Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rosewalk Village during CMS and state inspections, most recent first.
A resident with stroke and left-sided hemiplegia had care plans requiring assistance with elimination, toileting every shift, and documentation of urine and bowel outputs every shift. Review of output reports showed multiple shifts and days with no recorded urine outputs across February and March, and the DON confirmed staff should have been monitoring and recording outputs every shift.
Failure to Hold Interdisciplinary Care Plan Meetings After MDS Assessments: The facility did not timely hold interdisciplinary care plan meetings for three residents after MDS assessments were completed. Two residents receiving hospice services had incomplete care plan documentation, and one resident with depression and diabetes stated he had not attended a care plan meeting. The SSD confirmed that no interdisciplinary care plan meetings had been held for these residents.
Failure to provide vision services for a resident with impaired vision and moderate cognitive impairment. The care plan indicated eyeglasses were worn and eye doctor visits were to be arranged as needed, and the resident had consented to eye care. However, the resident reported waiting years for new eyeglasses and had never been seen by an eye doctor since admission; the SSD confirmed no eye doctor visit had occurred and did not know why.
A resident with anxiety, depression, and encephalopathy had multiple behavior-related episodes, including refusal of meds and weights, tearfulness, verbal aggression, profanity, yelling, and combative behavior when restricted from certain areas. The record showed some behaviors and helpful interventions, such as preferred caregivers and diversional activities, were not included on the care plan, and the SSD confirmed the verbally aggressive behaviors were not care planned before the cited revision.
Failure to assist with dental services for two residents. One resident with DM, HTN, and dentures wanted dental care for loose dentures, but the outside dentist would not see her because of an unpaid bill and she had not been seen since readmission. Another resident with ESRD had incomplete documentation for dental follow-up after prior authorization for new dentures and missed emergency dental appointments, with no record of the reason for the visits or the status of the dentures.
A resident with severe dementia and a known risk for elopement exited the facility unsupervised while wearing a wanderguard device that failed to trigger an alarm. The resident was found in the community with multiple injuries and required hospital treatment. Staff did not document when the resident was discovered missing, and interviews indicated that no alarm was heard at the time of the incident. The exit door involved was found to have incomplete wanderguard coverage due to only one antenna being installed.
The facility failed to dispose of expired food items in a timely manner, affecting all 98 residents receiving food from the kitchen. Expired items were found in both dry storage and the walk-in refrigerator, and pies were improperly stored uncovered. The Dietary Manager acknowledged the oversight, which violated the facility's food storage policy.
The facility failed to maintain infection control by not ensuring hand hygiene before donning gloves during medication administration for several residents and not using PPE for a resident requiring enhanced barrier precautions. An LPN did not perform hand hygiene before a blood glucose check, another LPN failed to do so before administering medications, and a Unit Manager handled medication with bare hands. Additionally, CNAs did not use gowns and gloves for a resident with a dialysis port, despite care plan requirements.
A resident with diabetes was nearly administered insulin lispro despite a blood sugar reading below the physician's prescribed threshold. An LPN was observed preparing to give 12 units of insulin lispro when the resident's blood sugar was 122 mg/dL, contrary to the order to hold insulin if below 150 mg/dL. The LPN acknowledged the error, highlighting a significant medication administration oversight.
A resident with multiple health conditions, including hemiplegia, was found to have her call light out of reach, despite needing it for assistance. Observations confirmed the call light was inaccessible, and the DON acknowledged the lack of a specific policy on call light accessibility, relying instead on general standards of care.
The facility failed to ensure that arbitration agreements were properly explained and signed by the appropriate representatives for two residents with cognitive impairments. One resident signed without a legal representative despite being incapacitated, and another signed without the physical presence of her POA, who only gave verbal consent.
The facility failed to respect the dignity and rights of three residents during interactions with an LPN. A resident with heart disease reported rude behavior and gestures from the LPN, while another with heart failure described the LPN as pushy and demanding. A third resident with quadriplegia recounted an argument involving inappropriate language. The facility's policy on resident rights was not upheld.
A resident with multiple health conditions did not receive adequate assistance with ADLs, including regular hair shampooing and mobilization to a wheelchair. Despite being scheduled for showers, the resident reported not having received a full bed bath or hair wash in over a week, and her wheelchair was missing for several days. Staff interviews revealed inconsistencies in care, and the facility lacked a specific ADL policy, relying on general standards of care.
