Indianapolis, IN

Westpark A Waters Community

1-star overall rating with 2-star inspections with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

1316 N Tibbs Ave, Indianapolis, IN

(317) 634-8330

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Infinity Healthcare Consulting

Operator or chain grouping

Approved since

1991-11-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

70 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.56

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.56

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.22

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.35

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.12

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.05

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.52

CMS adjusted RN staffing hours

Adjusted total hours

3.12

CMS adjusted total nurse staffing hours

Case-mix index

1.47

Higher values indicate more complex resident acuity

RN turnover

67%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

66%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,089

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

8.44

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

1.08

Baseline 76.74% · Performance 68.52% · Measure score 1.08 · Achievement 0 · Improvement 1.08

Adjusted total nurse staffing

0.60

Baseline 2.74 hours · Performance 3.08 hours · Measure score 0.60 · Achievement 0 · Improvement 0.60

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 62
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 82
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	80.7%	93.6% 12.9 pts worse	93.4% 12.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 75.9% · Q2 80.6% · Q3 84.2% · Q4 81.0% · 4Q avg 80.7%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	90.6%	95.4% 4.8 pts worse	95.5% 4.9 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 90.6%
Percentage of long-stay residents experiencing one or more falls with major injury	5.0%	3.8% 1.2 pts worse	3.3% 1.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 7.9% · Q4 4.8% · 4Q avg 5.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	39.8%	24.6% 15.2 pts worse	11.4% 28.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 46.2% · Q3 35.3% · Q4 36.1% · 4Q avg 39.8%
Percentage of long-stay residents who lose too much weight	8.2%	5.6% 2.6 pts worse	5.4% 2.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 6.7% · Q3 8.6% · Q4 7.5% · 4Q avg 8.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	19.9%	23.5% 3.6 pts better	19.6% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 20.0% · Q3 27.8% · Q4 14.6% · 4Q avg 19.9%
Percentage of long-stay residents who received an antipsychotic medication	13.1%	14.8% 1.7 pts better	16.7% 3.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q3 22.2% · Q4 16.1% · 4Q avg 13.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	12.4%	13.3% 0.9 pts better	16.3% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 12.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	3.8%	11.7% 7.9 pts better	14.9% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.3% · Q3 2.9% · Q4 5.1% · 4Q avg 3.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.6%	0.4% 0.2 pts worse	1.0% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.2%	1.2% 1 pts worse	1.7% 0.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 4.9% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	24.2%	24.2% About the same	19.8% 4.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 50.0% · Q3 16.7% · Q4 17.5% · 4Q avg 24.2%
Percentage of long-stay residents with pressure ulcers	6.9%	4.1% 2.8 pts worse	5.1% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 9.6% · Q3 5.7% · Q4 5.7% · 4Q avg 6.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	43.8%	81.6% 37.8 pts worse	81.7% 37.9 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 33.3% · Q3 50.0% · Q4 53.7% · 4Q avg 43.8%
Percentage of short-stay residents who newly received an antipsychotic medication	2.7%	1.3% 1.4 pts worse	1.6% 1.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	50.0%	79.0% 29 pts worse	79.7% 29.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-06-10 · Fire 2025-06-10

13 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2024-04-05 · Fire 2024-04-05

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

5 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Cycle 3 Health 2023-02-27 · Fire 2023-02-27

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

10 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-06-10

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-06-10

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-07-08

E · Potential for more than minimal harm 2025-06-10

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-07-08

F · Potential for more than minimal harm 2024-04-05

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-05-06

F · Potential for more than minimal harm 2024-04-05

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2024-05-06

F · Potential for more than minimal harm 2024-04-05

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-05-06

F · Potential for more than minimal harm 2024-04-05

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-05-06

E · Potential for more than minimal harm 2024-04-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-12

F · Potential for more than minimal harm 2023-02-27

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-04-19

F · Potential for more than minimal harm 2023-02-27

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-04-19

F · Potential for more than minimal harm 2023-02-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-04-19

F · Potential for more than minimal harm 2023-02-27

K500 · Services Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2023-04-19

F · Potential for more than minimal harm 2023-02-27

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-04-19

E · Potential for more than minimal harm 2023-02-27

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-04-19

E · Potential for more than minimal harm 2023-02-27

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-04-19

E · Potential for more than minimal harm 2023-02-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-04-19

E · Potential for more than minimal harm 2023-02-27

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-04-19

E · Potential for more than minimal harm 2023-02-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-04-19

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-10-10

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-12-17

D · Potential for more than minimal harm 2025-10-10

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-12-05

E · Potential for more than minimal harm 2025-06-10

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-06-10

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-07-14

E · Potential for more than minimal harm 2025-06-10