Inspection Report Summary
The most recent inspection on May 13, 2025, found the facility in compliance with no deficiencies cited during follow-up visits related to multiple complaint investigations. Earlier inspections showed a pattern of deficiencies primarily involving resident neglect, including failure to properly assess and treat pressure wounds, inadequate supervision leading to resident elopement, and incidents of physical abuse and unsafe transfers. Several complaints were substantiated, such as neglect resulting in resident injuries and abuse confirmed by video evidence, which led to staff termination and corrective actions. No fines, immediate jeopardy findings, or license suspensions were listed in the available reports, and most complaint investigations following the substantiated cases were corrected or found to have no deficiencies. The recent clean findings suggest improvement in addressing prior issues related to resident care and safety.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
48 residents
Based on a May 2025 inspection.
Census over time
Inspection Report
Follow-Up
Census: 48
Deficiencies: 0
Date: May 13, 2025
Visit Reason
This visit was for the Post Survey Revisit (PSR) for the Investigation of Complaint IN00454251 completed on February 28, 2025, in conjunction with PSRs for other complaint investigations completed earlier in 2025.
Complaint Details
The visit was related to multiple complaint investigations (IN00454251, IN00445842, IN00450524, IN00456036, IN00456196). Complaints IN00454251, IN00445842, and IN00450524 were corrected. Complaints IN00456036 and IN00456196 had no deficiencies related to the allegations cited.
Findings
Brookdale Carmel was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-5 regarding the PSR to the Investigation of Complaint IN00454251. Complaints IN00454251, IN00445842, and IN00450524 were corrected; no deficiencies were cited related to complaints IN00456036 and IN00456196.
Report Facts
Facility number: 10416
Residential census: 48
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: May 13, 2025
Visit Reason
This visit was for the investigation of complaints IN00456036 and IN00456196, in conjunction with post survey revisits for complaints IN00445842, IN00450524, and IN00454251.
Complaint Details
Complaints IN00456036 and IN00456196 had no deficiencies related to the allegations. Complaints IN00445842, IN00450524, and IN00454251 were corrected.
Findings
No deficiencies related to complaints IN00456036 and IN00456196 were cited. Complaints IN00445842, IN00450524, and IN00454251 were corrected. The facility was found to be in compliance with relevant regulations.
Report Facts
Facility number: 10416
Residential census: 48
Inspection Report
Follow-Up
Census: 48
Deficiencies: 0
Date: May 12, 2025
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaints IN00445842 and IN00450524 completed on January 16, 2025, in conjunction with the PSR to the Investigation of Complaint IN00454251 completed on February 28, 2025, and the Investigation of Complaints IN00456036 and IN00456196.
Complaint Details
Complaint IN00445842-corrected. Complaint IN00450524-corrected. Complaint IN00454251-corrected. Complaint IN00456036-No deficiencies related to the allegations are cited. Complaint IN00456196-No deficiencies related to the allegations are cited.
Findings
Brookdale Carmel was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-5 regarding the PSR to the Investigations of Complaints IN00445842, IN00450524, and IN00454251. No deficiencies related to the allegations were cited for Complaints IN00456036 and IN00456196.
Report Facts
Facility number: 10416
Residential census: 48
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 1
Date: Feb 27, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453749 and IN00454251. Complaint IN00453749 had no deficiencies related to the allegations, while Complaint IN00454251 resulted in state deficiencies related to neglect.
Complaint Details
Complaint IN00453749 had no deficiencies related to the allegations. Complaint IN00454251 was substantiated with state deficiencies cited related to neglect of Resident C's pressure wounds.
Findings
The facility failed to ensure a resident (Resident C) was free from neglect when new pressure wounds were not appropriately identified, assessed, and reported to the physician, and licensed nurses treated pressure ulcers without physician orders. Resident C was hospitalized with multiple pressure wounds that were not properly managed at the facility.
Deficiencies (1)
Failed to ensure a resident was free from neglect when new pressure wounds were not appropriately identified, assessed, and reported to the physician, and licensed nurses treated pressure ulcers without physician orders for 1 of 3 residents reviewed for neglect (Resident C).
