Inspection Report Summary
The most recent inspection on March 7, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern, with several citations primarily involving medication management, emergency preparedness, life safety code compliance, and resident care issues such as documentation and infection control. Complaint investigations were mostly unsubstantiated, though one complaint in May 2023 was substantiated with a deficiency related to improper use of a Hoyer lift resulting in resident injury. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement in recent months, with the latest inspections indicating compliance after prior findings.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
23.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
467% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 13, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident where the facility allegedly failed to provide adequate supervision during incontinence care, resulting in a resident being rolled off the bed and hospitalized.
Complaint Details
The complaint investigation substantiated that Resident B was not properly supervised during incontinence care, leading to a fall and hospitalization with a traumatic brain injury. The resident required two-person assistance and a bariatric bed due to weight and mobility limitations. Staff left the resident unattended during care, which was against facility policy.
Findings
The facility failed to ensure proper supervision during incontinence care for Resident B, who rolled off the bed and sustained an eight-millimeter frontal subdural hematoma. Staff left the resident unattended during care, and the resident required a bariatric bed which was not properly utilized. Staff education on safe bed mobility and supervision was documented following the incident.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Report Facts
Residents reviewed for accidents: 3
Resident B weight: 300
Subdural hematoma thickness: 8
EMS personnel: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 4 | Named in the finding related to failure to provide adequate supervision during incontinence care | |
| LPN 5 | Named in the finding related to leaving the resident during care and failure to provide supervision | |
| Executive Director | Executive Director | Provided interview confirming Resident B did not return after hospital discharge |
| Speech Therapist 2 | Speech Therapist | Provided interview regarding Resident B's physical therapy evaluation and care needs |
| CNA 3 | Provided interview regarding Resident B's care needs and bed setup | |
| Environmental Service Director | Environmental Service Director | Provided interview regarding bed sizes and bariatric bed setup |
| Central Supply staff member | Responsible for bariatric bed setup for Resident B |
Inspection Report
Complaint Investigation
Census: 142
Capacity: 142
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454191.
Complaint Details
Complaint IN00454191 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. Carmel Health & Living Community 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 Complaint IN00454191.
Report Facts
Census SNF beds: 14
Census SNF/NF beds: 128
Total census beds: 142
Census Medicare residents: 13
Census Medicaid residents: 95
Census other payor residents: 34
Total census residents: 142
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 26, 2025
Visit Reason
Paper compliance review related to an unrelated deficiency cited during the Investigation of Complaint IN00449027 completed on January 8, 2025.
Complaint Details
Investigation of Complaint IN00449027 completed on January 8, 2025; paper compliance review was conducted.
Findings
Carmel Health & Living Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the unrelated deficiency cited during the complaint investigation.
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452502, IN00452584, and IN00452969 at Carmel Health & Living Community.
Complaint Details
Complaints IN00452502, IN00452584, and IN00452969 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00452502, IN00452584, and IN00452969 were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF beds: 14
Census SNF/NF beds: 129
Total census: 143
Medicare census: 32
Medicaid census: 94
Other payor census: 17
Inspection Report
Re-Inspection
Census: 145
Capacity: 188
Deficiencies: 0
Date: Jan 9, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 12/09/24.
Findings
At this PSR survey, Carmel Health & Living Community was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements. The facility was determined to be fully sprinklered with appropriate fire alarm and smoke detection systems in place.
Report Facts
Certified beds: 188
Census: 145
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
The inspection was conducted following a complaint regarding a staff member (RN 1) potentially taking residents' narcotic medications without proper documentation of administration.
Complaint Details
Complaint investigation triggered by a report from Qualified Medication Aide (QMA) 5 that RN 1 was signing out narcotic medications but not documenting administration. Investigation found no discrepancies in narcotic counts but confirmed documentation failures. RN 1 was suspended and then terminated for failure to follow policy.
Findings
The facility failed to ensure that narcotic medications were properly documented as administered in the residents' medical records for 2 of 2 residents reviewed. RN 1 signed out narcotics on the count sheet but did not document administration on the EMAR, leading to her termination.
Deficiencies (1)
Failure to follow policy and procedure when administering narcotics for 2 of 2 residents reviewed, including lack of documentation of narcotic administration in the EMAR despite signing out medications on the narcotic count sheet.
Report Facts
Dates and times narcotics signed out: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Named in medication administration documentation deficiency and subsequent termination for failure to follow policy. |
| Qualified Medication Aide 5 | Qualified Medication Aide | Reported concern about RN 1's narcotic medication handling. |
| Clinical Support Nurse | Provided facility documents and interviewed regarding RN 1's termination. |
Inspection Report
Complaint Investigation
Census: 139
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449027 at Carmel Health & Living Community on January 7 and 8, 2025.
Complaint Details
Complaint IN00449027 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited; however, an unrelated deficiency was found involving failure of a staff member to follow policy and procedure when administering narcotics to two residents. RN 1 was terminated for not documenting narcotic administration properly despite all narcotics being accounted for.
