Inspection Reports for
The Waters of Greencastle
1601 Hospital Dr, Greencastle, IN 46135, GREENCASTLE, IN, 46135
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
50% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
64% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00460151 and IN00460938.
Complaint Details
Complaint IN00460151 and Complaint IN00460938 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00460151 and IN00460938 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 64
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 46
Census Payor Type - Other: 16
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 12, 2025
Visit Reason
This document is a paper compliance review related to the Investigation of Complaint IN00458584 completed on May 15, 2025.
Complaint Details
Investigation of Complaint IN00458584 completed on May 15, 2025. The facility was found to be in compliance.
Findings
The Waters of Greencastle was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 1
Date: May 14, 2025
Visit Reason
This visit was conducted to investigate complaints IN00455978, IN00458584, and IN00459380 regarding the facility.
Complaint Details
Complaint IN00458584 was substantiated with federal/state deficiencies cited at F550. Complaints IN00455978 and IN00459380 had no deficiencies related to the allegations.
Findings
The facility failed to honor a resident's preference regarding meal service for 1 of 3 records reviewed. The resident was required to eat meals in the dining room despite his preference to eat in his room, which caused distress.
Deficiencies (1)
483.10(a)(1)(2)(b)(1)(2) Resident Rights/Exercise of Rights: The facility failed to honor a resident's preference to eat meals in his room and required him to eat in the dining room despite his cognitive intactness and awareness of aspiration risk.
Report Facts
Resident census: 66
Licensed capacity: 66
Meal refusals: 17
Meal refusals: 3
Meal refusals: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Etienne | Administrator | Signed the report and involved in corrective action plan |
| Director of Nursing (DON) | Interviewed regarding meal service policy and resident care | |
| Assistant Director of Nursing (ADON) | Accompanied wound care observation and involved in resident meal service |
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
This visit was conducted to investigate Complaints IN00451366 and IN00445615 at the facility.
Complaint Details
Complaint IN00451366 and Complaint IN00445615 were investigated. No deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in Complaints IN00451366 and IN00445615 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 66
Census Payor Type - Medicare: 2
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 14
Inspection Report
Life Safety
Deficiencies: 0
Date: Oct 15, 2024
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted.
Findings
The Waters of Greencastle was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Life Safety
Census: 65
Capacity: 100
Deficiencies: 3
Date: Oct 15, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and the 2012 edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements due to incomplete documentation of preventative maintenance for battery-operated smoke alarms, lack of an approved method to return cooking appliances to their approved locations, and missing sprinkler escutcheon in a soiled utility room. Corrective actions were planned and implemented.
Deficiencies (3)
NFPA 101: Documentation for preventative maintenance of battery-operated smoke alarms in resident rooms was incomplete, lacking records of battery changes.
NFPA 101: The facility failed to provide an approved method to ensure cooking appliances are returned to their approved design location after maintenance or cleaning.
NFPA 101: The ceiling construction in the Memory Springs soiled utility room was not maintained, with a missing escutcheon around a sprinkler head.
Report Facts
Facility capacity: 100
Resident census: 65
Staff affected: 5
Residents affected: 20
Inspection Report
Renewal
Census: 67
Capacity: 67
Deficiencies: 3
Date: Sep 30, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in September 2024.
Findings
The facility was cited for deficiencies related to nutrition and hydration status maintenance, timely addressing pharmacy recommendations, and sanitation issues in food procurement and service. Specific issues included failure to complete reweights after significant weight changes, delayed response to pharmacy recommendations, and inadequate sanitation of drinking glasses and snack serving practices.
Deficiencies (3)
483.25(g)(1)-(3) Nutrition/Hydration Status Maintenance: The facility failed to ensure a reweight was completed for a resident with a significant weight change.
483.45(d)(1)-(6) Drug Regimen is Free from Unnecessary Drugs: The facility failed to ensure a pharmacy recommendation was addressed in a timely manner for a resident.
483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary: The facility failed to ensure adequate sanitation of drinking glasses, pitchers, and kitchen equipment and failed to ensure snacks were served in a sanitary manner.