Report Facts
Survey dates: February 27 and 28, 2025
Resident census: 51
Wound measurements: 4.5
Wound measurements: 3
Wound measurements: 6
Wound measurements: 5
Wound measurements: 2.5
Wound measurements: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamala Williams | Executive Director | Signed the report |
| LPN 4 | Licensed Practical Nurse | Provided wound care and communicated with resident's POA regarding wounds |
| LPN 5 | Licensed Practical Nurse | Provided wound care and medication administration to Resident C |
| LPN 6 | Licensed Practical Nurse | Provided wound care and medication administration to Resident C |
| LPN 7 | Licensed Practical Nurse | Reported resident's condition and sent Resident C to ER |
| Director of Wellness | Interviewed and provided facility policies and corrective actions | |
| CNA 3 | Certified Nursing Assistant | Reported wounds and provided direct care to Resident C |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 2
Date: Jan 15, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00445842 and IN00450524 regarding allegations of neglect and abuse at Brookdale Carmel.
Complaint Details
The investigation was triggered by complaints IN00445842 and IN00450524. Complaint IN00445842 involved neglect related to improper wheelchair transfer causing Resident B to fall and sustain injuries. Complaint IN00450524 involved physical abuse of Resident C by CNA 1, substantiated by video evidence. Resident B passed away following the fall. CNA 1 was suspended and terminated following the abuse incident.
Findings
The facility failed to ensure staff used wheelchair foot pedals during a wheelchair transfer, resulting in Resident B falling and sustaining multiple injuries before passing away. Additionally, the facility failed to protect Resident C from physical abuse by a CNA, which was confirmed by video evidence leading to the CNA's termination.
Deficiencies (2)
Failure to ensure staff used wheelchair foot pedals during wheelchair transfer, leading to Resident B's fall and injuries.
Failure to protect Resident C from physical abuse by CNA 1, confirmed by video showing CNA striking the resident and tossing him onto the bed.
Report Facts
Residential Census: 54
Survey Dates: Inspection conducted on January 15 and 16, 2025
Incident Date Resident B Fall: October 15, 2024 at 2:20 p.m.
Resident B Date of Death: October 17, 2024 at 11:15 p.m.
Incident Date Resident C Abuse: January 1, 2025 at 7:50 a.m.
Plan of Correction Completion Date: February 6, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamala Williams | Executive Director | Signed the report and plan of correction |
| CNA 1 | Certified Nursing Assistant | Perpetrator of physical abuse against Resident C, suspended and terminated |
| CNA 2 | Certified Nursing Assistant | Failed to use wheelchair foot pedals during transfer of Resident B, causing fall |
| CNA 4 | Certified Nursing Assistant | Witnessed Resident B fall and alerted CNA 2 |
| CNA 5 | Certified Nursing Assistant | Provided information about Resident B's wheelchair footrests |
| Director of Nursing | Director of Nursing | Interviewed regarding the incidents and facility policies |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 3
Date: Oct 17, 2024
Visit Reason
This visit was for the investigation of complaints IN00435497, IN00435498, IN00435788, and IN00435971 regarding resident care and notification issues.
Complaint Details
The investigation was triggered by complaints alleging improper care techniques, failure to notify family of falls and injuries, and inadequate assistance during transfers. The complaints were substantiated with findings related to Resident B.
Findings
The facility was found deficient in treating a resident with respect and dignity, failing to notify a responsible party of a resident's fall, and not providing assistance with activities of daily living as ordered by therapy. Specifically, improper turning techniques, failure to notify family of falls, and inadequate staffing during mechanical lift transfers were observed.
Deficiencies (3)
Facility failed to ensure a resident was treated with respect and dignity during care when a CNA used an improper technique to turn the resident in bed.
Facility failed to notify a responsible party of a resident's fall for 1 of 7 residents reviewed for notification.
Facility failed to ensure assistance with activities of daily living was provided based on the resident's needs and as ordered by therapy for 1 of 1 resident reviewed for transfers.
Report Facts
Residential Census: 50
Survey Dates: Inspection conducted on October 16 and 17, 2024
Corrective Action Observation Frequency: 3
Corrective Action Observation Frequency: 10
Audit Percentage: 20
Audit Percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Pamala Williams | Executive Director | Signed the report and plan of correction |
| CNA 1 | Observed using improper technique to turn resident and performing mechanical lift transfer alone | |
| CNA 2 | Interviewed regarding mechanical lift procedure requiring two staff | |
| Director of Nursing | Present during observations and interviews; provided facility policies and acknowledged deficiencies |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: May 2, 2024
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00431812.
Complaint Details
Complaint IN00431812 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 the State Residential Licensure Survey requirements.
Report Facts
Residential Census: 49
Inspection Report
Re-Inspection
Census: 49
Deficiencies: 0
Date: Aug 15, 2023
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the State Residential Licensure Survey completed on June 14, 2023.
Findings
Brookdale Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the State Residential Licensure Survey.
