Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WATERS OF WAKARUSA SKILLED NURSING FACILITY, THE
WAKARUSA, IN · 133 certified beds · Last Life Safety survey March 14, 2025
CMS Certification Number 155582 · first certified October 1995
Ownership
Operated by INFINITY HEALTHCARE CONSULTING · For profit - Partnership
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IN
35 citations — more than 93% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 10.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2026 to May 2026), and past the point by which nine in ten IN facilities have been surveyed. This facility’s last Life Safety survey was March 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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4 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 35 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 35 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 35 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 6, 2023 | 13 |
| April 3, 2024 | 8 |
| March 14, 2025 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-03-14 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-03-14 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 2 | 2025-03-14 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-03-14 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-04-03 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2025-03-14 |
| E-0031 | Provide emergency officials' contact information. | 2 | 2025-03-14 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-03-14 |
What the citations cover
- Smoke Deficiencies 12
- Emergency Preparedness Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Miscellaneous Deficiencies 4
- Other 7
| Category | Citations |
|---|---|
| Smoke Deficiencies | 12 |
| Emergency Preparedness Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Services Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 14, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (June 6, 2025) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 19, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 6, 2025) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (June 6, 2025) |
April 3, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 15, 2024) |
| E-0031 | Provide emergency officials' contact information. | Deficient, Provider has date of correction (June 15, 2024) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (June 15, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 15, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 15, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 15, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (June 15, 2024) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (June 15, 2024) |
February 6, 2023 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0300 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 17, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 10, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 17, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.