Westpark A Waters Community
Inspection Findings
F-Tag F0554
F 0554
Allow residents to self-administer drugs if determined clinically appropriate.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview and record review, the facility failed to have the interdisciplinary team determine and document that a resident was capable to safely self-administer medications for 1 of 1 resident randomly observed. (Resident C) Findings include: The clinical record for Resident C was reviewed
on 10/10/25 at 11:00 a.m. The diagnoses included, but were not limited to, gastro-esophageal reflux disease (GERD). A physician's order, dated 7/8/25, indicated Resident C was to receive 500 milligrams of a chewable calcium carbonate tablet three times a day. An observation was conducted of Resident C's room
on 10/10/25 at 11:27 a.m. The resident's room was observed with the door open. A medication cup with a pink tablet was observed on a bedside table. The resident nor staff member was present in the room at that time. An observation was conducted of Resident C's room with the Director of Nursing on 10/10/25 at 11:53 a.m. The resident's door was observed open with a medication cup that contained a pink tablet on a bedside table. The resident nor a staff member was present. The Director of Nursing indicated at that time,
the medication was a chewable calcium carbonate tablet (TUMS). An interview was conducted with the Director of Nursing on 10/10/25 at 1:45 p.m. She indicated Resident C did not have a self-administration of medication assessment that had been conducted. She should not have medications left at bedside. A Medication Self-Administration policy was provided by the Director of Nursing 10/10/25 2:12 p.m. It indicated Purpose: To provide procedures for determining if the resident can safely self-administer and store medications in their room. Policy: 1. Residents who request to self-administer drugs will be assessed at the time of admission or thereafter to determine if the practice is safe, based on the results of the ‘Resident Assessment-Self-administration Tool'. 2. The assessment results will be discussed with the attending physician and an order obtained to self-administer if appropriate.8. Prescription medications stored in the resident's room should be written on the medication record ‘May keep at bedside'. 3.1-11(a)
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/10/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Westpark A Waters Community
1316 N Tibbs Ave Indianapolis, IN 46222
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0755
Federal health inspectors cited WESTPARK A WATERS COMMUNITY in INDIANAPOLIS, IN for a deficiency under regulatory tag F-F0755 during a complaint investigation conducted on 2025-10-10.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of WESTPARK A WATERS COMMUNITY.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-05.
WESTPARK A WATERS COMMUNITY in INDIANAPOLIS, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in INDIANAPOLIS, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTPARK A WATERS COMMUNITY or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.