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The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating is scored from 1 to 5 stars and combines results from health inspections, staffing levels, and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 161st out of 267 homes in Indiana.| Staff type | Hours / day | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 22m per day | ▼ 45% State avg: 40m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 1h 9m per day | ▲ 50% State avg: 46m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 17m per day | ■ Avg State avg: 2h 16m per day · National avg: 2h 20m per day |
|
Total Nursing (Weekend)
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 11m per day | ■ Avg State avg: 3h 14m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 1m per day | ▼ 75% State avg: 4m per day · National avg: 4m per day |
|
RN (Weekend)
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 21m per day | ▼ 22% State avg: 27m per day · National avg: 28m per day |
Residents typically stay for brief periods, with frequent admissions and discharges throughout the year.
27% of new residents, usually for short-term rehab.
65% of new residents, often for short stays.
8% of new residents, often for long-term daily care.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #263 / 267Payroll — state benchmarkedThis home is ranked 263rd out of 267 homes in Indiana.Shows total annual staff payroll benchmarked to the Indiana average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Lower than the Indiana average: 68.1%The Waters of Middletown Skilled Nursing Facility is legally operated by Johnson Memorial Hospital, and administrated by Ashley Blackmon.
Key information about the people who lead and staff this community.
In Indiana, the Department of Health, Division of Long Term Care is the primary regulatory body that performs onsite inspections and quality of care reviews for all licensed facilities.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the Indiana state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Deficiencies are formal regulatory issues recorded during state inspections.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total deficiencies
Formal regulatory issues recorded by inspectors across all inspection types.
| 33 | 36 | This facility has 8% fewer total deficiencies than a typical Indiana nursing home (33 vs. IN avg 36).↓ 8% better |
|
Deficiencies per year
Average deficiencies per year since 2022.
| 8.3 | 9 | This facility has 8% fewer deficiencies per year than a typical Indiana nursing home (8.3 vs. IN avg 9).↓ 8% better |
|
Deficiencies per inspection
Average deficiencies per inspection.
| 1.9 | 1.9 | This facility has deficiencies per inspection in line with the Indiana average (1.9 vs. IN avg 1.9).— At avg |
State inspections evaluate whether the facility meets health and safety standards.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total visits
Combined count of all on-site visits — routine inspections, complaint visits, follow-ups, and other focused visits.
| 17 | 19 | This facility has 11% fewer total visits than a typical Indiana nursing home (17 vs. IN avg 19).↓ 11% better |
|
Inspections with deficiencies
Inspections that resulted in at least one regulatory deficiency.
| 7 | 7 | This facility has inspections with deficiencies in line with the Indiana average (7 vs. IN avg 7).— At avg |
|
Inspection deficiency rate
Percentage of inspections that resulted in at least one deficiency.
| 41% | 37% | This facility has 4 percentage points higher inspection deficiency rate than a typical Indiana nursing home (41% vs. IN avg 37%).↑ 4% worse |
|
Inspections
Routine, scheduled inspections conducted by state regulators.
| 7 | 13 | This facility has 46% fewer inspections than a typical Indiana nursing home (7 vs. IN avg 13).↓ 46% better |
Complaints are formal concerns filed by residents, families, or staff. Investigations are on-site follow-ups.
| Metric | This Facility | IN Average | vs. IN Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 4 | 5 | This facility has 20% fewer total complaints than a typical Indiana nursing home (4 vs. IN avg 5).↓ 20% better |
|
Complaints per year
Average complaints per year since 2022.
| 1 | 1.3 | This facility has 23% fewer complaints per year than a typical Indiana nursing home (1 vs. IN avg 1.3).↓ 23% better |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
The most recent inspections on January 8, 2025, found the Waters of Middletown Skilled Nursing Facility in compliance with all applicable federal and state regulations, including Life Safety Code requirements, and corrected previously investigated complaints. Earlier inspections showed a pattern of deficiencies primarily related to Life Safety Code compliance, such as fire safety equipment maintenance and door hardware, as well as resident care issues including dignity, medication administration, infection control, and staffing adequacy. Complaint investigations substantiated deficiencies involving abuse prevention, staffing, and care planning, though several complaints were also found unsubstantiated or corrected. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent clean inspections suggest improvement in addressing prior deficiencies.
