth Rd, Lebanon, IN 46052 · Boone County · (765) 482-6391
64 certified beds, about 42 residents a day · For profit - Corporation · Medicare and Medicaid since 1983
Inside a hospital Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
2 of 5
Staffing
1 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 155211 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on September 11, 2025, inspectors cited 9 health deficiencies (the Indiana average is 7.2, the national average 9.2).
None of its 31 health citations since July 2023 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.19 hours per resident per day, against 3.69 across Indiana and 3.86 nationally. Registered nurses accounted for 0.43 of those hours.
65.9% of nursing staff left within the year CMS measured (Indiana average 45.9%).
CMS links it to Infinity Healthcare Consulting, an affiliated group of 70 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
1307/23
103/24
709/24
107/25
909/25
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 31 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
26D
2E
3F
Potential for minimal harm
0A
0B
0C
September 11, 2025Standard inspection · 9 citations
- F 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.
Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure grievance forms and/or a grievance process was readily and easily accessible for residents for 43 of 43 residents who resided in the facility.
- F Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to answer call lights in a timely and appropriate manner as evidenced by delayed call light response times, residents left waiting for toileting assistance, residents left on bedpans, staff and resident interviews reporting inadequate staffing levels. This deficient practice had the potential to effect 43 of 43 residents who resided in the facility and received nursing care.
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and interview, the facility failed to send adequate documentation with a resident to the hospital and failed to reconcile a resident's medications, who was discharging to his home for 2 of 3 residents reviewed for discharge (Resident 44 and Resident 46).
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review and interview, the facility failed to accurately code a Minimum Data Set (MDS) for types of medications used by the residents for 2 of 5 residents reviewed for MDS accuracy (Residents 51 and 41).
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, record review, and interview, the facility failed to prevent the potential for accidents when medications were left at bedside and the resident was not supervised to take his medications for 1 of 1 random observation (Resident 33).
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the correct prescribed solutions were used for 3 of 8 peritoneal dialysis treatments, and failed to follow appropriate infection control measures to properly and timely dispose of the used dialysate (fluid pulled off during the dialysis treatment) (Resident 47).
- D 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.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure nursing staff had the necessary skills to administer a resident's medication and administer the right dose to a resident (Resident 24).
- D 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.
Inspectors wroteBased on observations and interviews, the facility failed to date medications and remove expired medications from use for 1 of 2 medication carts and 1 of 2 medication rooms.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interviews and record review, the facility failed to ensure accurate documentation related to wound care orders for a pressure ulcer and administration of a controlled substance for 1 of 19 Residents reviewed for accurate documentation (Resident 2).
July 31, 2025Complaint inspection · 1 citation
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review, the facility failed to follow safety guidelines and to provide adequate employee training resulting in a resident's wheelchair falling over during transport in a facility vehicle for 1 of 3 residents reviewed for accidents (Resident B).
September 12, 2024Standard inspection, Complaint inspection · 7 citations
- D Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident had a self-adminstration asessment for a medication (Ventolin) stored at bedside for 1 of 12 residents (Resident 34) reviewed for medications at bedside.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on and interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately coded for 5 of 12 residents reviewed for resident assessments (Residents 6, 34, 13, 43 and 29).
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was at risk for developing pressure ulcers, received a pressure reducing device for her wheelchair for 1 of 2 residents reviewed for pressure ulcers (Resident 29).
- D 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.
Inspectors wroteBased on record review and interview, the facility failed to assess on a quarterly basis to determine any improvement, decline or remained the same level with mobility and Range of Motion (ROM) for 2 of 3 residents reviewed (Resident 1 and 36).
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received oxygen as ordered for 1 of 1 resident reviewed for Oxygen services (Resident 29).
- D 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.
Inspectors wroteBased on record review and interview, the facility failed to label tuberculosis testing serum appropriately for 1 of 2 medications rooms reviewed (100 hall).
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective handwashing of staff delivering lunch trays for 2 of 4 residents observed for receiving lunch trays (Residents 42 and 43).
