Inspection Report Summary
The most recent inspection on June 24, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a recurring deficiency with the facility’s failure to provide a continuous protected path of travel to an exit discharge for all stairwell exits, noted in multiple Life Safety Code surveys. Other cited issues included medication administration errors, delayed resident care, and food storage concerns, primarily identified during annual and renewal surveys. Several complaint investigations were substantiated but did not result in cited deficiencies, and no fines or enforcement actions were listed in the available reports. The facility’s inspection history shows some ongoing challenges with fire safety compliance and resident care processes, but recent complaint investigations have consistently found no deficiencies, indicating some stability in those areas.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
157% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
106 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 106
Deficiencies: 0
Date: Jun 24, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00458837, IN00460266, IN00460695, and IN00461973 at Rosewalk Village at Lafayette.
Complaint Details
Complaints IN00458837, IN00460266, IN00460695, and IN00461973 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the investigation of these complaints.
Report Facts
Census: 106
Census Bed Type Total: 106
Medicare Census: 6
Medicaid Census: 93
Other Payor Census: 7
Inspection Report
Life Safety
Census: 108
Capacity: 141
Deficiencies: 1
Date: Jun 18, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 05/01/25 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found in compliance with the National Fire Protection Association (NFPA) 101A, Chapter 4, Fire Safety Evaluation System for Health Care Occupancies, achieving a passing score on the FSES survey. However, the facility failed to provide a continuous protected path of travel to an exit discharge for all four stairwell exits as required by the Life Safety Code section 7.2 Means of Egress Components.
Deficiencies (1)
Failed to provide a continuous protected path of travel to an exit discharge for 4 of 4 stairwell exits in accordance with LSC section 7.2 Means of Egress Components.
Report Facts
Facility capacity: 141
Census: 108
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Participated in observation during the facility tour related to stairwell exit deficiencies |
Inspection Report
Annual Inspection
Census: 111
Capacity: 141
Deficiencies: 2
Date: May 1, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively on 05/01/2025.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the Life Safety Code survey found the facility not in compliance with certain fire safety requirements, including failure to provide a continuous protected path of travel to an exit discharge for all stairwell exits and failure to maintain automatic sprinkler systems according to NFPA 25 standards.
Deficiencies (2)
Failed to provide a continuous protected path of travel to an exit discharge for 4 of 4 stairwell exits in accordance with LSC section 7.2 Means of Egress Components.
Failed to maintain automatic sprinkler systems in accordance with NFPA 25, including delayed replacement of Cooler and Freezer dry pendants.
Report Facts
Certified beds: 141
Census: 111
Deficiencies cited: 2
Compliance date: May 21, 2025
Compliance date: Jun 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Anderson | Executive Director | Named in relation to review of findings at exit conference |
| Maintenance Supervisor | Interviewed regarding stairwell exits and sprinkler system deficiencies |
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
This visit was conducted for the investigation of three complaints: IN00458283, IN00458395, and IN00458592.
Complaint Details
Complaints IN00458283, IN00458395, and IN00458592 were investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 110
Total Capacity: 110
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 92
Census Payor Type - Other: 11
Inspection Report
Routine
Deficiencies: 5
Date: Apr 4, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, care planning, incontinence care, and food safety at Rosewalk Village at Lafayette.
Findings
The facility was found deficient in multiple areas including failure to complete required PASARR assessments when psychotropic medications and mental health diagnoses were added, failure to conduct timely care plan meetings for residents, failure to provide timely incontinence care, administration of insulin doses against physician's ordered hold parameters, and improper food storage practices in the kitchen.
Deficiencies (5)
Failed to ensure a preadmission screening and resident review (PASARR) was completed when an antipsychotic medication and mental health diagnosis was added for 1 of 1 resident reviewed.
Failed to ensure care plan meetings were held with the resident and the resident's representative in a timely manner for 4 of 4 residents reviewed.
Failed to ensure a dependent resident was provided incontinence care in a timely manner for 1 of 1 dependent resident reviewed.
