A list of the most recent deficiencies for The Waters of Indianapolis. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-09 | 2023-12-14 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-09 | 2023-12-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-18 | 2023-08-26 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-06-16 | 2023-08-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-06-16 | 2023-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-16 | 2023-07-22 | N |
| Dispose of garbage and refuse properly. | Health | 2023-06-16 | 2023-07-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-16 | 2023-07-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-21 | 2023-05-15 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Meet other general requirements. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-08-02 | 2022-09-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-02 | 2022-09-21 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-08-02 | 2022-09-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-08-02 | 2022-09-21 | N |
| 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. | Fire Safety | 2021-06-22 | 2021-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-22 | 2021-09-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-22 | 2021-09-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-22 | 2021-09-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Meet other general requirements. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Install proper backup exit lighting. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-22 | 2021-08-20 | N |
| 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. | Health | 2021-05-26 | 2021-06-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-26 | 2021-06-21 | N |
| 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. | Health | 2021-05-26 | 2021-06-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-26 | 2021-06-21 | N |
| Dispose of garbage and refuse properly. | Health | 2021-05-26 | 2021-06-21 | N |