Deficiencies (1)
Failure to ensure a staff member followed the policy and procedure when administering narcotics for 2 residents, including failure to document narcotic administration on the EMAR while signing out narcotics on the count sheet.
Report Facts
Census: 139
SNF beds: 11
SNF/NF beds: 128
Medicare residents: 27
Medicaid residents: 102
Other residents: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Named in deficiency for failure to follow policy and procedure when administering narcotics; terminated for failure to document narcotic administration on EMAR. | |
| Alyssa Holliday | HFA | Laboratory Director or Provider/Supplier Representative who signed the report. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 19, 2024
Visit Reason
Paper compliance review related to the Recertification and State Licensure survey and the Investigation of Complaint IN00446463 completed on November 4, 2024.
Complaint Details
Investigation of Complaint IN00446463 was completed and found in compliance.
Findings
Carmel Health & Living Community 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 of the Recertification and State Licensure survey and the Investigation of Complaint IN00446463.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Date: Dec 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447970 and IN00448315 at Carmel Health & Living Community.
Complaint Details
Investigation of Complaints IN00447970 and IN00448315 found no deficiencies related to the allegations; both complaints were not substantiated.
Findings
No deficiencies related to the allegations in complaints IN00447970 and IN00448315 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census SNF beds: 9
Census SNF/NF beds: 124
Total census: 133
Medicare census: 23
Medicaid census: 102
Other payor census: 8
Inspection Report
Life Safety
Census: 130
Capacity: 188
Deficiencies: 4
Date: Dec 9, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal and state regulations.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including failure to meet emergency power system testing requirements, damaged sprinkler heads, combustible decorations on a resident room door, and incomplete generator load testing records.
Deficiencies (4)
Failed to implement emergency power system inspection, testing, and maintenance requirements; generator exercised less than 30 minutes for twelve of the last twelve months.
Sprinkler heads in the kitchen dish area and lower level corridor were damaged due to bent deflectors.
Combustible holiday wrapping paper covered over 90% of the corridor door to resident room 720, not treated with fire retardant material.
Failed to maintain a complete written record of monthly generator load testing for 12 of the last 12 months for 1 of 3 generators.
Report Facts
Certified beds: 188
Census: 130
Generator run time: 20
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Holliday | HFA | Laboratory Director's or Provider/Supplier Representative's signature on the report |
| Environmental Services Director | Interviewed regarding generator testing and sprinkler head observations | |
| Administrator | Interviewed and present at exit conference | |
| Assistant Administrator | Interviewed and present at exit conference | |
| Maintenance Director | Responsible for re-education and monitoring generator run times | |
| Maintenance Supervisor | Contracted to replace damaged sprinkler heads |
Inspection Report
Recertification
Census: 143
Capacity: 143
Deficiencies: 11
Date: Nov 4, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of complaints IN00438262 and IN00446463.
Complaint Details
Complaint IN00438262: No deficiencies related to the allegations are cited. Complaint IN00446463: Federal/State deficiencies related to the allegations are cited at F804 (food temperature).
Findings
The facility was found deficient in multiple areas including resident rights regarding mail privacy, PASARR accuracy, comprehensive care planning, quality of care including medication administration and communication, accident hazards, respiratory care, pharmacy procedures, medication storage, dental services, food temperature, and environmental safety.
Deficiencies (11)
Facility failed to ensure mail was delivered unopened for 1 of 1 resident reviewed for resident rights (Resident 135).
Facility failed to ensure pre-admission screening and resident reviews (PASARR) were accurate and updated for 2 of 3 residents reviewed (Residents 87 and D).
Facility failed to ensure a comprehensive person-centered care plan was developed for a resident diagnosed and treated for insomnia (Resident F).
Facility failed to ensure staff followed physician's orders to hold medications, administer PRN medications according to parameters, obtain daily weights, and communicate with urologist and hospice provider for 5 of 5 residents reviewed (Residents G, H, F, 33, and 105).
Facility failed to ensure a resident did not have smoking articles in their room (Resident 241).
Facility failed to ensure the correct amount of oxygen was administered as ordered by the physician for 2 of 3 residents reviewed for respiratory care (Residents 10 and 37).
Facility failed to ensure on-coming and off-going staff signed the narcotic count books each shift for 2 of 3 medication carts reviewed for drug reconciliation (700-unit and 400-unit).
Facility failed to ensure medications and supplements were labeled and dated, expired medications were removed, and medications were stored safe and secured for 3 of 3 units and 2 of 2 residents reviewed for medication storage (500-unit, 800-unit, 700-unit, Resident 80 and Resident 45).
Facility failed to ensure a resident received dental services to repair or replace partial dentures for 1 of 1 resident reviewed (Resident 122).
Facility failed to ensure food was served at a safe and appetizing temperature for 1 of 1 room tray tested (200 hall).
Facility failed to ensure a safe, functional, sanitary, and comfortable environment was provided for 5 of 142 rooms reviewed (Rooms 314, 401, 428, 527, 719).