Failed to ensure insulin doses were not administered when blood sugar readings were below the physician's ordered hold parameter for 1 of 2 residents reviewed.
Failed to ensure employee food and drinks were not stored in the kitchen, cardboard boxes were off the floor, and expired food was discarded, potentially affecting all residents receiving food from the kitchen.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 110
Insulin doses administered below hold parameter: 26
Insulin doses administered below hold parameter: 8
Insulin doses administered below hold parameter: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Indicated Resident 97 did not have new PASARR completed; acknowledged care plan meeting deficiencies; indicated no employee food/drinks in kitchen; provided facility policies | |
| Social Service Director | Indicated Resident 97 did not have new PASARR completed; indicated care plan meetings should occur quarterly | |
| Director of Nursing | Indicated family did not attend care plan meeting; acknowledged care plan meeting deficiencies; indicated insulin administration issues and quality improvement plan | |
| Certified Nursing Assistant 2 | CNA | Observed Resident 39 in soiled condition; indicated residents checked every 2 hours |
| Certified Nursing Assistant 3 | CNA | Indicated residents should be checked every 2 hours |
| Certified Nursing Assistant 4 | CNA | Indicated residents checked and changed every hour in dining room; described CNA job duties |
| Licensed Practical Nurse 6 | LPN | Indicated insulin doses held would be marked on MAR |
| Registered Nurse 7 | RN | Indicated insulin doses should be held if blood sugar below ordered parameter |
| Dietary Manager | DM | Indicated cardboard boxes should not be stored on floor in kitchen |
Inspection Report
Renewal
Census: 110
Capacity: 110
Deficiencies: 4
Date: Apr 4, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 30 to April 4, 2025.
Findings
The facility was found deficient in several areas including failure to complete required PASARR assessments when psychotropic medications and mental health diagnoses were added, delayed incontinence care for a dependent resident, administration of insulin doses below physician's ordered hold parameters, and improper food storage and sanitation practices in the kitchen.
Deficiencies (4)
Failed to ensure a preadmission screening and resident review (PASARR) was completed when an antipsychotic medication and mental health diagnosis was added for 1 of 1 resident reviewed.
Failed to ensure a dependent resident was provided incontinence care in a timely manner.
Failed to ensure insulin doses were not administered when blood sugar readings were below the physician's ordered hold parameter.
Failed to ensure employee food and drinks were not stored in the kitchen, cardboard boxes were off the floor, and expired food was discarded.
Report Facts
Census: 110
Total Capacity: 110
Deficiencies cited: 4
Insulin doses administered below hold parameter: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Anderson | Executive Director | Named as facility representative and interviewed regarding PASARR assessments |
| Social Service Director | Interviewed regarding PASARR assessments and corrective actions | |
| Certified Nursing Assistant 2 | Interviewed regarding incontinence care for Resident 39 | |
| Certified Nursing Assistant 3 | Interviewed regarding toileting schedules | |
| Certified Nursing Assistant 4 | Interviewed regarding resident checks and changes in dining room | |
| LPN 6 | Interviewed regarding insulin administration and MAR documentation | |
| RN 7 | Interviewed regarding insulin dose holding practices | |
| Director of Nursing | Interviewed regarding insulin administration issues and policies | |
| Cook 7 | Interviewed regarding food and drink storage in kitchen | |
| Dietary Manager | Interviewed regarding food storage and kitchen sanitation |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 4, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
Rosewalk Village at Lafayette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453219 and IN00454274 at Rosewalk Village at Lafayette.
Complaint Details
Complaint IN00453219 and Complaint IN00454274 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00453219 and IN00454274 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 107
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 88
Census Payor Type - Other: 14
Inspection Report
Complaint Investigation
Census: 110
Capacity: 110
Deficiencies: 0
Date: Dec 5, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00445544 and IN00448078 at Rosewalk Village at Lafayette.
Complaint Details
Complaint IN00445544 and Complaint IN00448078 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00445544 and IN00448078 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF beds: 110
Census total residents: 110
Census Medicare residents: 4
Census Medicaid residents: 91
Census other payor residents: 15
Inspection Report
Complaint Investigation
Census: 108
Capacity: 108
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00441863, IN00442210, and IN00442511.
