01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-06-10 | 13 | 2025-06-10 | 3 |
| Cycle 2 | 2024-04-05 | 7 | 2024-04-05 | 5 |
| Cycle 3 | 2023-02-27 | 5 | 2023-02-27 | 10 |
CMS CCN 1553892026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Westpark A Waters Community
1316 N Tibbs Ave · Indianapolis, IN 46222 · Marion County
Certified beds89CMS provider file
Recent citation rows43current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
43 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 6 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-10-10 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2025-12-17 · complaint2025-10-10 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-12-05 · complaint2025-06-10 · HEALTHF0550Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0804Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0847Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-07-142025-06-10 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2025-07-082025-06-10 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2025-07-082025-06-10 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2025-07-082024-04-05 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2024-05-062024-04-05 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2024-05-062024-04-05 · FIREE0029Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop a communication plan.
Correction field: Deficient, Provider has date of correction · 2024-05-062024-04-05 · FIREE0036Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish emergency prep training and testing.
Correction field: Deficient, Provider has date of correction · 2024-05-062024-04-05 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-05-152024-04-05 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-05-152024-04-05 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-05-152024-04-05 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2024-05-1503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- MAJOR HOSPITALOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 08/01/2012
- MCCARROLL, DAVIDIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 08/01/2012
- COUCH, GINAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 06/01/2014
- SPOOR, NICOLEIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 06/01/2014
- HORNER, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 08/01/2012
- WESTPARK A WATERS COMMUNITY LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
- BLISKO, MICHAELIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
- GUBIN, MOISHEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
- LERMAN, TEDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/01/2014
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.27per resident day
RN hours0.62per resident day
Weekend nurse hours2.99per resident day
Staff turnover76.1%CMS reported field
06 / LOCAL RECORDS
Open the Indianapolis ledger →Other published facilities nearby
Allison Pointe Healthcare Center144 beds · CMS overall 2/583 citation rowsAlpha Home - A Waters Community86 beds · CMS overall 1/557 citation rowsAltenheim Health & Living Community87 beds · CMS overall 4/538 citation rowsAmerican Village150 beds · CMS overall 3/573 citation rowsArlington Place Health Campus84 beds · CMS overall 4/536 citation rowsBethany Village100 beds · CMS overall 2/539 citation rowsBrickyard Healthcare - Brookview Care Center136 beds · CMS overall 3/543 citation rowsBrickyard Healthcare - Churchman Care Center115 beds · CMS overall 4/547 citation rows