Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Waters Of Indianapolis, The during CMS and state inspections, most recent first.
A male resident with moderate cognitive impairment and a history of sexually inappropriate behavior was found leaving the room of a female resident with similar cognitive deficits, who was discovered with her gown and brief disturbed after yelling for help. The female resident indicated inappropriate touching by pointing to her breast, and staff confirmed the male resident was not supposed to be in her room.
A facility failed to provide a complete description to state authorities regarding an allegation of sexual abuse involving a resident found in a compromised state after a male resident was observed leaving her room. Staff observed the resident's brief unfastened and gown pulled up, but the report submitted only briefly described the allegation, omitting key observed details.
Surveyors found that bathroom wall heater covers were removed, leaving exposed heating elements in three rooms, and that two bathroom door frames had rusted away, exposing jagged edges. The Maintenance Supervisor confirmed these conditions should not have been present, and no relevant maintenance policy was provided.
A dietary aide with facial hair was observed handling uncovered food and drinks in the kitchen without wearing a beard net, contrary to facility policy and state sanitation requirements. This lapse in personal hygiene standards had the potential to affect all residents receiving food from the kitchen.
An electrical cord from a floor buffer was left curled and raised in the middle of a hallway used by cognitively impaired, self-mobile residents. A resident with dementia and a history of falls was observed stepping over the cord at the technician's instruction, with no caution signs posted. Staff interviews confirmed the cord should not have been left in the walkway and that a caution sign was needed. The facility lacked a policy for accident prevention.
A deficiency occurred when a resident with severe cognitive impairment and high fall risk was allowed to keep her bed in the highest position, as per her preference, without this being addressed in her comprehensive care plan. Staff confirmed the omission, and facility policy required care plans to be updated for such issues.
A treatment cart containing various topical medications was found unlocked and unattended in a hallway near several residents in wheelchairs. An LPN confirmed the cart should have been locked, and facility policy requires medication carts to be secured or attended by authorized staff.
The facility did not complete the required two-step TB skin test for two residents, both of whom had significant medical conditions. In both cases, the necessary TB screening was either refused or not documented, and the alternative TB screening tool assessment was not completed at the time of admission as required by facility policy. This deficiency was confirmed by interviews with the RNC and DON.
A CNA administered medication to a resident without being authorized or qualified, bypassing the nurse and facility protocols. The resident, who was cognitively intact and had a physician's order for acetaminophen as needed, received two capsules from the CNA after requesting pain relief. The resident noticed the pills were different from his usual medication and reported feeling unwell, leading to an emergency room evaluation. Facility policy and state regulations prohibit CNAs from administering medications.
A resident's antidiabetic medication was misappropriated in a facility, despite being stored in a locked medication room accessible only to staff. The resident, who was cognitively intact and had Type 2 diabetes, had a physician's order for tirzepatide to be administered weekly. The medication box, which should have contained four doses, was found with only one remaining, and later, that dose also went missing. An internal investigation could not determine who took the medication.
A cognitively intact resident was not allowed to sign out for a leave of absence, despite facility policy indicating residents have the right to leave. The DON stated the resident could leave with family or friends but not with her boyfriend or alone. A physician's order restricted the resident from leaving, with no stop date provided.
A resident alleged being hit by a Floor Technician while wheeling down a hall, but the incident was not immediately reported to the administrator, and the initial report to the state survey agency was incomplete. Interviews revealed discrepancies in staff awareness and reporting, with one CNA unaware of the incident and another failing to act on overheard information. The facility's policy requires prompt reporting of suspected abuse, but a policy for state health department reporting was unavailable.
A resident reported being hit by a Floor Technician while in her wheelchair, but the facility failed to immediately remove the alleged perpetrator as required by their abuse policy. The incident was known to the DON and other staff, but no immediate action was taken to ensure the resident's safety or separate the staff member from residents.
The facility failed to store medications according to professional principles, as observed during medication pass observations. A QMA used a pill packet with a torn-off label, and an LPN did not date a newly opened bottle of eye drops. The DON confirmed these actions were against facility policy, and no policy was available for dating opened medications.
An LPN failed to maintain infection control by not performing hand hygiene before and after administering Zaditor eye drops to a resident. The LPN donned gloves without washing hands, administered the drops, and left the room without washing hands, contrary to the facility's policy.