Complaint Details
Complaints IN00441863, IN00442210, and IN00442511 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 108
Total Capacity: 108
Medicare Census: 5
Medicaid Census: 94
Other Payor Census: 9
Inspection Report
Complaint Investigation
Census: 111
Capacity: 111
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441572.
Complaint Details
Complaint IN00441572 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00441572 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 7
Medicaid census: 97
Other payor census: 7
Inspection Report
Life Safety
Census: 110
Capacity: 141
Deficiencies: 1
Date: Aug 15, 2024
Visit Reason
A Fire Safety Evaluation (FSES) Survey and a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found in compliance with NFPA 101A Chapter 4 and the Life Safety Code (LSC) for Health Care Occupancies. However, a deficiency was noted where the facility failed to provide a continuous protected path of travel to an exit discharge for all four stairwell exits, which did not discharge into a public way, yard, court, or exit passageway as required by LSC section 7.2.
Deficiencies (1)
Failed to provide a continuous protected path of travel to an exit discharge for 4 of 4 stairwell exits in accordance with LSC section 7.2 Means of Egress Components.
Report Facts
Facility capacity: 141
Census: 110
Number of deficient stairwell exits: 4
Inspection Report
Complaint Investigation
Census: 112
Capacity: 112
Deficiencies: 0
Date: Aug 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00439985.
Complaint Details
Complaint IN00439985 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 5
Medicaid residents: 96
Other payor residents: 11
Inspection Report
Life Safety
Census: 107
Capacity: 141
Deficiencies: 3
Date: Jun 17, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The Emergency Preparedness survey found the facility in compliance with requirements. The Life Safety Code survey found the facility not in compliance with several fire safety requirements including egress door locking arrangements, stairway discharge paths, and sprinkler head maintenance.
Deficiencies (3)
Failed to ensure the means of egress through 1 of 8 exits were readily accessible; exit door was magnetically locked with a four-digit code not posted at the exit.
Failed to provide a continuous protected path of travel to an exit discharge for 4 of 4 stairwell exits; stairwells did not discharge into a public way or approved exit passageway.
Failed to ensure 16 of over 100 sprinkler heads were clean, free of foreign materials, and corrosion; paint was found on multiple sprinkler heads in resident rooms.
Report Facts
Certified beds: 141
Census: 107
Exits with egress issue: 1
Stairwell exits with discharge issue: 4
Sprinkler heads with paint or debris: 16
Residents potentially affected: 14
Staff potentially affected: 8
Visitors potentially affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Anderson | Executive Director | Signed the report |
| Maintenance Supervisor | Interviewed regarding egress door locking and sprinkler head conditions |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 107
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00435648.
Complaint Details
Investigation of Complaint IN00435648 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00435648 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Medicare census: 4
Medicaid census: 91
Other payor census: 12
Inspection Report
Annual Inspection
Census: 104
Capacity: 104
Deficiencies: 3
Date: May 29, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of four complaints (IN00433022, IN00434158, IN00434300, and IN00434621).
Complaint Details
Complaints IN00433022, IN00434158, IN00434300, and IN00434621 were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in three main areas: failure to follow physician orders and hypoglycemic protocol for insulin administration for one resident; failure to notify the physician timely about significant weight loss for one resident; and failure to properly label over-the-counter medications on medication carts. No deficiencies were related to the investigated complaints.
Deficiencies (3)
Failed to ensure insulin doses were held per physician's order, timely physician notification, and follow hypoglycemic protocol for 1 of 2 residents reviewed for insulin (Resident 5).
Failed to notify the physician about significant weight loss in a timely manner for 1 of 5 residents reviewed for nutrition (Resident 67).
Failed to ensure over-the-counter medications were labeled with directions for use and physician's name for 1 of 3 medication carts reviewed (Cart 100).