March 7, 2024Complaint inspection · 1 citation
- D Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right for his medical record to be kept private and confidential when it was not discussed without the resident's permission for 1 of 3 residents reviewed for resident's rights (Resident H).
July 14, 2023Standard inspection · 13 citations
- F Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on interview and record review, the facility failed to ensure compliance with Indiana Department of Environmental Management's (IDEM) requirement to submit documentation of a fully certified Water Distribution Manager to comply with the Safe Drinking Water Act. Further, the facility failed to ensure a Plan of Correction was submitted after an onsite inspected which resulted in deficient practice on [DATE]. These deficient practices had the potential to effect 43 of 43 residents who resided in the facility.
- E 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.
Inspectors wroteBased on observation, and interview, the facility failed to ensure medications were stored properly in 2 of 2 medication carts, and 2 of 2 treatment carts reviewed for medication storage (100 hallway, and 200 hallway).
- E Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all kitchen foods were covered, hand washing was correctly completed in the kitchen and dining room (Resident 7 and 10), and failed to clean to fryer in a timely manner for 2 of 2 days of observations. These deficient practices had the potential to effect 43 of 43 residents who received food from the kitchen.
- D 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.
Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's choice of code status was documented consistently in the medical record and the physician and staff were aware of the resident's choice for 1 of 2 residents reviewed for code status (Resident 196).
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an unusual occurrence that directly affected the wellbeing and health of a resident (Resident 32) was reported to the State Department of Health. This deficient practice had the potential to effect 1 of 3 residents reviewed for accident.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteA. Based on record review and interview, the facility failed to ensure a resident received a complete neurological assessment after an unwitnessed fall for 1of 3 residents reviewed for accidents (Resident 30). B. Based on record review and interview the facility failed to ensure a resident with a history of seizures had follow up assessments and physician notification after having seizure activity for 1 of 2 residents reviewed for quality care with catheter use (Resident 45).
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary treatments and services to promote the healing of a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident 196).
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview and record review, the facility failed to ensure, a resident (Resident 45) with a history of electrolyte imbalance, seizures and urinary tract infections (UTIs) received ordered labs in a timely manner for a urinalysis, reported and reviewed labs in a timely manner for 1 of 2 resident reviewed for catheter use.
- D Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was at risk for nutritional decline received thorough monitoring and interventions to prevent avoidable weight loss for 1 of 2 residents reviewed for nutrition (Resident 30).
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain relief and failed to update his pain management care plan to include leg pain for 1 of 1 residents reviewed for pain management (Resident 8).
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record reviews and interviews the facility failed to properly reconcile and account for medications that were sent home with a resident who discharged from the facility for 1 of 2 residents reviewed for discharge (Resident 44).
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error related to administering a potassium extended release tablet dissolved in water with an indication of do not crush (Resident 16) for 1 of 29 residents observed for medication administration, and failed to hold a hypertensive medication Coreg per manufactures guidelines related to a low blood pressure reading (Resident 15) 1 of 29 residents observed for medication administration
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, (Resident 32) received a pneumococcal vaccination upon her admission and written consent for 1 of 5 residents reviewed for vaccination status.
Fire safety inspections
5 fire safety citations on file: 2 on September 11, 2025, 2 on September 12, 2024, 1 on July 14, 2023.
Every fire safety citation5 citations
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Provide properly protected cooking facilities.