Report Facts
Census Bed Type SNF/NF: 120
Census Bed Type SNF: 23
Total Census: 143
Medicare Census: 14
Medicaid Census: 115
Other Payor Census: 14
Narcotic log missing signatures: 31
Narcotic log missing signatures: 28
Narcotic log missing signatures: 34
Narcotic log missing signatures: 33
Narcotic log missing signatures: 39
Narcotic log missing signatures: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Holliday | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Unit Manager 4 | Interviewed regarding mail delivery, narcotic logs, medication storage, and environmental issues | |
| Business Office Manager | BOM | Interviewed regarding mail opening incident |
| Executive Director | ED | Interviewed regarding mail policy and environmental issues |
| Clinical Support nurse | Interviewed regarding PASARR, care plans, and medication orders | |
| Social Services 14 | Interviewed regarding PASARR and care plan responsibilities | |
| RN 10 | Interviewed regarding oxygen administration and medication administration | |
| Director of Nursing | DON | Interviewed regarding hospice orders, medication administration, narcotic logs, and oxygen administration |
| Assistant Director of Nursing | ADON | Interviewed regarding medication administration and hospice communication |
| Unit Manager 8 | Interviewed regarding communication with providers and hospice orders | |
| CNA 20 | Observed and interviewed regarding resident with vape in room | |
| LPN 16 | Observed medication cart and interviewed regarding expired medications | |
| LPN 17 | Observed medication cart and interviewed regarding medication storage | |
| Unit Manager 19 | Interviewed regarding exposed wires in room | |
| Administrator | Interviewed regarding dental services and environmental issues | |
| CNA 5 | Interviewed regarding resident's missing dentures | |
| Unit Manager 18 | Interviewed regarding communication about resident's antibiotic | |
| Hospice nurse RN 12 | Interviewed regarding hospice medication orders |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Nov 4, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to follow physician's orders, medication administration errors, lack of communication with outside providers, and food safety concerns at Carmel Health & Living Community.
Complaint Details
The complaint investigation revealed multiple failures including medication administration errors, failure to follow physician's orders, lack of communication with outside providers, and food safety issues. Specific residents (G, H, F, 33, 105, E, D, B, C) were affected by these deficiencies.
Findings
The facility failed to follow physician's orders for medication administration, including holding medications based on parameters, administering as needed medications, obtaining daily weights, and communicating with outside providers. Additionally, the facility failed to ensure food was served at a safe and appetizing temperature.
Deficiencies (7)
Failure to hold blood pressure medication metoprolol when blood pressure readings were below physician's parameters.
Failure to obtain daily weights and administer Lasix as ordered for weight gain.
Failure to administer as needed clonidine for high systolic blood pressure as ordered.
Failure to hold insulin (Humalog) doses when blood sugar was below physician's hold parameters.
Failure to communicate and follow up with outside providers regarding antibiotic orders for urinary tract infection, resulting in a 6-day delay in treatment.
Failure to discontinue medications (melatonin and lorazepam) per hospice nurse orders, resulting in continued administration after discontinuation.
Failure to serve food at a safe and appetizing temperature; food was served cold below the required temperature.
Report Facts
Medication administration dates: 4
Missed daily weights: 4
Missed Lasix administrations: 3
Missed as needed clonidine administrations: 15
Delay in antibiotic treatment: 6
Food temperature: 100
Food temperature: 101
Food temperature: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 8 | Unit Manager | Indicated nursing staff were not supposed to give metoprolol when blood pressure was low; checked hospice binders; involved in medication order issues. |
| Director of Nursing | Director of Nursing (DON) | Indicated missing daily weights and Lasix administrations; discussed hospice nurse order communication. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Indicated uncertainty about missing daily weights and Lasix administration. |
| Corporate Support Nurse | Corporate Support Nurse | Indicated facility lacked policy for following physician's orders and follow-up communication with outside providers. |
| Clinical Support Nurse | Clinical Support Nurse | Indicated Humalog doses were to be held when blood sugar was less than 150. |
| Unit Manager 4 | Unit Manager | Indicated as needed clonidine was to be given when systolic blood pressure was greater than 160. |
| RN 9 | Registered Nurse | Described procedure for handling residents returning from appointments without paperwork. |
| Unit Manager 18 | Unit Manager | Indicated no receipt of faxed antibiotic orders for Resident H. |
| Hospice Nurse RN 12 | Hospice Nurse | Communicated new medication orders and protocol for order communication; unable to verify if orders were placed. |
| Administrator | Administrator | Indicated Resident H returned from outpatient appointment without paperwork. |
| Assistant Dining Services Supervisor | Assistant Dining Services Supervisor | Indicated hot food should be served at least 120 degrees or higher and reheated if below. |
Inspection Report
Routine
Deficiencies: 11
Date: Nov 4, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, safety, and facility environment at Carmel Health & Living Community.
Findings
The facility was found deficient in multiple areas including failure to ensure resident mail privacy, inaccurate PASARR screenings, incomplete care plans, medication administration errors, unsafe storage and labeling of medications, inadequate dental services, improper oxygen administration, unsafe environment conditions, and food served at unsafe temperatures.