Report Facts
Census: 104
Total Capacity: 104
Insulin doses given despite hold order: 3
Blood sugar readings below 60 mg/dL: 2
Weight loss percentage: 14
Weight loss percentage: 13
Medication bottles unlabeled: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Anderson | Executive Director | Signed the inspection report |
| Director of Nursing | Director of Nursing | Interviewed regarding hypoglycemic protocol, physician notification, and medication labeling policies |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding medication hold orders and hypoglycemic protocol |
| Facility Pharmacist | Facility Pharmacist | Interviewed regarding labeling standards for OTC medications |
Inspection Report
Renewal
Deficiencies: 0
Date: May 29, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure survey.
Findings
Rosewalk Village at Lafayette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Routine
Deficiencies: 3
Date: May 29, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication administration, resident care, nutrition, and medication storage at Rosewalk Village at Lafayette.
Findings
The facility was found deficient in multiple areas including failure to hold insulin doses per physician's orders and follow hypoglycemic protocols for one resident, delayed notification to the physician regarding significant weight loss for another resident, and improper labeling of over-the-counter medications on medication carts.
Deficiencies (3)
Failed to ensure insulin doses were held per physician's order, timely notification to physician, and adherence to hypoglycemic protocol for 1 of 2 residents reviewed for insulin.
Failed to notify the physician about significant weight loss in a timely manner for 1 of 5 residents reviewed for nutrition.
Failed to ensure over the counter medications were labeled with directions for use and physician's name for 1 of 3 medication carts reviewed.
Report Facts
Blood sugar readings: 109
Blood sugar readings: 83
Blood sugar readings: 95
Blood sugar readings: 56
Blood sugar readings: 58
Weight: 216
Weight: 197
Weight: 198
Weight: 171
Weight: 172
Medication count: 365
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | ADON | Indicated nurses would know when to hold medication by looking at the hold order on the MAR and described protocol for notifying physician about blood sugar levels. |
| Director of Nursing | DON | Indicated nurse should notify Nurse Practitioner by writing blood sugar on non-urgent log and described policy for medication labeling and notification of significant weight loss. |
| LPN 2 | Licensed Practical Nurse | Observed medication cart 100 with unlabeled OTC medications. |
| Facility pharmacist | Indicated need to look up professional standards for labeling OTC medications and emailed requirements for OTC medication labeling. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00419813, IN00417167, and IN00430141.
Complaint Details
Complaints IN00419813, IN00417167, and IN00430141 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF/NF: 103
Total Capacity: 103
Census Payor Type Medicare: 2
Census Payor Type Medicaid: 87
Census Payor Type Other: 14
Inspection Report
Life Safety
Census: 103
Capacity: 141
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
A Fire Safety Evaluation (FSES) Survey and a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Rosewalk Village was found in compliance with NFPA 101A Chapter 4 for the FSES survey, providing a level of Life Safety at least equivalent to NFPA 101 Life Safety Code. However, the facility failed to provide a continuous protected path of travel to an exit discharge for all four stairwell exits, which could affect all residents, staff, and visitors.
Deficiencies (1)
Failed to provide a continuous protected path of travel to an exit discharge for 4 of 4 stairwell exits in accordance with LSC section 7.2 Means of Egress Components.
Report Facts
Facility capacity: 141
Census: 103
Number of deficient stairwell exits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding stairwell exit deficiencies and agreed on findings | |
| Executive Director | Participated in exit conference reviewing findings | |
| Facility Administrator | Provided information about planned Fire Safety Evaluation System (FSES) to determine compliance |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
Date: Jun 1, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00409053.
Complaint Details
Complaint IN00409053 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 104
Total Capacity: 104
Medicare Census: 6
Medicaid Census: 85
Other Payor Census: 13
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Date: May 11, 2023
Visit Reason
This visit was for the investigation of Complaint IN00407682.
Complaint Details
Complaint IN00407682 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00407682 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 103
Census Payor Type - Medicare: 4
Census Payor Type - Medicaid: 88
Census Payor Type - Other: 11
Inspection Report
Life Safety
Census: 102
Capacity: 141
Deficiencies: 6
Date: Apr 17, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety from Fire requirements and the 2012 edition of NFPA 101 Life Safety Code. Multiple deficiencies were identified including issues with stairway exits, hazardous area enclosures, fire alarm system maintenance, portable fire extinguisher installation, combustible decorations, and electrical panel access.
