The Waters of Indianapolis failed to provide a complete description of the sexual abuse allegation when reporting the incident to state health department officials, according to a December 31 federal inspection.
The incident occurred December 5 at approximately 11:00 a.m. when CNA 1 was at the nurse's station and heard Resident C yelling. As the nursing assistant walked toward the woman's room, she observed Resident B wheeling out of Resident C's room.
When CNA 1 asked why he was in the female resident's room, Resident B said he had gotten lost. The nursing assistant instructed him that he was not supposed to be in a female resident's room.
Inside Resident C's room, CNA 1 found the woman lying in bed with her sheet pulled approximately halfway down, her gown pulled up, and her brief unfastened on the left side and bent approximately halfway down in the front.
CNA 1 found this suspicious because she had just changed Resident C's brief and repositioned her in bed. The nursing assistant left everything exactly as she found it and immediately went to get RN 1 so the nurse could observe the scene.
When both staff members returned to the room, nothing had changed. Resident C remained with her sheet pulled halfway down and 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 woman was unable to verbalize what had happened but pointed at her breast.
Since Resident C's brief was unfastened, RN 1 asked if Resident B had touched her anywhere else besides her breast. Resident C indicated no.
The facility submitted a reportable incident to authorities at 12:30 p.m. that same day, approximately one hour and forty minutes after CNA 1 wrote her statement about the incident.
But the facility's brief description to the state health department indicated only that "Resident C made an allegation that Resident B touched her breast." The report omitted the circumstances of how Resident B was discovered leaving Resident C's room and the condition in which the woman was found.
During the December 31 inspection, Resident C was unable to describe details of the sexual abuse allegation. She repeated the word "fine" after each question during the interview.
Resident B's room was located just across the hallway from Resident C's room.
The facility's Abuse Prevention Program policy, dated October 22, 2022, requires that allegations of abuse must be reported. Federal regulations require nursing homes to immediately report suspected abuse, neglect, or theft to proper authorities and provide complete information about incidents.
The inspection found the facility failed to ensure a full description of the sexual abuse allegation was reported to the state health department. The violation affected few residents and posed minimal harm or potential for actual harm.
CNA 1's written statement, completed at 11:50 a.m. on December 5, documented that she heard Resident C yelling and observed Resident B wheeling out of the woman's room. The statement described finding Resident C with her gown pulled up, sheet off, and brief open.
RN 1 confirmed during her interview that CNA 1 had reported hearing Resident C yelling "no" before entering the room to find Resident B inside. The nurse said Resident B was escorted out and back to his room across the hallway.
The Director of Nursing provided copies of the facility's reportable incident and CNA 1's written statement during the inspection. The documents showed a significant discrepancy between the detailed observations recorded by staff and the minimal information transmitted to state authorities.
When CNA 1 initially discovered the scene, she noted that Resident C's brief was "unfasted" on the left side and "bent down in the front." The nursing assistant had recently provided care to Resident C, making the disturbed condition of her clothing and bedding immediately noticeable.
The timing of events showed that staff documented detailed observations within two hours of the incident. CNA 1 completed her written statement at 11:50 a.m., and the facility submitted its reportable incident at 12:30 p.m.
However, the facility's communication to state health department officials stripped away the contextual details that staff had carefully documented. The report reduced the incident to a simple allegation without describing the circumstances that led staff to believe abuse had occurred.
RN 1 confirmed that when she entered Resident C's room with CNA 1, the woman's positioning and clothing remained exactly as the nursing assistant had initially found her. This preservation of the scene allowed the nurse to make her own observations before questioning Resident C.
The inspection revealed that while facility staff followed proper procedures for documenting and investigating the incident internally, they failed to provide complete information to external authorities as required by federal regulations.
Resident C's inability to provide details during the December 31 interview underscored the importance of staff observations in documenting what occurred. The woman's condition when found, combined with her immediate response pointing to her breast, formed the basis for the sexual abuse allegation.
The facility's incomplete reporting to state authorities meant that officials received only a fraction of the information available about the incident. Key details about Resident B being found leaving the room, Resident C's yelling, and the disturbed condition of her clothing and bedding were omitted from the official report.
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.