A resident with a history of cerebral infarction and cognitive deficits was verbally abused by a CNA during a smoke break. The CNA, upset about the assignment, screamed and yelled at the resident, continuing the abuse inside the building. Despite the resident's request to stop, the CNA taunted and called her a snitch. The facility's policy defines such behavior as verbal abuse.
A facility failed to complete a self-medication administration assessment for a resident with medications left at their bedside. The resident, diagnosed with chronic obstructive pulmonary disease, alcohol dependence, and anxiety, was found with a cup of medications unattended. Interviews confirmed that medications should not be left in resident rooms, and the facility's policy required staff to ensure medication is swallowed.
A facility failed to perform required smoking assessments for a resident with multiple health conditions and moderate cognitive impairment. The resident, identified as a supervised smoker, had not been assessed since 9/19/22, despite the facility's policy requiring quarterly and annual assessments. The DON confirmed the oversight, which was contrary to the facility's Smoking Policy.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
A male resident with a history of Alzheimer's disease, hemiplegia, and moderate cognitive impairment was observed leaving the room of a female resident who was also moderately cognitively impaired and had diagnoses including hemiplegia, aphasia, and dementia. The female resident was found by staff with her gown pulled up and her brief unfastened on one side shortly after she was heard yelling. The male resident indicated he had gotten lost when questioned by staff. Upon assessment, the female resident was unable to verbally describe the incident but pointed to her breast, indicating inappropriate touching. This was the first reported incident of abuse involving the male resident. Staff interviews and record reviews confirmed that the male resident had previously exhibited sexually inappropriate behaviors and had a care plan addressing these behaviors. Despite this, he was able to enter the female resident's room and allegedly touch her inappropriately. The incident was documented as a reportable event, and the facility's policy on abuse prevention was reviewed as part of the investigation.
Failure to Fully Report Sexual Abuse Allegation to State Authorities
Penalty
Summary
The facility failed to ensure a full description of an allegation of sexual abuse was reported to the state health department for one of three residents reviewed for abuse. The incident involved a male resident observed leaving a female resident's room, after which the female resident was found lying in bed with her sheet pulled down, her brief unlatched on one side and bent down in the front, and her gown pulled up. Staff interviews and written statements indicated that the female resident was yelling, and when staff entered her room, they found her in a compromised state. The male resident was seen leaving her room and stated he had gotten lost. The CNA immediately notified the RN, who observed the same condition of the resident and questioned her about the incident. The resident was unable to verbalize details but pointed to her breast, indicating where she had been touched. The facility's reportable incident documentation only briefly described the allegation, stating that the female resident alleged the male resident touched her breast. However, the full circumstances observed by staff, including the resident's physical state and the sequence of events, were not fully detailed in the report to the state health department. The facility's policy required that all allegations of abuse be reported, but the report submitted lacked a comprehensive description of the incident as observed and documented by staff.
Failure to Maintain Safe and Comfortable Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe and comfortable environment for residents, staff, and the public by leaving bathroom wall heater covers removed in three rooms within the secured memory care unit. The exposed metal heating elements, located approximately six inches from the floor, were visible in the bathrooms of rooms H-8, H-10, and H-11. The Maintenance Supervisor confirmed during an interview that the heaters were still operational and acknowledged that the heating elements should not have been left exposed to residents. Additionally, the facility failed to ensure that bathroom door frames were free from rust and decay in two rooms. The bathroom door frames in rooms H-10 and H-11 were found to have rusted areas, with the metal frames rusted away from the floor up by two to three inches, leaving jagged, rusted edges exposed. The Maintenance Supervisor confirmed that the door frames should not have been left in this condition. The facility was unable to provide a policy regarding the maintenance of bathroom wall heaters or the rusted door frames at the time of the survey.
Dietary Staff Failed to Wear Beard Net While Handling Food and Drinks
Penalty
Summary
During a kitchen observation, a dietary aide was seen working near uncovered prepared foods on the steam table and handling drinks for residents without wearing a beard net, despite having facial hair approximately one fourth inch in length on his chin. The aide was observed scooping ice and pouring drinks to be served to residents, with his facial hair uncovered in the food preparation area. Interviews with the Dietary Manager and Assistant Director of Nursing confirmed that facility policy and professional standards require all staff to wear hair restraints, including beard nets, when in the kitchen or around food and drinks. A review of the facility's Food Safety & Sanitation policy and Indiana Food Establishment Sanitation Requirements further supported the need for proper hair restraints to prevent hair from contacting exposed food. This failure had the potential to affect all residents receiving food from the kitchen.