Deficiencies (6)
Failed to provide a continuous protected path of travel to an exit discharge for 4 of 4 stairwell exits in accordance with LSC section 7.2 Means of Egress Components.
Failed to ensure the corridor door to 1 of over 25 hazardous areas was provided with a self-closing device which would cause the door to automatically close and latch into the door frame.
Failed to maintain 1 of 1 fire alarm systems in accordance with NFPA 72; a ceiling mounted smoke detector was not mounted flush on the ceiling with an approximate one inch gap.
Failed to ensure 2 of 2 portable fire extinguishers in the Maintenance office were installed in accordance with NFPA 10; extinguishers were sitting on the floor and not mounted or protected from falling.
Failed to ensure 1 of 84 resident rooms was maintained in accordance with LSC 19.7.5.6; resident room had five candles with wicks, which are combustible decorations.
Failed to ensure access and working space was maintained in enclosures housing electrical apparatus in 1 of 1 Maintenance Supervisor's office; electrical panels were obstructed by a ladder, tool chest, and warning cones.
Report Facts
Certified beds: 141
Census: 102
Hazardous area storage boxes: 27
Resident rooms: 84
Candles: 5
Fire extinguishers: 2
Electrical panels: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Anderson | Executive Director | Named in exit conference and plan of correction discussions |
| Maintenance Supervisor | Interviewed and acknowledged deficiencies related to stairwell exits, hazardous area door, smoke detector, fire extinguishers, and electrical panel obstructions |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Mar 28, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident care, medication management, and food service.
Findings
The facility was found deficient in multiple areas including catheter care, medication management (expired medications, pharmacy recommendations, psychotropic medication use), medication storage labeling, and food service quality and temperature control. Deficiencies were generally of minimal harm but affected several residents.
Deficiencies (7)
Failed to provide thorough catheter care for 1 of 1 residents observed, resulting in potential for urinary tract infections.
Failed to have a formal Catheter Care policy; used a facility form instead.
Failed to ensure lorazepam was not administered after expiration and failed to reconcile controlled substance records for medication storage.
Failed to ensure pharmacy recommendations were addressed by prescriber within 30 days for unnecessary medications.
Failed to provide clinical rationale for prescribed antianxiety medication and for declining gradual dose reduction for psychotropic medications.
Failed to ensure insulin pens were dated when opened and unopened insulin was stored properly in the refrigerator.
Failed to ensure pureed foods were palatable, at proper consistency, and served at safe temperatures, affecting residents on pureed diets.
Report Facts
Medication doses administered: 17
Pharmacy recommendation response days: 47
Medication dose: 7.5
Medication dose: 10
Medication dose: 5
Medication dose: 150
Medication dose: 100
Medication dose: 7.5
Medication dose: 2
Medication dose: 0.5
Medication doses: 27
Medication doses: 17
Temperature: 126.1
Temperature: 111.3
Temperature: 110.2
Temperature: 68.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Named in catheter care deficiency and insulin pen storage interview | |
| Assistant Director of Nursing | ADON | Named in catheter care observation and interview |
| Executive Director | ED | Interviewed regarding catheter care policy, medication management, and food service |
| Nurse 4 | Interviewed regarding medication expiration and controlled substance record | |
| Director of Nursing | DON | Interviewed regarding psychotropic medication prescribing and rationale |
| Registered Dietitian | RD | Observed and took temperatures of pureed food tray |
| Social Services Director | SSD | Interviewed regarding grievances about pureed food consistency |
Inspection Report
Annual Inspection
Census: 102
Capacity: 102
Deficiencies: 6
Date: Mar 28, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days in March 2023.
Findings
The facility was found deficient in multiple areas including catheter care, pharmacy services and medication storage, drug regimen review, unnecessary psychotropic medication use, drug labeling and storage, and food preparation and serving temperatures and consistency.
