Indiana State Department of Health
Division of Long Term Care
 
CONSUMER REPORT
 
WATERS OF INDIANAPOLIS, THE
 
NURSING HOME
SKILLED NURSING FACILITY / NURSING FACILITY DUALLY CERTIFIED
Created on: 07/25/2025
 
Posted to the Web on: 08/06/2025
 
 



Basic Information

FACILITY CONTACT INFORMATION:
Address: 3895 S KEYSTONE AVE
City: INDIANAPOLIS
Telephone: (317) 787-5364
Web Site:  
 
NAME CHANGES:
Most recent name change: N/A
Date of most recent name change: N/A
 
LICENSE INFORMATION:
  License number: 25-000537-1
  License effective date: 05/01/2025
  License expiration date: 04/30/2026
 


Administration and Staff

Administrator: ALICIA HARRIS
  Start date: 09/11/2024
 
Director of Nursing: KAMALKIT KAUR
  Start date: 03/20/2025
 
Medical director: Jayne Croghan
  Start date:   /  /  
 
Wound care specialist:  
  Start date:   /  /  
 
Infection preventionist:  
  Start date:   /  /  
 


Ownership

CURENT OWNERSHIP:
 
Owning corporation: MAJOR HOSPITAL
2451 INTELLPLEX DR
SHELBYVILLE IN 46176
 
Ownership type:  OTHER
 
Officer(s): DANA CALDWELL
            JEFF BEATY
            JOHN COFFIN
            JAN SANDMAN
            SHERRI TANDY
            PAULA GUSTAFSON
            GENE JONES
            RALPH MERCURI
            LINDA WESSIC
            ROB KINDER
            RYAN CLAXTON
            MELANIE STEVENS
            PHILP MATTHEW HAEHL
            ALEXANDER ISAKOVAN
 
PREVIOUS OWNERSHIP CHANGES:
Name of previous owner: THE WATERS OF INDIANAPOLIS
Date of last change of ownership: 05/19/2014
 


Bed Counts and Census

COMPREHENSIVE CARE BEDS:
Number of Medicaid beds (NF):                     0
Number of Medicare beds (SNF):                    0
Number of Medicare/Medicaid beds (SNF/NF):        81
Number of non-certified comprehensive care beds (State Licensed only):     0
Total number of comprehensive care beds:     81
 
RESIDENTIAL CARE BEDS:
 
Total number of residential beds:            0
 
Total number of beds in facility:            81
 
CENSUS:
Facility census:  64
As reported by the facility on: 01/05/2024
 
Number of comprehensive care beds occupied in this facility. 0
As reported by the facility on: 01/05/2024
 
Residential care beds occupied:  0
As reported by the facility on: 01/05/2024
 
Alzheimer Beds:  0
Alzheimer Beds Occupied:  0
As reported by the facility on:   /  /  
 
Ventilator Beds:  0
Ventilator Beds Occupied:  0
As reported by the facility on:   /  /  
 


Sprinklers and Smoke Detectors

This facility is: FULLY SPRINKLERED
 
Number of comprehensive care resident rooms: 39
Number of comprehensive care resident rooms with battery 
                    operated smoke detectors: 39
Number of comprehensive care resident rooms 
             with hard wired and/or wireless smoke detectors: 0
 
Person completing form - DAVE PATTON
Title of the person who completed the sprinkler, smoke detector form submitted to the ISDH. MAINTENANCE DIRECTOR
Date form completed - 06/10/2025
 


Nurse Aide Training

NURSE AIDE TRAINING PROGRAM APPROVALS:
Nurse aide training and competency evaluation program (NATCEP) approved: 03/06/2001
Nurse aide training and competency evaluation program (NATCEP) expires: 04/01/2003
Nurse aide training and competency evaluation program (NATCEP) banned: Yes
Nurse aide training and competency evaluation program (NATCEP) ban expires: 09/02/2026
 
CLINICAL TRAINING SITES:
This facility is a Clinical training site for the following nurse aide training (NAT) classroom sites: 
     PRAYER TIME CHRISTIAN CAREER CENTER
         Approved: 05/18/2001
         Terminated: 02/08/2007
     WATERS OF INDIANAPOLIS, THE
         Approved: N/A
         Terminated: 02/08/2007
     CENTRAL NINE CAREER CENTER
         Approved: N/A
         Terminated: 09/03/2024
     IVY TECH COMMUNITY COLLEGE
         Approved: N/A
         Terminated: 09/03/2024
     PERSEVERANCE HEALTH CARE TRAINING CENTER
         Approved: 02/03/2022
         Terminated: 09/03/2024
     ALL HEARTS TRAINING SERVICES, LLC
         Approved: 06/22/2022
         Terminated: 09/03/2024
     ENCHANTED HEARTS TRAINING INSTITUTE
         Approved: 04/12/2022
         Terminated: 09/03/2024
     INDYS HEALTH CARE TRAINING CENTER LLC
         Approved: 06/27/2022
         Terminated: 09/03/2024
     THE ATATJ INSTITUTE LLC
         Approved: 08/23/2021
         Terminated: 09/03/2024
 