Electrical Cord Left in Walkway Creates Accident Hazard for Cognitively Impaired Residents
Penalty
Summary
A deficiency was identified when an electrical cord from a floor buffer machine was observed lying in the middle of a walkway in the Memory Care Unit, used by residents, including those who are cognitively impaired and self-mobile. The cord, approximately 20 feet long and one inch in circumference, was curled and raised above the floor by eight to ten inches at multiple points, creating a tripping hazard. No caution signs were posted in the area during the floor technician's use of the buffer. The technician instructed a resident to step over the cord without moving it or ensuring the area was safe. The technician also stated that he did not believe a caution sign was necessary since the floor was not wet, but acknowledged the cord should be kept near the wall due to the high number of ambulatory residents in the unit. A resident with a diagnosis of dementia, who was moderately cognitively impaired and at risk for falls, was observed stepping over the cord as instructed by the technician. The resident's care plan indicated a risk of falls related to weakness and medications. Interviews with staff confirmed that the cord should not have been left in the middle of the hallway and that a caution sign should have been posted. Additionally, the facility did not have a policy for the prevention of accidents or potential hazards, as confirmed by the Regional Director of Operations.
Failure to Address Resident's Bed Height Preference in Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop a person-centered comprehensive care plan that addressed all of a resident's needs, specifically the resident's preference to keep the bed in a high position despite being at high risk for falls. Observations showed the resident resting in bed with the bed in the highest position on multiple occasions, with the bed control device within reach and no staff present. The resident, who had diagnoses including vascular dementia and right-sided hemiplegia/hemiparesis following a stroke, was assessed as severely cognitively impaired and at high risk for falls. The care plan in place addressed fall risk related to right-sided deficits but did not address the resident's expressed preference for bed height. Interviews with staff confirmed that the resident had been educated about the safety concerns of keeping the bed elevated but continued to adjust it to the highest position. The Assistant Director of Nursing acknowledged that the clinical record lacked a care plan addressing this specific preference. Facility policy required comprehensive care plans to be reviewed and updated based on changes in the resident's condition or newly developed issues, but this was not done in this case.
Unattended and Unlocked Treatment Cart with Medications
Penalty
Summary
A treatment cart located in the Faith Hall was observed to be unlocked and easily accessible, with no staff present in the area. Several residents in wheelchairs were seated approximately four feet from the unattended cart. The cart contained multiple tubes of medications, including antifungal cream, fludocinonide cream, and gentamicin cream, all labeled with instructions to keep out of reach. During an interview, an LPN confirmed that the cart should have been locked. The facility's current policy requires that medication carts be locked or attended by authorized personnel, which was not followed in this instance.
Failure to Complete Required TB Screening for Two Residents
Penalty
Summary
The facility failed to implement proper infection control practices related to tuberculosis (TB) screening for two residents. One resident, with diagnoses including paraplegia, bipolar disorder, and chronic osteomyelitis, was admitted and had orders for a two-step TB skin test. The first step was refused by the resident, and the second step was not documented as administered. Although a TB screening tool assessment was eventually completed several months after admission, neither the first nor second step of the TB skin test was performed at the appropriate time. Interviews with the Regional Nurse Consultant (RNC) and Director of Nursing (DON) confirmed that the resident had refused all vaccines and TB skin tests, and that the TB screening tool assessment should have been completed at admission or at the time of refusal. Another resident, with diagnoses including congestive heart failure, right above-knee amputation, and kidney failure, was also admitted without documentation of either step of the two-step TB skin test. A TB screening tool assessment was completed many months after admission. The RNC and DON confirmed that this resident had not received the required TB tests upon admission, as required by facility policy. Review of the facility's TB testing policy indicated that all residents admitted from the community should have completed TB screening using the two-step method upon admission.
Unqualified Staff Administered Medication to Resident
Penalty
Summary
A certified nursing assistant (CNA) administered medication to a resident without being qualified or authorized to do so, in violation of facility policy and state regulations. The incident occurred when the resident requested pain medication for a headache, and the CNA, instead of notifying a nurse, retrieved two capsules from behind the nurses' station and gave them directly to the resident. The resident, who was cognitively intact and had a physician's order for acetaminophen as needed, noticed the pills did not resemble his usual Tylenol and subsequently reported feeling unwell. He informed the nurse, who then contacted the physician and sent the resident to the emergency room for evaluation. Toxicology results confirmed the medication given was acetaminophen. The facility's investigation included statements from the CNA, who admitted to giving the pills to avoid making the resident wait for a nurse, and from the RN on duty, who was unaware of the resident's pain or the medication administration. The CNA's job description and the Indiana State Department of Health Nurse Aide Curriculum both explicitly prohibit CNAs from administering medications. The resident's clinical record indicated ongoing pain issues, and the care plan required medication administration by qualified personnel, which was not followed in this instance.