Deficiencies (6)
Failed to ensure thorough washing during catheter care for one resident, resulting in redness and potential infection risk.
Failed to ensure lorazepam was not administered after expiration and controlled substance records were not reconciled accurately.
Failed to ensure pharmacy recommendations were addressed by prescribers within 30 days for unnecessary medications.
Failed to ensure psychotropic medications had clinical rationale documented and gradual dose reductions were appropriately considered.
Failed to ensure insulin pens were dated when opened and unopened insulin was stored properly in the refrigerator.
Failed to ensure pureed foods were served at proper temperatures and with appropriate pudding-thick consistency.
Report Facts
Survey dates: 6
Census: 102
Total capacity: 102
Expired lorazepam discard date: 2023
Pharmacy recommendation response days: 47
Temperature of pureed cauliflower: 126.1
Temperature of pureed bread: 111.3
Temperature of pureed chicken pot pie: 110.2
Temperature of pureed pears: 68.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nathan Anderson | Executive Director | Signed the report and provided interviews regarding facility policies and deficiencies. |
| LPN 3 | Observed providing catheter care and interviewed regarding medication storage and insulin pen labeling. | |
| Assistant Director of Nursing | ADON | Observed providing catheter care and interviewed regarding catheter care procedures. |
| Nurse 4 | Interviewed regarding medication expiration awareness. | |
| Registered Dietitian | RD | Conducted meal temperature observations and provided input on food preparation. |
| Social Services Director | SSD | Reported grievances regarding pureed food consistency. |
Inspection Report
Renewal
Deficiencies: 0
Date: Mar 28, 2023
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure Survey completed on March 28, 2023.
Findings
Rosewalk Village at Lafayette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 100
Capacity: 100
Deficiencies: 0
Date: Feb 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402381.
Complaint Details
Complaint IN00402381 was substantiated; however, no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare residents: 6
Medicaid residents: 82
Other residents: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00388932 completed on September 9, 2022.
Complaint Details
Investigation of Complaint IN00388932 completed on September 9, 2022; paper compliance review found the facility in compliance.
Findings
Rosewalk Village at Lafayette was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Date: Sep 28, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00391009.
Complaint Details
Complaint IN00391009 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint IN00391009 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Medicare census: 6
Medicaid census: 79
Other payor census: 12
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 1
Date: Sep 8, 2022
Visit Reason
This visit was for the investigation of Complaint IN00388932, which was substantiated with federal/state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00388932 was substantiated. The investigation found deficiencies related to failure to follow physician orders for timely follow-up care and treatment of a resident's surgical wound infection.
Findings
The facility failed to follow a physician's order to have a resident seen at the physician's clinic one week after admission, resulting in delayed follow-up care and infection management for the resident's surgical wound. The resident missed the orthopedic appointment, and the facility staff did not reschedule it timely, leading to an infection that required antibiotic treatment and wound care.
Deficiencies (1)
Failure to ensure a resident was seen at the physician's clinic one week after admission as ordered, resulting in delayed treatment of a surgical wound infection.
Report Facts
Census: 97
Total Capacity: 97
Medicare residents: 8
Medicaid residents: 79
Other residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP 3 | Nurse Practitioner | Observed resident, removed staples and bandage, wrote orders for wound care and scheduling physician visit |
| Director of Nursing | Director of Nursing | Interviewed regarding missed appointment and resident care |
| NP 4 | Nurse Practitioner | Consulted regarding cast duration and resident observation |
| Supervisor of NP 3 | Supervisor | Interviewed about responsibility for scheduling and resident care |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 93
Deficiencies: 0
Date: Aug 25, 2022
Visit Reason
This visit was conducted for the investigation of four complaints: IN00375857, IN00388106, IN00387681, and IN00384974.
Complaint Details
Complaints IN00375857, IN00388106, IN00387681, and IN00384974 were all substantiated, but no deficiencies related to the allegations were cited.
Findings
All four complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable federal and state regulations.
Report Facts
Census SNF/NF beds: 93
Census total residents: 93
Census Medicare residents: 15
Census Medicaid residents: 69
Census other payor residents: 9
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