Complaints

NUMBER OF SUBSTANTIATED COMPLAINTS: 
 
  Current year:  0
  Previous year:  0
  2 years previous:  0

 


Facility Report Card



 


 
03/01/2020 Current QTR
12/01/2019 Previous QTR
09/01/2019 Previous QTR
06/01/2019 Previous QTR


Report Card Score
302
302
245
329


Rank of Score
69
70
83
60


Average Score
302
296
295
296


 
*Facility report card scores have not been updated since March 1, 2020 due to changes in the survey process during the ongoing COVID-19 pandemic. 
The facility report card score is calculated four times per calendar year 
for the two most recent nursing home health surveys.  The facility report card score 
also includes all complaint surveys, life safety code surveys, emergency preparedness surveys, 
and any follow-up surveys that occur within the two most recent nursing home health surveys. 
The facility report card score ranges from 500 to 0, with 500 being the best score possible. 
 
View the Scope and Severity grid
 
View the scoring methodology
 



Overview of Survey findings




 
 The Most Recent Set
 2ND Most Recent Set
 3RD Most Recent Set

Immediate Jeopardy
No
No
No


 Substandard Quality of Care 
No
No
No


Administrator Change
No
No
No


Owner Change
No
No
No


Number of Substantiated Complaints With Deficiencies
0
0
0


Deficiency Free Standard Health Survey
No
No
No


 
    The term 'Recent Set' referenced above relates to the referenced annual survey,
    and any other surveys performed between it and the previous annual survey.
 

 


Enforcement Actions

 
Federal Certification Actions Imposed
     Mand. Deny Pay for New Admits-3 Mo.
     Date Imposed: 09/03/2024  Date Ended: 09/16/2024
 
Date terminated from Medicare/Medicaid: N/A
 


Survey History


    The survey report is not posted until the report has been provided to the facility and their plan of correction submitted and approved.
    The survey report therefore will likely not be posted until four to six weeks after the exit date.
        
    In the grid below click on an event ID that is underlined to see the survey report for that event.


 
Event ID
Survey Type
Exit Date

8OOS11
Complaint
03/21/2025


PHX112
Complaint, Follow Up
03/04/2025


PHX111
Complaint
02/07/2025


6ZWD11
Complaint
01/09/2025


9KI611
Complaint
12/16/2024


LY8F12
Complaint, Follow Up
12/16/2024


LY8F11
Complaint
11/14/2024


XFU012
Follow Up, Recertification, State Licensure
09/13/2024


XFU023
Recertification, Follow Up, Life Safety Code
09/09/2024


XFU022
Recertification, Follow Up, Life Safety Code
08/29/2024


XC1M11
Complaint
08/15/2024


XFU021
Recertification, Life Safety Code
07/02/2024


XFU011
Recertification, Complaint, State Licensure
06/03/2024


8NB011
Complaint
04/30/2024


KZTN11
Complaint
01/30/2024


FKVC11
Complaint
01/16/2024


TWOE12
Complaint, Follow Up
01/02/2024


TWOE11
Complaint
11/09/2023


5PQK11
Complaint
09/07/2023


8F7M22
Recertification, Follow Up, Life Safety Code
09/07/2023


8F7M12
Recertification, Follow Up, State Licensure
08/29/2023


7PB211
Complaint
08/21/2023


0NOF11
Complaint
08/11/2023


8F7M21
Recertification, Life Safety Code
07/18/2023


8F7M11
Recertification, Complaint, State Licensure
06/16/2023


CP7I12
Complaint, Follow Up
05/23/2023


CP7I11
Complaint
04/21/2023


CQ8111
Complaint
04/06/2023


JR1111
Complaint
03/01/2023


LKJT11
Complaint
11/22/2022


297O22
Recertification, Follow Up, Life Safety Code
10/27/2022


P5FT11
Complaint
10/19/2022


VF1611
Complaint
10/05/2022


297O12
Recertification, Follow Up, State Licensure
09/27/2022


297O21
Recertification, Life Safety Code
09/01/2022


297O11
Recertification, State Licensure
08/02/2022


 
 


Links and Resources

 
CMS nursing home compare page 
 
    In addition to the information provided on this 
    web site, the Centers for Medicare & Medicaid Services (CMS) has a web site 
    which contains information on every Medicare and Medicaid certified nursing 
    home in the country. The CMS nursing home survey results contain summary information 
    about a facility's noncompliance of regulations regarding the care of residents 
    found in the nursing homes. You can locate nursing homes in your area and find 
    information about compliance with federal regulations.
 
Resources and links to other organizations
 
Choosing a Nursing Home
 
Overview of the Survey Process
 
State Wide Grouping of all Scores
   
Overview of current comprehensive facility scores
   
Spreadsheet of current comprehensive facility names and scores
   
Legal Disclaimer for Long Term Care Reports.