Inspection Report
Renewal
Census: 48
Deficiencies: 1
Date: Jun 14, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on June 13 and 14, 2023, to assess compliance with state residential care regulations.
Findings
The facility failed to ensure a resident with Alzheimer's disease and dementia was free from neglect when the resident used a metal dishwasher spray arm to chip away at a window frame and elope through the window without staff knowledge. The resident was found outside and returned to the facility. The facility lacked an elopement risk assessment and adequate monitoring for this resident.
Deficiencies (1)
Failed to ensure a resident with Alzheimer's disease and dementia was free from neglect related to elopement through a window using a metal dishwasher spray arm.
Report Facts
Residential Census: 48
Residents with memory impairment: 23
Residents reviewed for neglect: 7
Date of survey completion: Jun 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Woodcox | Executive Director | Signed as Laboratory Director's or Provider/Supplier Representative |
| Receptionist 4 | Observed and returned Resident 500 to the facility after elopement | |
| RN 1 | Registered Nurse | Provided interview regarding Resident 500's behavior and medication administration |
| CNA 2 | Certified Nursing Assistant | Observed Resident 500 outside during elopement |
| LPN 3 | Licensed Practical Nurse | Administered medications to Resident 500 and provided interview about resident's behavior |
Inspection Report
Re-Inspection
Census: 50
Deficiencies: 0
Date: May 9, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00400382 completed on February 3, 2023.
Complaint Details
Complaint IN00400382 was corrected.
Findings
Brookdale Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00400382.
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 0
Date: Apr 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404739.
Complaint Details
Complaint IN00404739 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Feb 3, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00400382, which was substantiated with state deficiencies cited related to the allegations.
Complaint Details
Complaint IN00400382 was substantiated. The resident eloped through a broken window lock and was missing for approximately three hours before being found by police. The facility did not perform elopement risk assessments on residents and had inadequate window security measures.
Findings
The facility failed to ensure a resident with dementia was free from neglect when the resident eloped through a first-floor window without staff knowledge and wandered away from the facility for approximately three hours before being found 1.6 miles away. The facility lacked elopement risk assessments and had inadequate window security.
Deficiencies (1)
Failed to ensure a resident with dementia was free from neglect when the resident eloped through a first-floor window without staff knowledge and wandered away from the facility.
Report Facts
Residential Census: 48
Distance resident wandered: 1.6
Time resident location unknown: 3
Date of resident admission: Jan 16, 2023
Date resident transferred to psych hospital: Jan 30, 2023
Date systemic changes completion: Mar 6, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Woodcox | Executive Director | Interviewed regarding the elopement incident and facility response |
| Director of Nursing | Director of Nursing | Interviewed regarding resident transfer and facility elopement risk assessments |
| LPN 1 | Licensed Practical Nurse | Observed resident last before elopement and attempted to locate resident |
Inspection Report
Follow-Up
Census: 52
Deficiencies: 0
Date: Jan 6, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00394354 completed on November 18, 2022.
Complaint Details
Complaint IN00394354 was corrected.
Findings
Brookdale Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00394354.
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 1
Date: Nov 18, 2022
Visit Reason
This visit was for the investigation of Complaint IN00394354, which was substantiated with state deficiencies related to neglect.
Complaint Details
Complaint IN00394354 was substantiated. The resident was left on the floor for six hours after a fall on 11/3/22. CNA 3 was terminated for neglectful behavior, LPN 5 was not allowed to return due to failure to assess and assist the resident, and CNA 2 was written up for unsafe use of a Hoyer lift. The Safely You fall detection system alerted staff but was not properly acted upon.
Findings
The facility failed to ensure a cognitively impaired resident was free from neglect, as the resident was left on the floor for six hours after a fall without assessment by a licensed nurse, was not fed dinner, and was transported unsafely from his room to the lounge area using a Hoyer lift instead of a wheelchair.
Deficiencies (1)
Facility failed to ensure a cognitively impaired resident was free from neglect, including lack of injury assessment by a licensed nurse, delayed transfer after a fall, failure to feed dinner, and unsafe transport.
Report Facts
Residential Census: 53
Duration resident left on floor: 6
Residents at risk: 30
Quality assurance audit frequency: 5
Quality assurance audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Woodcox | Executive Director | Signed the report |
| CNA 3 | Terminated for leaving resident on floor for six hours and neglectful care | |
| LPN 5 | Licensed Practical Nurse | Contract labor associate not allowed to return due to failure to assess resident and notify staff |
| CNA 2 | Written up for unsafe use of Hoyer lift to transfer resident |
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