Misappropriation of Resident's Medication
Penalty
Summary
The facility failed to protect a resident's rights to be free from misappropriation of property, specifically medications. Resident C, who was cognitively intact and diagnosed with Type 2 diabetes mellitus, had a physician's order for tirzepatide, an antidiabetic medication, to be administered weekly. However, it was discovered that the medication was missing from the medication room. The medication box, which should have contained four pre-filled syringes, was found to have only one remaining, and subsequently, even that dose went missing. The medications were stored in a locked medication room accessible only to staff members, but an internal investigation could not determine who took the syringes. The issue was reported by an LPN to the former DON when it was noticed that Resident C's medication was missing. The facility's abuse policy, which includes protection against misappropriation of resident property, was in place at the time of the incident. Despite the locked storage, the facility failed to ensure the security of Resident C's medication, leading to the misappropriation of the resident's property.
Violation of Resident's Right to Leave Facility
Penalty
Summary
The facility failed to uphold the resident rights of a cognitively intact individual, identified as Resident C, by not allowing her to sign out for a leave of absence. During an interview, Resident C reported that staff had informed her she could not leave the facility. The Director of Nursing (DON) confirmed that while Resident C was permitted to leave with family or friends, she was not allowed to leave with her boyfriend or on her own, despite being cognitively intact. The clinical record review showed that Resident C had diagnoses including alcohol abuse, psychoactive substance abuse, and bipolar disorder, and an Admission Minimum Data Set (MDS) assessment confirmed her cognitive intactness. A physician's order, dated 12/24/24, restricted Resident C from going out on a leave of absence, with no stop date provided. The facility's policy, titled 'Your Rights and Protections as a Nursing Home Resident,' indicated that residents have the right to leave the facility, which was not honored in this case.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident, identified as Resident B, who was wheeling down the hall and attempted to pass a Floor Technician who was buffing the floor. During this interaction, the Floor Technician allegedly hit Resident B's right shoulder with his left arm. Resident B expressed her intention to report the incident, although she did not believe the Floor Technician intended to hit her. The incident was not immediately reported to the administrator, and the initial report to the state survey agency did not include all known information about the allegation. Interviews revealed discrepancies in staff awareness and reporting of the incident. CNA 1 was unaware of the incident, while CNA 2 overheard Resident B's intention to report being hit but did not act on this information. The Director of Nursing (DON) was uncertain about the completeness of the initial incident report, which required corporate approval before submission. The facility's policy mandates prompt reporting of any suspected abuse, but the facility was unable to provide a policy regarding reporting to the state health department.
Failure to Follow Abuse Policy and Remove Alleged Perpetrator
Penalty
Summary
The facility failed to adhere to its abuse policy by not immediately removing an alleged perpetrator of abuse from the premises. The incident involved a resident, Resident B, who reported that a Floor Technician hit her on the shoulder while she was attempting to pass him in her wheelchair as he was buffing the floor. The resident did not believe the Floor Technician intended to hit her, but she expressed her intention to report the incident. The Floor Technician admitted to touching the resident's hand while pulling the power cord out of the wall. Despite the resident's report, the Floor Technician was not immediately removed from the facility, as required by the facility's abuse prevention policy. The Director of Nursing (DON) and other staff members, including CNA 1 and CNA 2, were aware of the resident's allegation. However, there was a lack of immediate action to ensure the resident's safety and to separate the alleged perpetrator from the resident. CNA 2 overheard the resident's intention to report the incident but did not take any action to verify or report the situation. The facility's policy mandates that staff suspected of abuse should be immediately barred from resident contact and suspended from duty, which was not followed in this case.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in accordance with accepted professional principles during a medication pass observation. A Qualified Medication Aide (QMA) was observed pulling a pill packet from the medication cart that had its label torn off, leaving no information about the resident, medication name, strength, or instructions. The QMA acknowledged that the medication packet with the removed label should not have been left in the cart as it was unclear who the medication was for or what it was. The Director of Nursing (DON) confirmed that such medication packets should be removed from the cart, and the facility's policy indicated that medication containers with damaged labels should be returned to the pharmacy. Additionally, during another medication pass observation, an LPN opened a new bottle of Zaditor eye drops for a resident but failed to date the bottle upon opening. The DON indicated that the bottle should have been dated when opened. The facility was unable to provide a policy regarding the dating of opened medications. These observations were part of a complaint investigation related to Complaint IN00451215.