Read the full inspection reports for this facility, including detailed findings and corrective actions.
Show Inspection ReportsIndiana average 6
Last Health inspection on Dec 2024
Indiana average 25
Indiana average 4.12
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
14 of 22 citations resulted from standard inspections; 7 of 22 resulted from complaint investigations; and 1 of 22 came from combined inspections (standard and complaint).
100% better than Indiana averageIndiana average: 0.2
0
100% better than Indiana averageIndiana average: 0.6
Issues related to building safety, cleanliness, maintenance, and overall living conditions.
Dec 09, 2024
Corrected
Issues related to preventing and controlling infections, including hygiene practices and safety protocols.
Dec 09, 2024
Corrected
Issues related to food quality, meal service, and resident's nutritional needs.
Dec 09, 2024
Corrected
Issues related to how well residents receive appropriate treatment and support for their medical and daily care needs.
Dec 09, 2024
Corrected
Data sourced from CMS Health Deficiencies reports. Citation severity codes range from A (least serious) to L (most serious). Immediate Jeopardy (J-L) citations indicate situations where the facility's noncompliance has placed residents at risk of death or serious harm.
The Waters of Middletown Skilled Nursing Facility is located in MIDDLETOWN, Indiana.
Here are the financial assistance programs available to residents in Indiana.
0.0 miles from city center
Estimated distance in miles from Middletown's city center to The Waters of Middletown Skilled Nursing Facility's address, calculated via Google Maps.
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This data corresponds to Q2 2025 and is based on CMS Payroll-Based Journal.
3473584% better than Indiana averageIndiana average ratio: 0.00:1
10% worse than Indiana averageIndiana average: 7.7 hours
Manages medical care and health needs.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
10.4 hoursNo contractors work on this role.
Assists with medical care and medications.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.3 hoursNo contractors work on this role.
Helps with daily care and mobility.
Average shift length. Calculated as total hours divided by days worked and average staff per day.
6.9 hoursNo contractors work on this role.
Total hours from contractors
702 contractor hours this quarter
| Certified Nursing Assistant | 21 | 0 | 21 | 4,825 | 91 | 100% | 6.9 |
| Licensed Practical Nurse | 10 | 0 | 10 | 2,009 | 91 | 100% | 9.3 |
| Other Dietary Services Staff | 6 | 0 | 6 | 1,003 | 90 | 99% | 7.1 |
| RN Director of Nursing | 3 | 0 | 3 | 793 | 76 | 84% | 6.6 |
| Nurse Practitioner | 2 | 0 | 2 | 634 | 75 | 82% | 8.2 |
| Medication Aide/Technician | 5 | 0 | 5 | 624 | 63 | 69% | 7.5 |
| Mental Health Service Worker | 1 | 0 | 1 | 508 | 64 | 70% | 7.9 |
| Administrator | 1 | 0 | 1 | 464 | 58 | 64% | 8 |
| Registered Nurse | 4 | 0 | 4 | 455 | 41 | 45% | 10.4 |
| Speech Language Pathologist | 0 | 2 | 2 | 315 | 66 | 73% | 4.8 |
| Physical Therapy Assistant | 0 | 4 | 4 | 214 | 65 | 71% | 3.1 |
| Respiratory Therapy Technician | 0 | 2 | 2 | 123 | 40 | 44% | 3 |
| Qualified Social Worker | 0 | 3 | 3 | 47 | 31 | 34% | 1.5 |
| Physical Therapy Aide | 0 | 2 | 2 | 3 | 2 | 2% | 1.5 |
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
19Residents meet regularly to discuss policies, care quality, and activities
State-approved Nurse Aide Training and Competency Evaluation Program on-site
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
6.6
17% better than Indiana averageIndiana average: 8.0
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
14.9
13% better than Indiana averageIndiana average: 17.1
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
2.0%
83% better than Indiana averageIndiana average: 12.0%
Percent of long-stay residents whose ability to move independently worsened
19.5%
36% worse than Indiana averageIndiana average: 14.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