A resident with contractures did not receive the recommended splint application as advised by therapy staff. Despite being aware of the need for a splint, the resident reported that staff never applied it. Observations confirmed the absence of the splint, and the clinical record lacked orders or care plans for splint application, indicating a failure in care coordination.
The facility did not update the daily nurse staffing information, affecting all 98 residents. Observations showed outdated postings, and interviews revealed that the night shift nurse forgot to update the information. The facility's policy requires daily updates, but oversight occurred, especially on weekends.
Failure to Document Elimination Outputs per Care Plan
Penalty
Summary
The facility failed to ensure staff implemented Resident 3’s care plan by monitoring and documenting urine and bowel outputs every shift. Resident 3’s clinical record showed diagnoses including stroke with left side hemiplegia. An a.m. and p.m. assistance and monitoring of ADL care plan, dated 11/9/25, identified that the resident required assistance with elimination and included an intervention for staff to document urine and bowel outputs every shift. A toileting program care plan, dated 11/14/25, directed staff to toilet Resident 3 every shift, before and after meal service, upon rising, and during nightly checks. Review of the resident’s February 2026 and March 2026 output reports showed multiple days and shifts with no recorded urine outputs, including repeated gaps across day, evening, and night shifts. During interview, the DON stated staff should have been monitoring and recording the resident’s urine and bowel outputs every shift.
Failure to Hold Interdisciplinary Care Plan Meetings After MDS Assessments
Penalty
Summary
The facility failed to timely conduct interdisciplinary care plan meetings after comprehensive assessments for 3 residents. Resident 4 had diagnoses including diabetes and dementia, a quarterly MDS completed on 2/4/26 that indicated severely impaired cognition and hospice services, and a Care Plan Summary observation note dated 2/4/26 that was not completed. The clinical record did not contain information that an interdisciplinary care plan meeting had been held after that quarterly MDS assessment. Resident 9 had diagnoses including stroke and diabetes, a Significant Change of Status MDS completed on 2/18/26 that indicated severely impaired cognition and hospice services, and a Care Plan Summary observation note dated 2/11/26 stating to schedule care plan with hospice and family, but the remainder of the note was not completed. Resident 6 had diagnoses including depression and diabetes, a quarterly MDS completed on 1/20/26 that indicated he was cognitively intact, and a Care Plan Summary observation note dated 1/19/26 indicating a quarterly care plan was scheduled. During interview, Resident 6 stated he had not attended a care plan meeting, and the Social Service Director stated there had not been interdisciplinary care plan meetings held for Residents 4, 9, and 6.
Failure to Provide Vision Services
Penalty
Summary
The facility failed to ensure a resident received vision services for 1 of 1 residents reviewed for vision services. Resident 50 had diagnoses including stroke and was assessed on the quarterly Minimum Data Set as moderately cognitively impaired. The resident’s care plan, dated 10/4/23, indicated her vision was impaired, she wore eyeglasses, and staff were to arrange eye doctor visits as needed. An ancillary consent dated 10/6/23 indicated the resident wanted eye care. During interview, the resident stated she was supposed to receive a new set of eyeglasses, had been waiting for 3 years, and had never received them, and she had not been seen by an eye doctor since admission. The Social Services Director also stated the resident had not been seen by an eye doctor since admission and was unsure why.
Failure to Care Plan Behavioral Health Needs and Aggressive Behaviors
Penalty
Summary
The facility failed to care plan Resident 49’s behavioral health needs and behavior interventions. Resident 49 had diagnoses including anxiety, depression, and encephalopathy, and the annual MDS dated 12/9/2025 indicated the resident was cognitively intact and did not exhibit behaviors, hallucinations, delusions, or refusals of care. However, the clinical record showed multiple behavior-related events and care plan entries, including refusal of medications and weights, tearfulness, combative and aggressive behavior when restricted from certain areas, and a history of verbal or physical aggression when the resident could not have what she wanted immediately. The record also documented behavior episodes that were not reflected on the refusal care plan, including an 8/9/2025 incident of arguing with staff about showering independently, an 8/12/2025 verbal episode involving name-calling and cursing, a 10/1/2025 episode of extreme profanity, and a 10/30/2025 episode of yelling at the nurses’ station. During interview, the Social Services Director stated the resident had a history of verbal aggression, fixation on things or people, and helpful interventions such as preferred caregivers and diversional activities like getting her nails done, but confirmed these interventions were not on the care plan and the verbally aggressive behaviors were not care planned prior to 3/4/2026. The facility policy stated care plans should be initiated for problematic behavioral expressions and include individualized non-pharmacological interventions.
