Inspection Reports for Brookdale Carmel

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.

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.

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.

This visit was for the investigation of complaints IN00456036 and IN00456196, in conjunction with post survey revisits for complaints IN00445842, IN00450524, and IN00454251.

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.

Complaints IN00456036 and IN00456196 had no deficiencies related to the allegations. Complaints IN00445842, IN00450524, and IN00454251 were corrected.

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.

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.

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.

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.

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.

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.

This visit was conducted for the investigation of complaints IN00445842 and IN00450524 regarding allegations of neglect and abuse at Brookdale Carmel.

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.

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.

This visit was for the investigation of complaints IN00435497, IN00435498, IN00435788, and IN00435971 regarding resident care and notification issues.

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.

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.

This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00431812.

No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with the State Residential Licensure Survey requirements.

Complaint IN00431812 was investigated and found to have no deficiencies related to the allegations.

This visit was for a Post Survey Revisit (PSR) to the State Residential Licensure Survey completed on June 14, 2023.

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.

This visit was for a State Residential Licensure Survey conducted on June 13 and 14, 2023, to assess compliance with state residential care regulations.

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.

This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00400382 completed on February 3, 2023.

Brookdale Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00400382.

Complaint IN00400382 was corrected.

This visit was conducted for the investigation of Complaint IN00404739.

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.

Complaint IN00404739 was investigated and found to have no deficiencies related to the allegations.

This visit was conducted for the investigation of Complaint IN00400382, which was substantiated with state deficiencies cited related to the allegations.

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.

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.

This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00394354 completed on November 18, 2022.

Brookdale Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00394354.

Complaint IN00394354 was corrected.

This visit was for the investigation of Complaint IN00394354, which was substantiated with state deficiencies related to neglect.

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.

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.