Deficiencies per Year
16
12
8
4
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 142
Capacity: 142
Deficiencies: 0
Mar 7, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00454191.
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.
Complaint Details
Complaint IN00454191 was investigated and found to have no deficiencies related to the allegations.
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
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.
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.
Complaint Details
Investigation of Complaint IN00449027 completed on January 8, 2025; paper compliance review was conducted.
Inspection Report
Complaint Investigation
Census: 143
Deficiencies: 0
Feb 20, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00452502, IN00452584, and IN00452969 at Carmel Health & Living Community.
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.
Complaint Details
Complaints IN00452502, IN00452584, and IN00452969 were investigated and found to have no deficiencies related to the allegations.
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
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
Census: 139
Deficiencies: 1
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.
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.
Complaint Details
Complaint IN00449027 was investigated and found to have no deficiencies related to the allegations.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 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. | SS=D |
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
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.
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.
Complaint Details
Investigation of Complaint IN00446463 was completed and found in compliance.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Dec 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00447970 and IN00448315 at Carmel Health & Living Community.
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.
Complaint Details
Investigation of Complaints IN00447970 and IN00448315 found no deficiencies related to the allegations; both complaints were not substantiated.
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
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.
Severity Breakdown
SS=C: 2
SS=E: 1
SS=B: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; generator exercised less than 30 minutes for twelve of the last twelve months. | SS=C |
| Sprinkler heads in the kitchen dish area and lower level corridor were damaged due to bent deflectors. | SS=E |
| Combustible holiday wrapping paper covered over 90% of the corridor door to resident room 720, not treated with fire retardant material. | SS=B |
| Failed to maintain a complete written record of monthly generator load testing for 12 of the last 12 months for 1 of 3 generators. | SS=C |
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
Nov 4, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of complaints IN00438262 and IN00446463.
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.
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).
Severity Breakdown
SS=D: 10
SS=E: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Facility failed to ensure mail was delivered unopened for 1 of 1 resident reviewed for resident rights (Resident 135). | SS=D |
| 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). | SS=D |
| Facility failed to ensure a comprehensive person-centered care plan was developed for a resident diagnosed and treated for insomnia (Resident F). | SS=D |
| 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). | SS=E |
| Facility failed to ensure a resident did not have smoking articles in their room (Resident 241). | SS=D |
| 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). | SS=D |
| 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). | SS=D |
| 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). | SS=D |
| Facility failed to ensure a resident received dental services to repair or replace partial dentures for 1 of 1 resident reviewed (Resident 122). | SS=D |
| Facility failed to ensure food was served at a safe and appetizing temperature for 1 of 1 room tray tested (200 hall). | SS=D |
| 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). | SS=D |
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
Census: 135
Capacity: 135
Deficiencies: 0
May 6, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433160.
Findings
No deficiencies related to the allegations in Complaint IN00433160 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00433160 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census bed type: 135
Census payor type: 135
Inspection Report
Plan of Correction
Deficiencies: 0
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
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.
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.
Complaint Details
The investigation covered complaints IN00425000, IN00428864, and IN00428932. No deficiencies related to the allegations in these complaints were cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the interdisciplinary team determined a resident was clinically appropriate to self-administer medications for 1 of 1 residents observed. | SS=D |
| 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. | SS=D |
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
Life Safety
Census: 135
Capacity: 188
Deficiencies: 0
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
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.
Severity Breakdown
SS=E: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure 2 of over 6 horizontal exit fire door sets were arranged to automatically close and latch. | SS=E |
| Failed to ensure 1 of over 3 exit ramps met the slope requirement. | SS=E |
| 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. | SS=E |
| Failed to ensure 1 of over 10 hazardous area doors were provided with properly working self-closing devices. | SS=E |
| 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. | SS=E |
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
Oct 27, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00419759.
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.
Complaint Details
Complaint IN00419759 was investigated and no deficiencies related to the allegations were cited.
Deficiencies (7)
| Description |
|---|
| 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
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
Complaint Investigation
Census: 126
Deficiencies: 0
Jul 27, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413324.
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.
Complaint Details
Complaint IN00413324 was investigated and found to have no deficiencies related to the allegations.
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
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
Jun 23, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00407987 completed on May 9, 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 complaint investigation.
Complaint Details
Investigation of Complaint IN00407987 completed on May 9, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
May 24, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00408784.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00408784 was investigated and found to have no deficiencies related to the allegations.
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
Census: 136
Deficiencies: 1
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.
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.
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.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure staff members follow the Hoyer Lift Policy and Procedure to prevent falls or injury from a Hoyer lift transfer. | SS=D |
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
Apr 25, 2023
Visit Reason
This visit was for Investigation of multiple Complaints (IN00397137, IN00398770, IN00406781, IN00397046, IN00398768, IN00400373, IN00403758, IN00404541, IN00403649, and IN00405831).
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.
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.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| The Facility failed to ensure residents’ scheduled medications were available to meet the needs of 2 of 5 residents reviewed for medication availability. | SS=D |
| 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. | SS=D |
| 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. | SS=D |
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
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
Life Safety
Census: 123
Capacity: 188
Deficiencies: 0
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
Nov 17, 2022
Visit Reason
This visit was conducted for the investigation of three complaints: IN00394467, IN00389930, and IN00389668.
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.
Complaint Details
Complaint IN00394467 - Substantiated with no deficiencies cited. Complaint IN00389930 - Substantiated with no deficiencies cited. Complaint IN00389668 - Substantiated with no deficiencies cited.
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
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
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.
Severity Breakdown
SS=E: 12
SS=F: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to maintain latching hardware on 2 of 2 smoke barrier doors in the basement. | SS=E |
| Failed to ensure furnace closet in activities area was free and clear of hazards. | SS=E |
| Failed to ensure exit doors with magnetic locks had proper codes posted. | SS=E |
| Failed to ensure 1 of over 10 exit discharges had a level walking surface free of obstructions. | SS=E |
| Failed to ensure exit discharge from property to public way. | SS=E |
| Failed to ensure exit sign in basement had directional indicators. | SS=F |
| Failed to ensure hazardous area oxygen room door had properly working self-closing device. | SS=E |
| Failed to ensure sprinkler system installation met NFPA 13 requirements; sprinkler less than 1 inch from wall. | SS=E |
| Failed to ensure corridor doors had no impediment to closing and latching. | SS=E |
| Failed to ensure ground fault circuit interrupter (GFCI) protection in wet locations and locked electrical panels. | SS=E |
| Failed to ensure smoking areas were maintained with proper disposal containers. | SS=E |
| Failed to ensure portable space heaters were not used in resident care areas. | SS=E |
| Failed to ensure flexible cords and power strips were not used as substitutes for fixed wiring. | SS=E |
| Failed to ensure oxygen transfilling room was separated by one-hour fire-resistive construction; hole in wall by door. | SS=E |
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
Aug 10, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00379657, IN00379969, and IN00385351.
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.
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.
Severity Breakdown
SS=D: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to keep the call light within the resident's reach for 2 of 2 residents observed. | SS=D |
| Failed to identify and provide needed care in a timely manner for 1 of 2 residents reviewed for pressure ulcers. | SS=D |
| Failed to ensure medications were not left at the bedside without an order to self-administer for 1 of 1 resident observed. | SS=D |
| Failed to label the enteral feeding bag with feeding type and amount for 1 of 1 resident reviewed for tube feeding. | SS=D |
| 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. | SS=E |
| 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. | SS=E |
| 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. | SS=D |
Report Facts
Census: 119
Survey dates: 8
Deficiency counts: 7
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