Deficiencies (11)
Failed to ensure mail was delivered unopened for 1 of 1 resident reviewed for resident rights.
Failed to ensure pre-admission screening and resident reviews (PASARR) were accurate and updated for 2 of 3 residents reviewed.
Failed to ensure a comprehensive person-centered care plan was developed for a resident diagnosed and treated for insomnia.
Failed to ensure appropriate treatment and care according to orders, resident’s preferences and goals for 5 residents including medication administration errors and communication failures.
Failed to ensure a resident did not have smoking articles in their room.
Failed to ensure correct oxygen flow rate was administered as ordered for 2 of 3 residents reviewed for respiratory care.
Failed to ensure on-coming and off-going staff signed narcotic count books each shift for 2 of 3 medication carts reviewed.
Failed to ensure medications and supplements were labeled and dated, expired medications removed, and medications stored safely for 3 units and 2 residents reviewed.
Failed to ensure a resident received dental services to repair or replace partial dentures.
Failed to ensure food was served at a safe and appetizing temperature for 1 of 1 room tray tested.
Failed to ensure a safe, functional, sanitary, and comfortable environment was provided for 5 of 142 rooms reviewed.
Report Facts
Narcotic log missing signatures: 31
Narcotic log missing signatures: 28
Narcotic log missing signatures: 34
Narcotic log missing signatures: 33
Narcotic log missing signatures: 39
Narcotic log missing signatures: 30
Medication administration errors: 5
Medication administration errors: 4
Medication administration errors: 3
Medication administration errors: 9
Medication administration errors: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 4 | Indicated staff were supposed to sign narcotic logs and commented on medication and environment deficiencies | |
| Business Office Manager | BOM | Indicated facility opened resident's Medicaid mail under corporate direction |
| Executive Director | ED | Indicated no mail delivery policy and commented on environment issues |
| Director of Nursing | DON | Commented on medication administration and hospice communication |
| Assistant Director of Nursing | ADON | Commented on medication administration and hospice communication |
| Clinical Support nurse | Indicated facility did not have policies for PASARR, care plans, and medication orders | |
| Social Services 14 | Responsible for PASARR and care plan reviews | |
| Unit Manager 8 | Commented on medication administration and communication with providers | |
| RN 10 | Indicated medication administration and oxygen flow rate responsibilities | |
| LPN 16 | Observed medication cart deficiencies | |
| LPN 17 | Observed medication cart deficiencies | |
| CNA 20 | Observed resident with vape in room | |
| Unit Manager 19 | Commented on environment safety issues | |
| CNA 5 | Commented on resident dental status | |
| Administrator | Commented on dental services and environment | |
| Clinical Support nurse | Provided facility policies and comments on medication and dental services | |
| Assistant Dining Services Supervisor | Commented on food temperature standards | |
| Hospice nurse RN 12 | Communicated medication orders and protocol for new orders |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 135
Deficiencies: 0
Date: May 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433160.
Complaint Details
Complaint IN00433160 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00433160 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census bed type: 135
Census payor type: 135
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 23, 2024
Visit Reason
Paper compliance review to the unrelated deficiencies cited during the Complaint Investigation completed on March 1, 2024.
Findings
Carmel Health & Living Community 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 unrelated deficiencies.
Inspection Report
Complaint Investigation
Census: 140
Capacity: 140
Deficiencies: 2
Date: Mar 1, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00425000, IN00428864, and IN00428932). No deficiencies related to the allegations in these complaints were cited, but unrelated deficiencies were identified.
Complaint Details
The investigation covered complaints IN00425000, IN00428864, and IN00428932. No deficiencies related to the allegations in these complaints were cited.
Findings
The facility was found deficient in ensuring the interdisciplinary team determined clinical appropriateness for resident self-administration of medications, and failed to maintain infection control practices during medication administration. Specifically, one resident was found with medications at bedside without proper assessment or orders for self-administration, and one staff member was observed removing medication from packaging in an unsanitary manner.
Deficiencies (2)
Failed to ensure the interdisciplinary team determined a resident was clinically appropriate to self-administer medications for 1 of 1 residents observed.
Failed to ensure infection control practices were maintained when a staff member failed to remove medications from packaging in a sanitary manner for 1 of 5 residents reviewed.
Report Facts
Census: 140
Total Capacity: 140
Residents Medicare: 27
Residents Medicaid: 102
Residents Other: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Holliday | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 1 | Observed during medication self-administration deficiency | |
| LPN 2 | Observed during infection control deficiency related to medication administration |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 1, 2024
Visit Reason
The inspection was conducted to assess compliance with medication self-administration policies and infection prevention and control practices at the facility.
Findings
The facility failed to ensure that a resident was clinically appropriate to self-administer medications as required by policy, and failed to maintain proper infection control practices during medication administration when a staff member used fingers to remove medication from packaging.
Deficiencies (2)
Failed to ensure the interdisciplinary team determined a resident was clinically appropriate to self-administer medications.
Failed to ensure infection control practices were maintained when a staff member failed to remove medication from the packaging in a sanitary manner.