Report Facts
Census: 67
Total Capacity: 67
Weight loss percentage: 8.98
Weight loss percentage: 9
Weight loss percentage: 9.4
Weight loss percentage: 7.9
Weight loss percentage: 12.3
Pharmacy recommendation dates: 2
Date of plan of correction completion: Oct 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Etienne | Administrator | Signed the report and provided interview statements |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 30, 2024
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey completed on September 30, 2024.
Findings
The Waters of Greencastle was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: May 31, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00434650.
Complaint Details
Complaint IN00434650 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 66
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
Date: Apr 1, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00428694 and IN00420210 at the facility.
Complaint Details
Investigation of Complaints IN00428694 and IN00420210 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00428694 and IN00420210 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 64
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 47
Census Payor Type - Other: 13
Inspection Report
Re-Inspection
Census: 67
Capacity: 100
Deficiencies: 0
Date: Oct 23, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 09/06/23.
Findings
At this PSR survey, The Waters of Greencastle was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered except for three detached equipment storage sheds.
Inspection Report
Life Safety
Census: 62
Capacity: 100
Deficiencies: 6
Date: Sep 6, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements including emergency power system testing, battery-operated smoke alarm maintenance, sprinkler system maintenance, sprinkler escutcheon installation, corridor door latching, and emergency generator weekly testing documentation.
Deficiencies (6)
42 CFR 483.73(e)(2): Facility failed to document weekly generator testing for the weeks of 09/26/22 and 10/24/22.
NFPA 101 and NFPA 72: Battery-operated smoke alarms were tested monthly instead of weekly as per manufacturer instructions, and documentation for 24 of 48 alarms was incomplete for July and August 2023.
NFPA 13: Sprinkler head in resident room 119 was missing an escutcheon, leaving the hole around the sprinkler uncovered.
NFPA 25: Facility failed to maintain automatic sprinkler systems; dry pipe fire sprinkler system flush recommended in 2022 was not performed until scheduled for October 10, 2023.
NFPA 101: Corridor door to resident room 126 did not latch into the frame and double doors to Therapy Room were propped open with wedges, compromising smoke resistance.
NFPA 99 and NFPA 110: Written records of weekly emergency generator inspections were missing for 2 of 52 weeks.
Report Facts
Facility capacity: 100
Census: 62
Deficiencies cited: 6
Battery-operated smoke alarms: 48
Battery-operated smoke alarms missing documentation: 24
Weekly generator testing missing weeks: 2
Inspection Report
Recertification
Census: 63
Deficiencies: 9
Date: Aug 15, 2023
Visit Reason
Recertification and State Licensure Survey including investigation of four complaints.
Complaint Details
This survey included investigation of complaints IN00413552, IN00414142, IN00414261, and IN00414612. No deficiencies related to the allegations were cited.
Findings
The facility was found deficient in multiple areas including resident rights and dignity during blood glucose testing, unsafe water temperatures in resident bathrooms, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans, inadequate ADL care, improper medication labeling and storage, food safety violations including improper hand hygiene and food temperature monitoring, and infection control practices.
Deficiencies (9)
Resident rights were not maintained during blood glucose testing for 3 residents as staff failed to sanitize hands and maintain privacy.
Water temperatures in 8 of 9 shared resident bathrooms exceeded safe limits, reaching up to 130.6°F.
The Minimum Data Set (MDS) assessment for 1 resident was inaccurate regarding urinary catheter status.
Care plans for 3 residents were not revised to reflect current interventions including palm pillows and CPAP usage.
Fingernails of a resident with a contracted hand were not trimmed to prevent skin injury.
Medications were not properly labeled or stored; expired vaccines were found and insulin pens lacked open dates.
Food safety violations included improper handwashing by kitchen staff, unsanitary food handling, and incomplete food temperature monitoring.
Medication administration failed to follow infection control practices including hand hygiene and glove use during eye drop administration and blood glucose testing.
Licensed occupational therapist lacked knowledge to properly enter physician orders into medical records.