Failure to Assist With Dental Services
Penalty
Summary
The facility failed to provide assistance with scheduling and tracking dental services for two residents. One resident, who had diagnoses including diabetes and hypertension, was cognitively intact, edentulous, and wore upper and lower dentures. Her record showed she consented to dental services and later wanted to be seen because her dentures were loose after weight loss, but she had not seen the dentist about the loose dentures. The record also showed the dental provider contacted the facility about an outstanding bill from 2024, and the provider would not see the resident until the bill was paid in full. The Social Service Director stated the resident had not seen the dentist since readmission in October 2024. The second resident, who had end stage renal disease and was cognitively intact, had a dental visit in March 2025 for x-rays related to prior authorization for a new partial and new dentures. The record also showed emergency dental appointments in June and July 2025, but there was no documentation of the reason for those appointments or whether the resident made them. The resident stated her dentures did not fit correctly and her bite was off, and she had not been seen by a dentist in a while. The Social Service Director stated there was no documentation of the status of the new dentures or follow-up after the missed July appointment.
Failure to Prevent Elopement and Ensure Resident Safety
Penalty
Summary
A resident with diagnoses of vascular dementia and Alzheimer's dementia, who was identified as being at risk for elopement, exited the facility unsupervised while wearing a wanderguard device. The resident was able to leave through the G-hall exit door without staff knowledge, and the wanderguard alarm did not sound as expected. The resident was later found by a member of the community approximately 0.6 miles from the facility, having sustained multiple injuries including a laceration and hematoma to the forehead, periorbital edema, abrasions to the left knee and shoulder, and skin tears to the left hand. The resident was transported to the hospital for treatment of these injuries. Review of the resident's clinical record showed that the care plan included interventions for elopement risk, such as securing facility exits and using a wanderguard device, with orders to check the device for placement and function. Despite these interventions, there was no documentation in the electronic health record indicating when staff noticed the resident was missing, when a code silver was called, or when the search for the resident began. Additionally, there were no nursing progress notes documented from the time of the last elopement assessment until after the resident returned from the hospital, and no indication that the resident had any of the documented injuries prior to the elopement. Interviews with staff revealed that no one heard the wanderguard alarm sound at the time of the elopement, and the facility later discovered that the G-hall exit door had only one antenna, providing incomplete coverage for the double doors. The door company confirmed that the system was not providing full coverage and required an additional antenna for proper operation. The facility's policy required staff to know the location of residents under their care and to take appropriate action if a resident was missing, but these procedures were not effectively implemented in this incident.
Removal Plan
- Completed elopement risk assessments on all residents
- Conducted elopement drills with staff
- Educated all staff on the elopement procedure and high-risk behaviors
- Installed a second antenna on the G-hall double door exit
- Ensured proper operation of the elopement prevention system
- Increased the range of the elopement prevention system
- Changed door codes to prevent unauthorized exits
Expired Food Items Found in Facility's Kitchen
Penalty
Summary
The facility failed to ensure that expired food items were disposed of in a timely manner, which had the potential to affect all 98 residents receiving food from the kitchen. During an inspection of the dry storage area, several expired food items were found, including graham cracker crumbs, sugar-free Jell-O, pork-flavored gravy mix, cream soup base, brownie mix, cake mix, streusel topping, chocolate chips, assorted Jell-O, vanilla pudding, corn starch, peanut butter, rainbow sprinkles, oatmeal, and thickener. These items were identified as expired by the Culinary Aide, who explained the labeling system for delivery and expiration dates. In addition to the dry storage issues, the walk-in refrigerator contained expired items such as pre-made peanut butter and jelly sandwiches, green peppers, shredded lettuce, lettuce, shredded cheese, and English cucumbers. Furthermore, pies stored in the refrigerator were not covered, contrary to the facility's food storage policy. The Dietary Manager acknowledged that expired items should have been removed and disposed of properly and that the pies should have been covered. The facility's food storage policy, which was revised, mandates that food should be covered, labeled, and dated appropriately, with opened food not exceeding the manufacturer's use-by date.