Report Facts
Residents reviewed for medication administration: 5
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Observed leaving resident unattended during medication self-administration | |
| LPN 2 | Observed using fingers to remove medication from packaging |
Inspection Report
Life Safety
Census: 135
Capacity: 188
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
A Post Survey Revisit (PSR) to the 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
At this PSR Life Safety Code survey, Carmel Health & Living Community was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 188
Census: 135
Inspection Report
Life Safety
Census: 135
Capacity: 188
Deficiencies: 5
Date: Nov 14, 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) and the 2012 Edition of the NFPA 101 Life Safety Code.
Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including fire doors that failed to self-close and latch, an exit ramp not meeting slope requirements, confusing exit signage, hazardous area doors lacking self-closing devices, and improper use of electrical cords and power strips.
Deficiencies (5)
Failed to ensure 2 of over 6 horizontal exit fire door sets were arranged to automatically close and latch.
Failed to ensure 1 of over 3 exit ramps met the slope requirement.
Failed to ensure 1 of over 8 doors to the outside of the facility were not mistaken as a facility exit due to contradictory signage.
Failed to ensure 1 of over 10 hazardous area doors were provided with properly working self-closing devices.
Failed to ensure 1 of 1 flexible cords were not used as a substitute for fixed wiring and 2 of 2 power strips in patient care locations did not meet required UL ratings.
Report Facts
Certified beds: 188
Census: 135
Horizontal exit fire doors: 2
Horizontal exit fire doors total: 6
Exit ramps: 1
Exit ramps total: 3
Ramp run length: 100
Ramp elevation rise: 30
Hazardous area doors: 1
Power strips: 2
Staff affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Holliday | Administrator | Signed plan of correction letter |
| Maintenance Supervisor | Acknowledged deficiencies and participated in interviews | |
| Executive Director | Acknowledged deficiencies and participated in interviews |
Inspection Report
Annual Inspection
Census: 132
Capacity: 132
Deficiencies: 7
Date: Oct 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00419759.
Complaint Details
Complaint IN00419759 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found deficient in several areas including failure to ensure code status was clearly indicated for one resident, failure to maintain privacy for three residents, failure to ensure the right to file a grievance without interference for two residents, failure to follow physician orders for two residents, failure to obtain weekly weights as ordered for one resident, failure to ensure consistent midline IV care for one resident, and failure to ensure pain interventions were initiated consistently for two residents.
Deficiencies (7)
The facility failed to ensure code status was clearly indicated for 1 of 26 residents reviewed (Resident 81).
The facility failed to ensure privacy was maintained for 3 of 11 residents reviewed (Resident 8, Resident 43, Resident 64).
The facility failed to ensure the right to file a grievance without interference was maintained for 2 of 9 residents reviewed (Resident 36, Resident 97).
The facility failed to follow physician orders for 2 of 6 residents reviewed (Resident 4, Resident 98).
The facility failed to ensure weights weekly as ordered were obtained for 1 of 3 residents reviewed (Resident 40).
The facility failed to ensure consistent midline intravenous (IV) care for 1 of 1 resident reviewed with parenteral fluids (Resident 40).
The facility failed to ensure pain interventions were initiated consistently for 2 of 6 residents reviewed (Resident 238, Resident 4).
Report Facts
Census: 132
Total Capacity: 132
Residents reviewed for code status: 26
Residents reviewed for privacy: 11
Residents reviewed for grievance: 9
Residents reviewed for physician orders: 6
Residents reviewed for weight monitoring: 3
Residents reviewed for midline IV care: 1
Residents reviewed for pain management: 6
Inspection Report
Renewal
Deficiencies: 0
Date: Oct 27, 2023
Visit Reason
The visit was a paper compliance review related to the Recertification and State Licensure survey completed on October 27, 2023.
Findings
Carmel Health and Living 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
Routine
Deficiencies: 7
Date: Oct 27, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights, privacy, grievance procedures, medication administration, weight monitoring, IV care, and pain management at Carmel Health & Living Community.
Findings
The facility was found deficient in multiple areas including inconsistent documentation and communication of residents' code status, failure to maintain privacy during care discussions, interference with residents' grievance rights, failure to follow physician orders for medication administration, inadequate weight monitoring as ordered, inconsistent midline IV care without physician orders, and delayed or insufficient pain management interventions.
Deficiencies (7)
Failed to ensure code status was clearly indicated for 1 of 26 residents reviewed (Resident 81).
Failed to ensure privacy was maintained for 3 of 11 residents reviewed (Resident 8, Resident 43, Resident 64).
Failed to ensure the right to file a grievance without interference was maintained for 2 of 9 residents reviewed (Resident 36 and Resident 97).
Failed to follow physician orders for 2 of 6 residents reviewed (Resident 4 and Resident 98).
Failed to ensure weights weekly as ordered were obtained for 1 of 3 residents reviewed (Resident 40).
Failed to ensure consistent midline intravenous (IV) care for 1 of 1 resident reviewed with parenteral fluids (Resident 40).
Failed to ensure pain interventions were initiated consistently for 2 of 6 residents reviewed (Resident 238 and Resident 4).
