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Deficiency Records for The Waters of Indianapolis
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.
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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Develop a communication plan. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Meet other general requirements. | Fire Safety | 2024-07-02 | 2024-08-29 | 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 | 2024-07-02 | 2024-08-29 | 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 | 2024-07-02 | 2024-08-29 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-07-02 | 2024-08-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-06-03 | 2024-07-05 | N |
| Have policies on smoking. | Health | 2024-06-03 | 2024-07-05 | N |
| 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 |
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