Inspection Reports for Rittenhouse Village At Northside
1251 W 96th St, Indianapolis, IN 46260, IN, 46260
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Unclassified
Census Over Time
Inspection Report
Re-Inspection
Census: 64
Deficiencies: 0
Jul 14, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00460660 completed on June 3, 2025, conducted in conjunction with the Investigation of Complaint IN00462046.
Findings
Rittenhouse Village at Northside was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaint IN00460660.
Complaint Details
Complaint IN00460660 was corrected as of this visit.
Report Facts
Residential Census: 64
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Jul 14, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00462046 and was conducted in conjunction with a Post Survey Revisit to Investigation of Complaint IN00460660 completed on June 3, 2025.
Findings
No deficiencies related to the allegations of Complaint IN00462046 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation.
Complaint Details
Complaint IN00462046 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 1
Jun 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460660 regarding allegations of neglect related to a resident who wandered away from the facility.
Findings
The facility failed to ensure a resident with dementia was free from neglect when the resident eloped from the facility and was missing for approximately 14 hours, later found on a busy interstate. The resident was hospitalized and placed in a secured memory care unit. The facility lacked a prior elopement risk assessment for the resident and delayed notifying police.
Complaint Details
Complaint IN00460660 was substantiated with state deficiencies cited related to neglect when Resident B eloped from the facility and was found on Interstate 465 after approximately 14 hours missing. The facility delayed police notification by about four hours and lacked an elopement risk assessment prior to the incident.
Deficiencies (1)
| Description |
|---|
| Failed to ensure a resident was free from neglect when a resident with dementia wandered away from the facility and was missing for approximately 14 hours. |
Report Facts
Residential Census: 67
Duration resident missing: 14
Date of survey completion: Jun 3, 2025
Date of plan of correction completion: Jun 12, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamala Williams | Executive Director | Signed the report and involved in facility oversight |
| Director of Nursing | Interviewed regarding resident's condition and facility response | |
| Receptionist 1 | Reported resident missing and involved in communication | |
| Receptionist 6 | Witnessed resident leaving and reported incident | |
| QMA 3 | Noted changes in resident's behavior |
Inspection Report
Renewal
Census: 72
Deficiencies: 3
Apr 15, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 15 and 16, 2025, to assess compliance with state regulations for residential care facilities.
Findings
The facility was found deficient in personnel documentation, medication administration practices, and prior authorization for PRN narcotics. Specifically, job-specific orientations and job descriptions were missing for 5 new employees, medication was pre-set improperly by one staff member, and a Qualified Medication Aide administered PRN narcotics without prior nurse approval.
Deficiencies (3)
| Description |
|---|
| Failed to ensure general and job specific orientations were documented and job descriptions were in employee files for 5 of 5 new employees reviewed. |
| Failed to ensure staff did not prepare medication for more than one medication administration at a time (QMA 5). |
| Failed to ensure Qualified Medication Aide notified a licensed nurse and received prior approval to administer PRN narcotics for 1 of 8 residents reviewed. |
Report Facts
Residential Census: 72
Number of new employees reviewed: 5
Number of medication cups prepared: 5
Number of residents reviewed for PRN narcotics authorization: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Pamala Williams | Executive Director | Interviewed regarding personnel documentation and medication administration policies |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 8
Jul 2, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00427840.
Findings
No deficiencies were cited related to the complaint allegations. Deficiencies were found related to fire and disaster drill procedures, employee screening and training, personnel records, HVAC inspection, and food safety and sanitation standards.
Complaint Details
Complaint IN00427840 - No deficiencies related to the allegations are cited.
Deficiencies (8)
| Description |
|---|
| Failed to ensure the fire department was invited to attend a fire and disaster drill every six months during the last 12 months. |
| Failed to ensure background and reference checks were completed for 4 of 5 new employees reviewed. |
| Failed to ensure at least one staff member certified in CPR and First Aid was on the premises for 1 of 21 shifts reviewed. |
| Failed to ensure new employees received training in resident rights and six hours of dementia training for 4 of 5 new employees reviewed. |
| Failed to ensure new employees had received a two-step tuberculosis screening for 2 of 5 new employees reviewed. |
| Failed to maintain current and accurate personnel records including orientation documentation for 4 of 5 employees reviewed. |
| Failed to provide documentation of an annual HVAC inspection during the last 12 months. |
| Failed to maintain food preparation and serving areas in accordance with state and local sanitation and safe food handling standards, including failure to wear hair coverings, cover equipment, label and date food items, maintain thermometers and temperature logs, clean refrigerators and floors, and remove damaged cans. |
Report Facts
Residents present: 78
Number of new employees reviewed: 5
Number of shifts reviewed for CPR coverage: 21
Number of deficiencies cited: 8
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 1
Nov 29, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00421484, IN00419290, and IN00417835 at Rittenhouse Village at Northside.
Findings
The facility failed to ensure a resident was safe from physical abuse during an altercation between a resident and a staff member. The incident involved a physical fight initiated after a verbal altercation related to meal service. Staff 2 was terminated following the incident. No deficiencies were cited for the other two complaints.