Report Facts
Residents reviewed for code status: 26
Residents reviewed for privacy: 11
Residents reviewed for grievance rights: 9
Residents reviewed for medication order compliance: 6
Residents reviewed for weight monitoring: 3
Residents reviewed for IV care: 1
Residents reviewed for pain management: 6
Weight loss percentage: 5.2
Number of times insulin was held without documentation: 23
Number of times opioid medication administered without non-med intervention: 15
Number of times opioid medication administered without non-med intervention: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding code status, insulin administration, midline IV care, and pain management. |
| RN 10 | Registered Nurse | Provided policy information and interview regarding midline IV care. |
| Unit Manager 2 | Unit Manager | Interviewed regarding privacy policy. |
| Administrator | Administrator | Interviewed regarding grievance procedures and pain policy. |
| Social Services 4 | Social Services Staff | Interviewed regarding grievance assistance. |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413324.
Complaint Details
Complaint IN00413324 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 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census: 126
Census Bed Type - SNF/NF: 120
Census Bed Type - SNF: 6
Census Payor Type - Medicare: 5
Census Payor Type - Medicaid: 88
Census Payor Type - Other: 33
Inspection Report
Life Safety
Census: 127
Capacity: 188
Deficiencies: 0
Date: Jul 11, 2023
Visit Reason
This was a Pre-Occupancy Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Carmel Health & Living Community was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. The facility is fully sprinklered with appropriate smoke detection systems and all resident-accessible areas were sprinklered.
Report Facts
Facility capacity: 188
Census: 127
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00407987 completed on May 9, 2023.
Complaint Details
Investigation of Complaint IN00407987 completed on May 9, 2023; facility found in compliance.
Findings
Carmel Health & Living Community 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 of the complaint investigation.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Date: May 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408784.
Complaint Details
Complaint IN00408784 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 relevant regulations.
Report Facts
Census: 133
Census bed type - SNF: 2
Census bed type - SNF/NF: 131
Census payor type - Medicare: 9
Census payor type - Medicaid: 115
Census payor type - Other: 9
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 9, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding a resident (Resident B) being dropped from a Hoyer lift during transfer.
Complaint Details
This Federal tag relates to Complaint IN00407987. The complaint involved Resident B being dropped from a Hoyer lift due to staff not following proper procedures, including insufficient staff assistance during the transfer.
Findings
The facility failed to ensure that staff followed the Hoyer lift policy and procedure while transferring Resident B, resulting in the resident slipping out of the sling and being lowered to the floor. The incident caused minimal harm, including pain and a pulled muscle, and was attributed to inadequate staffing and use of an improperly sized Hoyer pad.
Deficiencies (1)
Failure to ensure a staff member followed the Hoyer lift policy and procedure while transferring a resident, resulting in a fall from the Hoyer lift.
Report Facts
Residents Affected: 2
Residents Affected: 1
Date of fall: Apr 30, 2023
Date of record review: May 8, 2023
Date of progress note: May 1, 2023
Date of physical therapy note: Apr 26, 2023
Muscle relaxer duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Performed the Hoyer lift transfer alone and was involved in the incident where Resident B fell |
| QMA 2 | Qualified Medication Aide | Was standing in the doorway during the transfer but did not assist inside the room as required |
| RN 3 | Registered Nurse | Assisted in getting Resident B off the floor after the fall |
| ED | Executive Director | Provided information about facility policy and staffing requirements for Hoyer lift transfers |
Inspection Report
Complaint Investigation
Census: 136
Deficiencies: 1
Date: May 8, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407987 regarding allegations of a resident being dropped from a Hoyer lift during transfer.
Complaint Details
Complaint IN00407987 was substantiated with federal/state deficiencies cited related to the allegation of a resident being dropped from a Hoyer lift during transfer.
Findings
The facility failed to ensure staff followed the Hoyer lift policy and procedure, resulting in a resident being lowered to the floor during transfer due to a loose sling and inadequate staff assistance. The resident sustained a muscle strain and pain managed by nursing staff and physician. The facility implemented corrective actions including re-education of staff and increased observation of Hoyer lift transfers.
Deficiencies (1)
Failure to ensure staff members follow the Hoyer Lift Policy and Procedure to prevent falls or injury from a Hoyer lift transfer.
Report Facts
Census total residents: 136
Census SNF beds: 7
Census SNF/NF beds: 129
Census Medicare residents: 13
Census Medicaid residents: 114
Census Other payor residents: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tiffany Tackett | RN | Facility representative signing the report |
| CNA 1 | Named in finding for performing Hoyer lift transfer alone resulting in resident fall | |
| RN 3 | Assisted in getting resident off floor after fall | |
| QMA 2 | Present in doorway during transfer but did not assist as required | |
| ED | Executive Director | Provided interview regarding care requirements and policy |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 3
Date: Apr 25, 2023
Visit Reason
This visit was for Investigation of multiple Complaints (IN00397137, IN00398770, IN00406781, IN00397046, IN00398768, IN00400373, IN00403758, IN00404541, IN00403649, and IN00405831).