Infection Control Deficiencies in Hand Hygiene and PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by several observed deficiencies in hand hygiene and personal protective equipment (PPE) usage. For Resident 20, an LPN did not perform hand hygiene before donning gloves to conduct a blood glucose check. Similarly, for Resident 12, another LPN failed to perform hand hygiene before donning gloves to administer a nasal spray and oral medications. Additionally, the Unit Manager was observed handling medication with bare hands without performing hand hygiene before administering Tylenol to Resident 24. Furthermore, the facility did not adhere to enhanced barrier precautions for Resident 2, who required such measures due to renal disease and the presence of a dialysis port and gastrostomy tube. Certified Nurse Aides were observed preparing the resident for dialysis without donning the required gown and gloves, despite the care plan indicating the necessity for enhanced barrier precautions. These observations highlight lapses in following the facility's hand hygiene and PPE policies, as outlined by the Director of Nursing.
Insulin Administration Error Due to Non-Adherence to Physician's Order
Penalty
Summary
The facility failed to adhere to a physician's order regarding insulin administration for a resident diagnosed with diabetes. The resident's care plan, dated October 21, 2024, highlighted the risk of adverse effects from hyperglycemia or hypoglycemia due to glucose-lowering medication. The physician's order, dated December 30, 2024, specified that insulin lispro should be held if the resident's blood sugar was below 150 mg/dL. However, during a random observation on March 9, 2025, an LPN was preparing to administer 12 units of insulin lispro to the resident despite a blood sugar reading of 122 mg/dL, which was below the threshold set by the physician's order. The LPN, upon reviewing the Medication Administration Record, acknowledged the oversight and confirmed that the insulin should have been held. This incident was documented during an interview with the LPN, who admitted the error. The facility's Medication Administration Skills Competency, last revised in July 2023, emphasizes the importance of adhering to the five rights of medication administration, which includes administering the right dose at the right time. The failure to follow the physician's order resulted in a significant medication error, as the insulin was nearly administered contrary to the prescribed parameters.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for a resident, identified as Resident G, who was reviewed for call light accessibility. Resident G's clinical record indicated multiple diagnoses, including anemia, cancer, heart failure, diabetes, hemiplegia caused by a stroke, and depression. The resident was cognitively intact but had impairment of her right upper extremity and required an interpreter for communication. During an observation, it was noted that the call light cord was attached to the wall mount and was hanging near the ground, out of sight and reach of the resident. Resident G confirmed that she sometimes did not have access to her call light, although she knew how to use it when available. Further observations revealed that the call light remained out of reach throughout the day. The Director of Nursing (DON) was interviewed and initially believed the call light was within reach, but upon testing, Resident G was unable to access it without assistance. The DON later acknowledged that there was no specific policy on call lights, and the facility followed general standards of care. This deficiency highlights the facility's failure to accommodate the resident's needs by ensuring the call light was accessible, as required by their own standards.
Failure to Ensure Proper Signing of Arbitration Agreements
Penalty
Summary
The facility failed to ensure that a binding arbitration agreement was properly explained and signed by the appropriate resident representatives for two residents. Resident 42, who was admitted with severe cognitive impairment and later deemed incapacitated, signed an arbitration agreement without the involvement of a legal representative. Despite having a temporary guardian appointed, the agreement was signed by Resident 42, who was unable to fully comprehend the document, as indicated by Admission Staff 3, who had to explain the agreement multiple times. Similarly, Resident 88, who was also cognitively impaired, signed an arbitration agreement without the physical presence of her power of attorney (POA), her daughter. Admission Staff 3 contacted the POA over the phone, who verbally consented to the signing, but did not sign the document herself. The facility had the option for electronic signing, but it was not utilized. These actions led to the deficiency as the facility did not ensure the agreements were properly explained and signed by the appropriate representatives.
