Rosewalk Village: Resident Found Outside Facility - IN
The incident triggered a federal citation at the Immediate Jeopardy level, the most serious classification available to inspectors, meaning the situation was judged to have placed residents at risk of serious harm or death. What made the finding harder to explain was this: the facility had already been cited for the same problem, at the same severity level, less than a year before.
The previous Immediate Jeopardy citation had begun on December 21, 2024.
The resident at the center of the more recent incident is identified in inspection records only as Resident B, a man whose family had reason to worry. His family member, interviewed by inspectors on November 10, told them she was concerned he had been found outside because "anything could have happened to him." The inspection report does not describe how long he was outside, what the weather conditions were, or what physical state he was found in. It does not say whether anyone saw him leave.
What it says is that nobody heard the door alarm.
Rosewalk Village uses a keypad entry system on its doors. Inspectors tested the doors themselves on November 12, applying pressure to see whether they would open without authorization. They did not. A staff member identified as Maintenance 2 opened the G-hall doors during that visit, and a high-pitched alarm sounded loudly. Maintenance 2 also showed inspectors something important: if the door was not closed all the way, the alarm would still sound. A door left slightly ajar would still trigger the alarm.
That detail matters because it narrows the explanations for why nobody heard anything when Resident B left. The door either closed behind him, or it did not. Either way, staff reported hearing nothing.
The Regional Director of Clinical Services told inspectors on November 12 that facility staff had been interviewed following the elopement and that no one heard an alarm. She said the facility had no additional information to provide about how Resident B got out.
The Executive Director, interviewed the following morning, raised another question he could not fully answer. He said he was unsure whether the door company that came to inspect the system after the elopement was the same company that had originally installed it, because the system was old. He added that the door company only came out when the facility called them, and only when there was an issue.
That description, a door system old enough that the executive director did not know its installer, maintained on a reactive basis rather than through scheduled inspection, is the backdrop against which Resident B walked out.
The aide who discovered Resident B was missing is identified in the report as QMA 6. During her interview with inspectors, she did not indicate what time she had found him missing or what time she had notified the nurse. Those are two of the most basic facts in any elopement investigation, the moment the absence was noticed and the moment the chain of response began. She did not provide either.
The facility's own elopement policy, dated October 2020, states that staff who have residents under their care are responsible for knowing the location of those residents and, in the case of a missing resident, ensuring appropriate action is taken. The Director of Nursing provided that policy to inspectors on November 10. The abuse prohibition policy, also provided during the inspection, includes language covering a facility's indifference or disregard for resident care, comfort, or safety resulting in physical harm, pain, mental anguish, or emotional harm.
The December 2024 Immediate Jeopardy citation had produced a significant corrective response, at least on paper. According to inspection records, the facility completed elopement risk assessments on all residents, conducted elopement drills with staff, educated all staff on elopement procedures and high-risk behaviors, installed a second antenna on the G-hall double door exit because the system had previously had only one, ensured the system was operating properly, increased the range, and changed the door codes to prevent unauthorized exits. Inspectors recorded that the Immediate Jeopardy from December 2024 was removed and corrected by October 31, 2025.
Thirteen days later, Resident B was found outside.
The inspection that produced the current citation was a complaint inspection, meaning someone reported a concern to regulators rather than the visit arising from a routine survey cycle. The inspection dates in the report run from November 10 through November 13, 2025.
The gap between what the facility implemented after December 2024 and what happened in November 2025 is not explained in the inspection record. The report does not say whether the second antenna installed on the G-hall doors was functioning at the time of Resident B's elopement. It does not say whether the range increase held. It does not say whether the door codes had been changed again, or whether staff had received any refresher training in the months between October 31, when the previous jeopardy was declared corrected, and the day Resident B walked out.
What the report does say is that no staff member heard the alarm, and that the facility, when asked, had nothing more to offer.
Elopements from memory care and secured units are among the most dangerous events that can occur in a nursing facility. Residents who leave without being noticed are frequently disoriented, unable to communicate where they live, and vulnerable to traffic, weather, and falls. The inspection record does not describe what Resident B experienced outside or how quickly he was found.
His family member, in her interview with inspectors, did not need a regulatory framework to explain the stakes. Anything could have happened to him, she said. She was right.
The facility's elopement policy requires staff to know where their residents are. On the day Resident B left, they did not. On the day he was found, the aide who discovered him missing could not tell inspectors what time she had noticed he was gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rosewalk Village from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
ROSEWALK VILLAGE in INDIANAPOLIS, IN was cited for violations during a health inspection on November 13, 2025.
The previous Immediate Jeopardy citation had begun on December 21, 2024.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.