Complaint Details
Complaints IN00397137, IN00398770, IN00406781, and IN00397046 had Federal/State deficiencies related to the allegations cited at F755, F759, and F842. Complaints IN00398768, IN00400373, IN00403758, IN00404541, IN00403649, and IN00405831 had no deficiencies related to the allegations.
Findings
The facility was found deficient in ensuring residents' scheduled medications were available, maintaining medication error rates below 5%, and accurately documenting medication administration on the EMAR. Several residents were affected by medication availability and administration errors, and documentation deficiencies were noted.
Deficiencies (3)
The Facility failed to ensure residents’ scheduled medications were available to meet the needs of 2 of 5 residents reviewed for medication availability.
The Facility failed to keep the medication error rate less than 5% when 3 errors were observed during 31 opportunities for errors for 3 of 5 residents observed during medication administration.
The facility failed to ensure a resident’s medications were completely and accurately documented on the EMAR (electronic medication administration record) for 1 of 5 residents reviewed for medication administration documentation.
Report Facts
Census: 133
Medication error rate: 9.67
Medication administration opportunities: 31
Medication administration errors: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Holliday | HFA | Laboratory Director's or Provider/Supplier Representative's Signature on report |
| LPN 12 | Observed pulling Resident T's morning medications and noted medication unavailability | |
| QMA 11 | Observed pulling Resident U's morning medications and noted medication unavailability and documentation issues | |
| RN 1 | Observed administering medications to Resident P with medication error | |
| DON | Director of Nursing | Present during medication administration observations and audits |
| ED | Executive Director | Provided current policy titled 'Licensed Nurse Med Pass Clinical Skills Validation' |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 25, 2023
Visit Reason
Paper compliance review to the Investigation of Complaints IN00397137, IN00398770, IN00406781, and IN00397046 completed on April 25, 2023.
Findings
Carmel Health & Living Community 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 of the investigations.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 25, 2023
Visit Reason
The inspection was conducted in response to multiple complaints (IN00397137, IN00398770, IN00406781, and IN00397046) regarding medication administration and pharmaceutical services at Carmel Health & Living Community.
Complaint Details
The inspection relates to complaints IN00397137, IN00398770, IN00406781, and IN00397046. The complaints involved medication availability, medication errors, and documentation issues.
Findings
The facility failed to ensure residents' scheduled medications were available and administered properly, resulting in medication errors affecting 3 of 5 residents observed. Additionally, medication administration documentation was incomplete for one resident. The medication error rate was 9.67%, exceeding the acceptable threshold of less than 5%.
Deficiencies (3)
Failed to ensure residents' scheduled medications were available to meet the needs of 2 of 5 residents reviewed for medication availability (Residents T and U).
Failed to keep the medication error rate less than 5% when three errors were observed during 31 opportunities for errors for 3 of 5 residents observed during medication administration (Residents P, T, and U).
Failed to ensure a resident's medications were completely and accurately documented on the EMAR for 1 of 5 residents reviewed for medication administration documentation (Resident T).
Report Facts
Medication error rate: 9.67
Medication errors observed: 3
Opportunities for errors: 31
Units of insulin administered: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 12 | Licensed Practical Nurse | Observed pulling Resident T's morning medications; noted medication unavailability. |
| QMA 11 | Qualified Medication Aide | Observed pulling Resident U's morning medications; noted medication unavailability and incomplete documentation. |
| RN 1 | Registered Nurse | Observed administering insulin to Resident P and failing to prime the insulin pen. |
| DON | Director of Nursing | Present during medication administration observations and medication availability checks. |
| ED | Executive Director | Provided current policy titled Licensed Nurse Med Pass Clinical Skills Validation. |
Inspection Report
Life Safety
Census: 123
Capacity: 188
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/15/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR Life Safety Code survey, Carmel Health & Living Community was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Complaint Investigation
Census: 125
Deficiencies: 0
Date: Nov 17, 2022
Visit Reason
This visit was conducted for the investigation of three complaints: IN00394467, IN00389930, and IN00389668.
Complaint Details
Complaint IN00394467 - Substantiated with no deficiencies cited. Complaint IN00389930 - Substantiated with no deficiencies cited. Complaint IN00389668 - Substantiated with no deficiencies cited.
Findings
All three complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type - SNF/NF: 121
Census Bed Type - SNF: 4
Census Bed Type - Total: 125
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 106
Census Payor Type - Other: 10
Census Payor Type - Total: 125
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 19, 2022
Visit Reason
Paper compliance review to the Recertification and State Licensure survey and Investigation of Complaint IN00379657 completed on August 10, 2022.
Findings
Carmel Health and Living was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey and Investigation of Complaint IN00379657.
Inspection Report
Life Safety
Census: 117
Capacity: 188
Deficiencies: 14
Date: Sep 15, 2022
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and 42 CFR 483.73 Emergency Preparedness survey.