- E Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- E Keep aisles, corridors, and exits free of obstruction in case of emergency.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Indiana | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.19 | 3.69 | 3.86 |
| Registered nurses | 0.43 | 0.67 | 0.69 |
| All nursing staff on weekends | 2.87 | 3.25 | 3.42 |
| Nurse aides | 2.05 | ||
| Licensed practical nurses | 0.71 | ||
| Nursing staff turnover (share who left in a year) | 65.9% | 45.9% | 45.8% |
| Registered nurse turnover | 60.0% | 40.3% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.67 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.32 on weekdays and 2.87 on weekends, 14% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.42 in April to June 2025 to 3.19 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.19 | 0.43 | 3.32 | 2.87 | 0.0% | 0 of 90 | 42 |
| Oct to Dec 2025 | 3.20 | 0.45 | 3.30 | 2.97 | 0.0% | 0 of 92 | 40 |
| Jul to Sep 2025 | 3.26 | 0.58 | 3.39 | 2.93 | 0.0% | 0 of 92 | 41 |
| Apr to Jun 2025 | 3.42 | 0.94 | 3.58 | 3.03 | 0.1% | 0 of 91 | 37 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Indiana, Jan to Mar 2026 | 3.63 | 0.62 | 3.80 | 3.19 | 3.4% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Indiana | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 9.4 | 11.0 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.2 | 0.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.7 | 1.1 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.8 | 3.9 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 8.5 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.4 | 11.9 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.1 | 3.6 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 18.6 | 13.6 | 15.4 |
Owners and operators
Legal business name: HENDRICKS COUNTY HOSPITAL. CMS links this home to Infinity Healthcare Consulting, a group of 70 nursing homes averaging 2.1 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Jones, Donna | Contracted managing employee | Individual | 12/27/2022 | |
| Engels, Erin | Corporate director | Individual | 07/15/2017 | |
| Gentry, Mark | Corporate director | Individual | 01/12/2022 | |
| Starkey, Tyler | Corporate director | Individual | 08/01/2020 | |
| Waite, John | Corporate director | Individual | 08/01/2020 | |
| Whicker, Timothy | Corporate director | Individual | 01/12/2022 | |
| Fenoughty, Deanna | Corporate officer | Individual | 07/10/2023 | |
| The Waters of Lebanon LLC | Operational/managerial control | Organization | 07/15/2017 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 11 problems in this area, most recently on September 11, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 5 problems in this area, most recently on September 11, 2025: "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."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on September 11, 2025: "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."
- When is the care plan meeting, and can family attend it?Inspectors cited 3 problems in this area, most recently on September 11, 2025: "Ensure each resident receives an accurate assessment."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.87 hours per resident per day, below the Indiana average of 3.25.
Other nursing homes nearby
- Signature Healthcare at Parkwood Lebanon, 3 mi · 5 of 5 stars · 21 citations
- Homewood Health Campus Lebanon, 4.5 mi · 2 of 5 stars · 35 citations
- Restoracy of Whitestown, the Whitestown, 5.1 mi · 5 of 5 stars · 8 citations
- Zionsville Meadows Zionsville, 9.5 mi · 5 of 5 stars · 18 citations
- Hoosier Village Indianapolis, 11.5 mi · 4 of 5 stars · 15 citations
- Copper Trace Health & Living Community Westfield, 12.4 mi · 3 of 5 stars · 17 citations
- Brownsburg Meadows Brownsburg, 12.6 mi · 3 of 5 stars · 24 citations
- Retreat at the Stratford, the Carmel, 12.7 mi · 4 of 5 stars · 12 citations
Indiana contacts for a concern about a nursing home
These are the official offices in Indiana. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Indiana Department of Health, Division of Long-Term Care, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Indiana Long-Term Care Ombudsman Program, 800-622-4484. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Indiana Department of Health, Nursing Home Report Cards, where Indiana publishes its own records on licensed homes.
Common questions
- What is Waters of Lebanon, the's Medicare star rating?
- CMS rates Waters of Lebanon, the 1 out of 5 stars overall, with 2 for health inspections, 1 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Waters of Lebanon, the get at its last inspection?
- 9 health deficiencies at the standard inspection on September 11, 2025. The Indiana average is 7.2.
- Has Waters of Lebanon, the been fined?
- CMS lists no fines in the last three years.
- Does Waters of Lebanon, the accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Waters of Lebanon, the?
- CMS lists 8 owners and managers, and links the home to Infinity Healthcare Consulting. Legal business name: HENDRICKS COUNTY HOSPITAL.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.