23.1%
6% better than Indiana averageIndiana average: 24.6%
Percent of long-stay residents experiencing one or more falls with major injury
4.1%
6% worse than Indiana averageIndiana average: 3.9%
Percent of long-stay high risk residents with pressure ulcers
2.2%
50% better than Indiana averageIndiana average: 4.4%
Percent of long-stay residents with a urinary tract infection
0.0%
100% better than Indiana averageIndiana average: 1.2%
Percent of long-stay residents who lose too much weight
5.3%
7% better than Indiana averageIndiana average: 5.7%
Percent of long-stay residents who have depressive symptoms
58.2%
141% worse than Indiana averageIndiana average: 24.1%
Percent of long-stay residents who received an antipsychotic medication
8.2%
34% better than Indiana averageIndiana average: 12.4%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
86.3%
8% worse than Indiana averageIndiana average: 93.7%
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
47.0%
43% worse than Indiana averageIndiana average: 81.7%
Percent of short-stay residents who newly received an antipsychotic medication
2.7%
97% worse than Indiana averageIndiana average: 1.4%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
45.7%
42% worse than Indiana averageIndiana average: 79.0%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
The information below is reported by the Indiana Department of Health, Division of Long Term Care.
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AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Decatur | 167 | 67.1% | -3% | 3.69 | -10% | +7% | 0 | 2 | 2.0 | - | 108 | - | 79 | Adams County Memorial Hospital | $12.8M | $5.6M | 43.8% | 155747 | ||||
| Adams Heritage |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Monroeville | 61 | 60.7% | -13% | 4.12 | +29% | +20% | 0 | 2 | 1.0 | - | 39 | A+ | 40 | Adams County Memorial Hospital | $5.5M | $2.5M | 44.8% | 155729 | ||||
| The Waters of Middletown Skilled Nursing Facility |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Middletown | 60 | 36.7% | -47% | 3.15 | -36% | -8% | 0 | 22 | 4.4 | - | 27 | - | 49 | The Waters Of Middletown Skilled Nursing Facility LLC | $2.9M | $1.4M | 48.3% | 155573 | ||||
| Addison Pointe Health & Rehabilitation Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Chesterton | 100 | 93.0% | +34% | 3.16 | -5% | -8% | 1 | 27 | 4.5 | 1 | 93 | - | 73 | Steven Dobben | $15.3M | $5.3M | 34.6% | 155805 | ||||
| Albany Health Care & Rehabilitation Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
AL Assisted Living A licensed, long-term care setting for seniors or individuals with disabilities who need help with daily activities — like bathing, dressing, and medication management — but not 24-hour skilled nursing. Offers housing, meals, and around-the-clock support while aiming to maximize resident independence. | Albany | 102 | 75.5% | +9% | 3.51 | +4% | +2% | 0 | 19 | 3.2 | 1 | 77 | - | 34 | Melanie Troxwell | $12.4M | $4.3M | 34.7% | 155432 |
Historical financial and operational data for The Waters of Middletown Skilled Nursing Facility based on CMS SNF Cost Reports.
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Melinda Surface is the Director of Nursing at The Waters of Middletown Skilled Nursing Facility.
The legal owner and operator of The Waters of Middletown Skilled Nursing Facility is Johnson Memorial Hospital.
The Waters of Middletown Skilled Nursing Facility has a walk score of 49. Somewhat walkable. A few nearby services may be reachable on foot, but most trips require transportation.
According to IN state health department records, The Waters of Middletown Skilled Nursing Facility's license number is 25-000342-1.
According to IN state health department records, The Waters of Middletown Skilled Nursing Facility's license expires on February 28, 2026.
The Waters of Middletown Skilled Nursing Facility's occupancy is 35%.
Ashley Blackmon is the administrator of The Waters of Middletown Skilled Nursing Facility.
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