Findings
The facility was found not in compliance with Life Safety Code requirements including issues with smoke barrier door latching, hazardous storage, exit door locking codes, exit discharge surfaces, exit signage, oxygen room door self-closing, sprinkler installation, corridor door latching, electrical safety including GFCI protection and locked electrical panels, smoking policy enforcement, portable space heaters use, extension cords and power strips usage, and oxygen transfilling room fire-resistance.
Deficiencies (14)
Failed to maintain latching hardware on 2 of 2 smoke barrier doors in the basement.
Failed to ensure furnace closet in activities area was free and clear of hazards.
Failed to ensure exit doors with magnetic locks had proper codes posted.
Failed to ensure 1 of over 10 exit discharges had a level walking surface free of obstructions.
Failed to ensure exit discharge from property to public way.
Failed to ensure exit sign in basement had directional indicators.
Failed to ensure hazardous area oxygen room door had properly working self-closing device.
Failed to ensure sprinkler system installation met NFPA 13 requirements; sprinkler less than 1 inch from wall.
Failed to ensure corridor doors had no impediment to closing and latching.
Failed to ensure ground fault circuit interrupter (GFCI) protection in wet locations and locked electrical panels.
Failed to ensure smoking areas were maintained with proper disposal containers.
Failed to ensure portable space heaters were not used in resident care areas.
Failed to ensure flexible cords and power strips were not used as substitutes for fixed wiring.
Failed to ensure oxygen transfilling room was separated by one-hour fire-resistive construction; hole in wall by door.
Report Facts
Certified beds: 188
Census: 117
Deficiencies cited: 13
Residents potentially affected: 25
Residents potentially affected: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alyssa Holliday | HFA Administrator | Named in plan of correction letter |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Named in plan of correction letter |
Inspection Report
Annual Inspection
Census: 119
Deficiencies: 7
Date: Aug 10, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00379657, IN00379969, and IN00385351.
Complaint Details
Complaint IN00379657 was substantiated with related federal/state deficiencies cited at F880. Complaints IN00379969 and IN00385351 were substantiated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach, timely care for pressure ulcers, medication storage and labeling, infection control practices including PPE use in isolation rooms, and food safety including proper labeling and drying of pans.
Deficiencies (7)
Failed to keep the call light within the resident's reach for 2 of 2 residents observed.
Failed to identify and provide needed care in a timely manner for 1 of 2 residents reviewed for pressure ulcers.
Failed to ensure medications were not left at the bedside without an order to self-administer for 1 of 1 resident observed.
Failed to label the enteral feeding bag with feeding type and amount for 1 of 1 resident reviewed for tube feeding.
Failed to label medications with open dates, ensure medications were stored in original containers, ensure insulin pen had legible label, and discard discontinued medications for 4 of 4 medication carts and 2 of 3 medication refrigerators.
Failed to ensure pans were thoroughly dried before storage, failed to ensure food items were labeled/dated with open dates, and failed to identify contents of containers in 1 of 2 kitchens and 3 of 4 units.
Failed to develop and implement written policies and procedures for infection control, including failure to ensure staff used appropriate PPE in isolation rooms for 2 of 2 observations.
Report Facts
Census: 119
Survey dates: 8
Deficiency counts: 7
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Aug 10, 2022
Visit Reason
The inspection was conducted based on complaint allegations regarding failure to accommodate resident needs, pressure ulcer care, medication safety, feeding tube care, medication storage, food safety, and infection control practices.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to resident care, medication management, infection control, and food safety.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within residents' reach, delayed pressure ulcer care, unsafe medication practices including leaving medications unattended, improper labeling of feeding tubes, inadequate medication storage and labeling, failure to properly label and store food items, and failure to use appropriate PPE in isolation rooms.
Deficiencies (7)
Failed to keep the call light within the resident's reach for 2 of 2 residents observed.
Failed to identify and provide timely care for pressure ulcers for 1 of 2 residents reviewed.
Medications were left at bedside without an order to self-administer for 1 of 1 resident observed.
Failed to label enteral feeding bag with feeding type and amount for 1 of 1 resident reviewed.
Failed to label medications with open dates, store medications in original containers, and discard discontinued medications for multiple medication carts and refrigerators.
Failed to ensure pans were thoroughly dried before storage, failed to label and date food items, and failed to identify contents in containers in kitchen and unit pantries.
Failed to ensure staff used appropriate PPE in isolation rooms for 2 of 2 observations.
Report Facts
Medication doses: 9
Medication bottles: 5
Pressure ulcer measurements: 5
Pressure ulcer measurements: 4
Feeding bag volume: 800
Feeding pump rate: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Observed not using appropriate PPE in isolation room and interviewed regarding call light placement. | |
| RN 4 | Interviewed regarding medication dating and storage practices. | |
| Director of Nursing | DON | Provided facility policies, interviewed about medication and infection control deficiencies. |
| Unit Manager | Interviewed regarding call light placement and pressure ulcer care. | |
| CNA 9 | Observed not wearing PPE properly in isolation room and interviewed about infection control. | |
| Dietary Manager | Interviewed regarding food storage and labeling deficiencies. | |
| Executive Director | ED | Interviewed regarding infection control policies and PPE use. |
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