Failure to Respect Resident Dignity and Rights
Penalty
Summary
The facility failed to ensure the dignity and respect of three residents, identified as Residents J, K, and L, during interactions with a Licensed Practical Nurse (LPN 22). Resident K, who was cognitively intact and diagnosed with heart disease, reported that LPN 22 was rude and disrespectful during an interaction involving the changing of her oxygen humidifier. The resident described an incident where LPN 22 made rude statements and gestures, including sticking up his middle finger. Although the incident was reported to the Executive Director (ED), Resident K did not receive an apology from LPN 22, who no longer worked at the facility. Resident J, also cognitively intact and diagnosed with heart failure, reported that LPN 22 was pushy and demanding, often waking him up at night to perform tasks such as taking a sip of water. Despite Resident J's requests for LPN 22 to be removed from his care, the LPN continued to be disrespectful. Resident J expressed that LPN 22's behavior was too forceful and made him uncomfortable. Resident L, diagnosed with quadriplegia and cognitively intact, recounted an argument with LPN 22 where the LPN used inappropriate language and rushed through care without listening to the resident's concerns. Resident L reported the incident to the Director of Nursing (DON) and the ED, describing LPN 22 as disrespectful. The facility's resident rights policy emphasizes the importance of treating residents with dignity and respect, which was not upheld in these interactions.
Deficiency in ADL Assistance for Resident
Penalty
Summary
The facility failed to provide adequate care and assistance with activities of daily living (ADLs) for Resident G, who was unable to perform these tasks independently. Resident G, who has a medical history including anemia, cancer, heart failure, diabetes, hemiplegia from a stroke, and depression, was observed in her room with oily, stringy, and tangled hair, indicating she had not received a shower or hair shampooing in 10-12 days. Despite being scheduled for showers twice a week, the resident reported not having received a full bed bath or hair wash recently, and her wheelchair was missing from her room for several days, preventing her from being mobilized as needed. Interviews with facility staff revealed inconsistencies in the care provided to Resident G. LPN 10 confirmed that the resident's showers were scheduled for specific days, but the resident had not been assisted to her wheelchair for some time. The Assistant Director of Nursing Services (ADNS) and the Director of Nursing (DON) were unaware of the wheelchair's location, which was later found and returned to the resident's room. The Occupational Therapist (OT) and Speech Therapist (ST) had evaluated the resident for wheelchair use, noting a decline in her mobility and the need for a larger wheelchair, but the nursing staff had not been actively facilitating her transfers. The care plan for Resident G indicated she required assistance with ADLs due to impaired mobility and a history of stroke, with a goal of maintaining her cleanliness and grooming. However, the facility's failure to adhere to this plan resulted in the resident not receiving the necessary care. The DON acknowledged the lack of a specific policy on ADLs, relying instead on general standards of care, which contributed to the oversight in Resident G's care.
Failure to Apply Recommended Splints for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with contractures received the recommended splint application as advised by therapy staff. Resident B, who has a history of hemiplegia and hemiparesis following a stroke, as well as multiple contractures and muscle wasting, was observed without the necessary splint on multiple occasions. Despite being cognitively intact and aware of the need for a splint, Resident B reported that the staff never applied it. The clinical record lacked any physician orders or care plans related to the application of splints, indicating a gap in the coordination and implementation of care. The therapy staff had recommended the use of a grip hand splint and an elbow extension splint to prevent the progression of contractures, and an in-service was conducted to ensure nursing staff understood the proper application of these splints. However, observations and interviews revealed that the splints were not being applied as needed. The facility's policy on the Restorative Nursing Program, which includes splint or brace assistance, was not followed, as evidenced by the absence of a resident-centered care plan with specific interventions for maintaining or improving function.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the daily posting of current nurse staffing information, which had the potential to affect all 98 residents residing in the facility. Observations on multiple occasions revealed that the staffing information posted was outdated, showing the date of 3/07/25 instead of the current date. Interviews with the Nurse Schedule Coordinator (NSC) and the Executive Director (ED) revealed that the NSC prepares the staffing sheets daily and leaves them for the night shift nurse to post the following morning. However, the night shift nurse forgot to update the posting, resulting in outdated information being displayed. The facility's policy requires that staffing information be posted at the beginning of each shift, including details such as the facility name, current date, resident census, and the number of hours worked by registered nurses, licensed practical nurses, and certified nurse aides. Despite this policy, the failure to update the staffing information was attributed to oversight by the night shift nurse, particularly on weekends when the NSC might not be present to ensure compliance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 994 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 17 | 0 |
| Miller's Merry Manor | 1.1 mi | ★★★★★ | 0 | 0 |
| Arlington Place Health Campus | 1.1 mi | ★★★★★ | 11 | 0 |
| Wildwood Healthcare Center | 2 mi | ★★★★★ | 9 | 0 |
| Brickyard Healthcare - Brookview Care Center | 2.1 mi | ★★★★★ | 11 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rosewalk Village.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.