Report Facts
Residents receiving pureed diets: 11
Residents receiving regular diets: 52
Water temperature: 130.6
Expired flu vaccine: 6
Insulin pen expiration: 28
Food temperature: 164
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in findings related to blood glucose testing and hand hygiene deficiencies. |
| RN 11 | Registered Nurse | Observed administering medications improperly and interviewed regarding medication handling. |
| Dietary Aide 5 | Dietary Aide | Observed with improper hand hygiene and food handling in kitchen. |
| Cook 19 | Cook | Observed with improper hand hygiene and food thermometer use. |
| DON | Director of Nursing | Provided multiple policy clarifications and education plans. |
| OT | Occupational Therapist | Failed to properly enter physician orders into medical record. |
| Administrator | Facility Administrator | Provided policy documents and interview responses. |
| Dietary Manager | Dietary Manager | Provided education and interview regarding kitchen practices. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
Paper compliance review to the Recertification and State Licensure Survey.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the paper compliance review.
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Date: Jun 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406165.
Complaint Details
Complaint IN00406165 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 69
Census Payor Type - Medicare: 56
Census Payor Type - Medicaid: 1
Census Payor Type - Other: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 24, 2023
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00399519 completed on March 15, 2023.
Complaint Details
Investigation of Complaint IN00399519 completed on March 15, 2023. The facility was found to be in compliance.
Findings
The Waters of Greencastle was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint.
Inspection Report
Complaint Investigation
Census: 66
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
This visit was conducted for the investigation of Complaints IN00396171 and IN00399519. Complaint IN00396171 had no deficiencies cited, while Complaint IN00399519 resulted in federal/state deficiencies related to quality of care.
Complaint Details
Complaint IN00399519 was substantiated with federal/state deficiencies cited. Complaint IN00396171 had no deficiencies related to the allegations.
Findings
The facility failed to ensure a skin assessment and post-fall assessment were completed for one resident (Resident C) who experienced falls in December 2022. Documentation was lacking for post-fall assessments and skin assessments related to a skin tear, and the facility's policy on incidents and falls was reviewed.
Deficiencies (1)
483.25 Quality of care: The facility failed to complete a skin assessment and post-fall assessment for Resident C after falls in December 2022. Documentation of treatment for a skin tear was also missing.
Report Facts
Resident census: 66
Medicare residents: 7
Medicaid residents: 50
Other residents: 9
Fall risk score: 17
BIMS score: 15
Deficiency completion date: Plan of correction completion date April 3, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Etienne | Administrator | Signed the report and interviewed regarding documentation of post-fall assessments |
| Director of Nursing (DON) | Interviewed regarding skin assessment policy and post-fall assessment requirements |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 0
Date: Aug 24, 2022
Visit Reason
This visit was for the investigation of Complaint IN00387937.
Complaint Details
Complaint IN00387937 was unsubstantiated due to lack of evidence.
Findings
The complaint IN00387937 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 42
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Aug 14, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00381281 and IN00382242.
Complaint Details
Complaint IN00381281 was unsubstantiated due to lack of evidence. Complaint IN00382242 was substantiated but no deficiencies related to the allegations were cited.
Findings
Complaint IN00381281 was unsubstantiated due to lack of evidence. Complaint IN00382242 was substantiated but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 59
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 41
Census Payor Type - Other: 10
Inspection Report
Re-Inspection
Census: 57
Capacity: 100
Deficiencies: 2
Date: Aug 11, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/27/22 was performed to verify compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found not in compliance with requirements related to emergency generator maintenance and testing. Specifically, the facility failed to maintain complete written records of monthly generator load testing and weekly inspections, which could affect all occupants.
Deficiencies (2)
NFPA 101 Electrical Systems - The facility failed to maintain a complete written record of monthly generator load testing for 1 of the last 12 months as required by NFPA 110 and NFPA 99 standards.
NFPA 101 Electrical Systems - The facility failed to maintain a written record of weekly generator inspections for 20 of 52 weeks, not meeting NFPA 110 and NFPA 99 requirements.
Report Facts
Facility capacity: 100
Resident census: 57
Weeks without weekly generator inspection documentation: 32
Months without monthly generator load testing: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding missing generator testing documentation | |
| Maintenance Supervisor/designee | Inserviced on generator testing requirements and responsible for weekly and monthly testing | |
| Administrator | Inserviced Maintenance Supervisor and responsible for monitoring compliance |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jun 27, 2022
Visit Reason
The visit was a Life Safety Code Recertification and State Licensure Survey conducted to assess compliance with fire safety and state licensure requirements.
Findings
The Waters of Greencastle was found in compliance with Medicare/Medicaid participation requirements, the Life Safety Code from Fire, and applicable state regulations.
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