What the assistant found inside Resident C's room on December 5th raised immediate suspicions. The woman was lying in bed with her sheet pulled halfway down, her gown pulled up, and her brief unfastened on the left side and bent down in the front.
The assistant had just changed the resident's brief and repositioned her in bed moments earlier.
Federal inspectors found that The Waters of Indianapolis failed to provide a complete description of the sexual abuse allegation to the state health department, violating requirements for reporting suspected abuse in nursing homes.
The incident began around 11:00 a.m. when CNA 1 was working at the nurse's station and heard Resident C yelling. As the assistant walked toward the resident's room, she observed Resident B wheeling out of Resident C's room. When asked why he was there, Resident B said he had gotten lost.
CNA 1 instructed Resident B that he was not supposed to be in a female resident's room. His room was directly across the hallway from Resident C's.
Inside Resident C's room, the nursing assistant discovered the disturbed clothing and bedding. Because she had just provided care to the resident, CNA 1 found the scene suspicious. She left everything exactly as she found it and immediately went to get RN 1 so the nurse could observe the same conditions.
When both staff members returned to the room, nothing had changed. Resident C remained with her sheet pulled halfway down, her brief unfastened on the left side and bent halfway down in the front.
RN 1 asked Resident C if she had been touched. The resident was unable to verbalize what had happened but pointed at her breast.
The nurse then asked if Resident B had touched her anywhere else besides her breast, given that her brief was unfastened. Resident C indicated no.
At 11:50 a.m., CNA 1 provided a written statement about the incident. Forty minutes later, at 12:30 p.m., the facility submitted a reportable incident to authorities.
But the brief description in that report only indicated that Resident C made an allegation that Resident B touched her breast. The facility failed to include the full circumstances that staff had observed.
The written statement from CNA 1 contained significantly more detail than what the facility reported to the state health department. The statement described hearing Resident C yelling, observing Resident B leaving her room, and finding the resident with her clothing and bedding disturbed in suspicious circumstances.
During the inspection on December 31st, investigators attempted to interview Resident C about the allegation. The resident was unable to describe details of the sexual abuse allegation that had been made against Resident B. She repeated the word "fine" after each question during the interview.
The facility's own policy, dated October 22nd, 2022, requires that allegations of abuse must be reported. The policy is titled "Abuse Prevention Program" and was provided by the Director of Nursing as the current policy used by the facility.
Federal regulations require nursing homes to immediately report suspected abuse, neglect, or theft to the administrator of the facility and to other officials in accordance with state law within 24 hours. Facilities must also report the results of investigations to proper authorities.
The incomplete reporting meant state health department officials received only a fraction of the information that facility staff had documented about the incident. They were not told about the male resident being found leaving the female resident's room, the disturbed clothing and bedding, or the nursing assistant's suspicions based on having just provided care.
The timing of events on December 5th showed that facility staff acted quickly to document what they observed. CNA 1 wrote her statement within an hour of the incident. The facility submitted its reportable incident report 40 minutes after that.
However, the content of what was reported failed to meet federal requirements for complete disclosure of suspected abuse allegations.
RN 1, who was caring for Resident C on the day of the incident, confirmed during the inspection interview that Resident C had made an allegation of sexual abuse against Resident B. The nurse described how CNA 1 reported hearing Resident C yelling "no" and how Resident B was escorted from the room back to his own room across the hallway.
The nurse observed the same disturbed clothing and bedding that the nursing assistant had found. When she asked Resident C about being touched, the resident pointed at her breast area, though she was unable to verbalize details of what had occurred.
CNA 1 provided consistent accounts during both her written statement on December 5th and her interview with inspectors on December 31st. She described the suspicious nature of finding Resident C's clothing disturbed after having just provided care, and her decision to immediately involve the nurse to witness the same conditions.
The male resident, Resident B, told staff he had gotten lost when questioned about why he was in the female resident's room. His room's location directly across the hallway from Resident C's room was noted in the inspection findings.
Federal inspectors determined that the facility's failure to provide complete information about the allegation constituted a violation of reporting requirements. The citation was issued under regulations requiring timely and thorough reporting of suspected abuse, neglect, or theft.
The incomplete report to state authorities meant that officials responsible for investigating nursing home abuse allegations received only partial information about an incident that facility staff had documented in much greater detail. The missing information included the circumstances under which the male resident was discovered, the condition in which the female resident was found, and the suspicions of staff members who provided the initial response.
The facility's violation was classified as causing minimal harm or potential for actual harm, affecting few residents. However, the failure to fully report suspected abuse allegations undermines the state's ability to conduct thorough investigations and protect vulnerable nursing home residents from potential future incidents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Indianapolis, The from 2025-12-31 including all violations, facility responses, and corrective action plans.