Complaint Details
Complaint IN00421484 was substantiated with state deficiencies cited. Complaints IN00419290 and IN00417835 had no deficiencies related to the allegations.
Deficiencies (1)
| Description |
|---|
| Failed to ensure a resident was safe from physical abuse when a resident and a staff member got into a verbal altercation which led to a physical altercation. |
Report Facts
Residential Census: 80
Survey Dates: November 28 and 29, 2023 (dates of inspection visit).
Termination Date: Staff 2 was terminated from employment on 11/10/22.
Plan of Correction Completion Date: Corrective actions to be completed by January 31, 2024.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Fink | Executive Director | Named as Executive Director who provided statements and oversight related to the incident and corrective actions. |
| Staff 2 | Staff member involved in the physical altercation with Resident B; terminated from employment. | |
| Resident B | Resident involved in the physical altercation with Staff 2. | |
| Dietary Supervisor 4 | Provided statement describing the incident and observations. | |
| QMA 3 | Witnessed part of the altercation and provided statements. | |
| QMA 5 | Witnessed part of the altercation and provided statements. |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 4
Sep 6, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414785 and IN00416806 regarding resident care and facility operations.
Findings
The facility failed to respond timely to an emergency pendant call for a resident who had fallen, failed to notify family of changes in level of care and medication, and failed to maintain kitchen equipment in working order. Corrective actions and plans of correction were outlined for each deficiency.
Complaint Details
The investigation was triggered by complaints IN00414785 and IN00416806. Complaint IN00414785 involved failure to respond to emergency calls and equipment maintenance issues. Complaint IN00416806 involved failure to notify family and physician of changes in resident care and missed medications.
Deficiencies (4)
| Description |
|---|
| Failed to respond to an emergency pendant call alert for 1 of 1 resident who had fallen and activated the call system for help. |
| Failed to notify the family for a change in the level of services and rates for 1 of 4 residents reviewed. |
| Failed to notify a resident's physician and family member of missed doses of medications for 1 of 4 residents reviewed. |
| Failed to maintain equipment in working order for 1 gas stove top in the kitchen, limiting meal preparation options. |
Report Facts
Residential Census: 82
Missed medication days: 2
Repair cost quote: 6550
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Daniel Fink | Executive Director | Signed the inspection report and involved in corrective action plans. |
| LPN 1 | Licensed Practical Nurse | Provided information on medication notification procedures. |
| LPN 2 | Licensed Practical Nurse | Provided information on medication notification procedures. |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
May 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407559.
Findings
No deficiencies related to the allegations in Complaint IN00407559 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Complaint Details
Complaint IN00407559 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 9
Apr 18, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00398798, IN00390967, IN00388371, IN00386777 and IN00384108.
Findings
No deficiencies were cited related to the complaints investigated. Deficiencies were found in fire drill documentation, dementia training, tuberculosis screening, HVAC inspection, kitchen sanitation, medication self-administration assessment, service plan signatures, and medication administration documentation.
Complaint Details
Investigation of Complaints IN00398798, IN00390967, IN00388371, IN00386777, and IN00384108 found no deficiencies related to the allegations.
Deficiencies (9)
| Description |
|---|
| Facility failed to conduct 3 of 12 required monthly fire drills (missing for 12/22, 1/23, and 2/23). |
| Failed to ensure six hours of dementia training within six months of hire and three hours annually thereafter for 1 of 9 employees reviewed. |
| Failed to perform second test of two-step Mantoux tuberculosis skin test for 1 of 5 new employees and annual tuberculosis screening for 1 of 5 established employees. |
| Failed to have yearly HVAC system inspection. |
| Failed to maintain kitchen and equipment in a sanitary manner, including debris on counters, unmeasured disinfectant concentration, dirty dining and bussing carts, and improperly labeled food and beverages. |
| Failed to assess and secure medications for 1 of 5 residents who self-administer medications. |
| Failed to ensure service plans were signed by residents or representatives for 5 of 9 residents reviewed. |
| Failed to document medication administration on MAR/TAR for 1 of 6 residents reviewed. |
| Failed to ensure yearly tuberculosis test or screening for 2 of 9 residents and two-step tuberculosis test for 3 of 9 residents reviewed. |
Report Facts
Fire drills missed: 3
Residents present: 80
Dementia training hours: 6
Dementia training hours: 3
Medication administration missing documentation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook 1 | Employee reviewed for dementia training deficiency. | |
| Maintenance Staff 4 | Interviewed regarding missing fire drill documentation and HVAC inspection. | |
| Assistant Executive Director | Provided multiple interviews and facility policies during inspection. | |
| Housekeeper 2 | Employee missing two-step tuberculosis skin test. | |
| Dementia Care Coordinator | Employee missing annual tuberculosis screening. | |
| Dietary Manager | Observed kitchen sanitation deficiencies. | |
| QMA 6 | Interviewed regarding medication administration documentation. |
Loading inspection reports...