Infection Control Breach During Eye Drop Administration
Penalty
Summary
The facility failed to maintain proper infection control during the administration of eye drops for one of the residents reviewed for medication administration. During a medication pass observation, an LPN administered Zaditor eye drops to a resident without performing hand hygiene before donning gloves. The LPN explained the procedure to the resident, donned gloves without washing hands, and administered the eye drops to both eyes. After the procedure, the LPN removed the gloves and left the room without performing hand hygiene. The Director of Nursing confirmed that the nurse should have washed her hands before putting on gloves, as per the facility's policy on eye drop administration, which requires handwashing before and after the procedure.
Verbal Abuse by CNA Towards Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse by a Certified Nursing Assistant (CNA). The incident involved Resident B, who has a medical history including cerebral infarction, encephalopathy, and cognitive communication deficit. On the evening of October 17, 2024, CNA 3 was observed by a witness to be verbally abusive towards Resident B during a smoke break. The CNA was upset about having to take residents out for their smoke break, which was not part of their assignment. The witness reported that CNA 3 screamed and yelled at Resident B both inside the building and during the smoke break, continuing the abusive behavior upon returning inside. The witness further described that CNA 3 stood on a chair at the nurses' station, screaming at Resident B when the resident inquired about the delay in their scheduled smoke break. Despite Resident B's request for CNA 3 to stop, the CNA continued to taunt and verbally abuse the resident, calling her a snitch. The facility's Administrator confirmed that CNA 3's behavior was not in line with the facility's policies on abuse prevention, which define verbal abuse as the use of disparaging and derogatory language towards residents. The incident was reported, and CNA 3 was suspended and subsequently terminated following the investigation.
Failure to Complete Self-Medication Assessment
Penalty
Summary
The facility failed to ensure a self-medication administration assessment was completed for a resident, identified as Resident 125, who had medications left at their bedside. During a tour, it was observed that Resident 125, who was in a wheelchair, had a clear plastic cup containing six tablets, one capsule, and one gelcap on their bedside table, with no staff present in the room or hallway. A review of Resident 125's clinical record revealed diagnoses including chronic obstructive pulmonary disease, alcohol dependence, and anxiety, but lacked a Self-Medication Administration Assessment. Interviews with RN 2 and the Director of Nursing confirmed that medications should not be left unattended in resident rooms, and the facility's policy required staff to remain with residents to ensure medication is swallowed. The Director of Nursing provided a policy titled Medication Administration, dated October 2021, which was stated to be currently followed by the facility.
Failure to Conduct Required Smoking Assessments
Penalty
Summary
The facility failed to perform safe smoking assessments per its policy for a resident with multiple health conditions, including multiple sclerosis, muscle wasting, flaccid hemiplegia, and unsteadiness on feet. The resident, who had moderate cognitive impairment, was identified as a supervised smoker requiring supervision during smoking activities. The most recent Smoking Risk Assessment in the resident's clinical record was dated over a year and a half ago, on 9/19/22, and indicated the resident required a protective apron during smoking breaks and had moderate problems with general awareness, orientation, and injury potential related to smoking materials. During an interview, the Director of Nursing (DON) acknowledged that the resident should have had smoking assessments conducted both quarterly and annually, as per the facility's policy. The facility's Smoking Policy, provided by the DON, stated that residents should be assessed for safe smoking behavior prior to smoking at the facility and further assessed quarterly, annually, after an unsafe smoking episode, and after a change of condition. The failure to conduct these assessments as required by the policy led to the deficiency identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Altenheim Health & Living Community | 0.8 mi | ★★★★★ | 2 | 0 |
| Bethany Village | 1.1 mi | ★★★★★ | 18 | 0 |
| Beech Grove Meadows | 1.3 mi | ★★★★★ | 12 | 0 |
| Fairway Village | 1.3 mi | ★★★★★ | 8 | 0 |
| Brickyard Healthcare - Churchman Care Center | 1.5 mi | ★★★★★ | 9 | 0 |
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