Inspection Reports for Independence Village of Carmel

IN, 46032

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Inspection Report Complaint Investigation Census: 70 Deficiencies: 0 Jul 8, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00461993.
Findings
No deficiencies related to the allegations are cited. Independence Village of Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00461993.
Complaint Details
Complaint IN00461993 - No deficiencies related to the allegations are cited.
Report Facts
Residential Census: 70
Inspection Report Complaint Investigation Census: 65 Deficiencies: 7 Apr 7, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00453792.
Findings
No deficiencies were found related to the complaint allegations. However, multiple deficiencies were cited including failure to hold fire drills with the local fire department every 6 months, staff CPR and first aid certification lapses, expired medication aide certification, incomplete staff orientations, food safety violations in the kitchen, missing annual health statements for residents, and incomplete 2-step tuberculosis testing for new admissions.
Complaint Details
Complaint IN00453792 was investigated and no deficiencies related to the allegations were cited.
Deficiencies (7)
Description
Failed to ensure fire and disaster drills were held in conjunction with the local fire department at least every 6 months.
Failed to ensure staff on duty met CPR and first aid training requirements for 14 of 14 shifts reviewed.
Failed to ensure a staff member maintained current state certification for 1 of 51 employees (Qualified Medication Aide certification expired).
Failed to ensure general and job specific orientations were documented for 3 of 5 employees reviewed.
Failed to ensure opened food items were dated and covered, gloves were changed between tasks, facial hair coverings were worn, and sanitizer solution was at correct concentration in the kitchen.
Failed to ensure annual health statements showing no evidence of infectious tuberculosis were provided for 2 of 8 residents reviewed.
Failed to ensure 2-step tuberculosis testing was completed for 2 of 8 residents reviewed upon admission.
Report Facts
Residents present: 65 Shifts reviewed for CPR and first aid: 14 Employees reviewed for certification: 51 Employees reviewed for orientation: 5 Residents reviewed for annual health statements: 8 Residents reviewed for tuberculosis testing: 8
Employees Mentioned
NameTitleContext
Dana LarsonExecutive DirectorInterviewed regarding facility policies and deficiencies
Maintenance DirectorInterviewed about fire drill invitations to local fire department
Assistant Director of HealthInterviewed regarding medication aide certification and resident health information
Executive ChefInterviewed regarding kitchen food safety deficiencies
Property AdministratorInterviewed regarding staff orientation documentation
Inspection Report Complaint Investigation Census: 56 Deficiencies: 2 Sep 26, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00435470, IN00440010, and IN00442237) concerning resident rights and misappropriation of property.
Findings
The facility was found deficient for failing to ensure a resident was treated with respect and dignity during personal care, and for failing to keep a resident's credit card safe during admission. Staff members involved in abuse and theft were terminated. One complaint was not substantiated.
Complaint Details
Complaint IN00435470 related to misappropriation of property with state deficiencies cited. Complaint IN00440010 related to resident rights violations with state deficiencies cited. Complaint IN00442237 was not substantiated with no deficiencies cited.
Deficiencies (2)
Description
Failure to ensure a resident was treated with respect and dignity when a staff member handled the resident inappropriately during personal care.
Failure to ensure a resident's credit card was kept safe and secure during admission, resulting in misappropriation of property.
Report Facts
Residential Census: 56 Credit card charges: 35.11 Credit card charges: 514.38
Employees Mentioned
NameTitleContext
Dana LarsonExecutive DirectorSigned the report and involved in investigation and corrective actions.
CNA 1Terminated for handling Resident C inappropriately during personal care.
Dietary Server 5Terminated for misappropriation of Resident D's credit card.
Dietary Server 6Terminated for involvement in theft of Resident D's credit card.
Inspection Report Complaint Investigation Census: 57 Deficiencies: 3 Apr 24, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00422623.
Findings
No deficiencies related to the complaint allegations were cited. However, deficiencies were found related to personnel orientation documentation, HVAC annual inspection, and medication refrigerator temperature monitoring.
Complaint Details
Complaint IN00422623 was investigated and no deficiencies related to the allegations were cited.
Deficiencies (3)
Description
Failed to ensure job specific orientation was documented in the employee's personnel record for 3 of 3 new employees reviewed (CNA 1, LPN 2, QMA 3).
Failed to ensure the heating, ventilation, and air conditioning system (HVAC) was inspected annually; no documentation of annual HVAC inspection from April 2023 through April 2024 was provided.
Failed to ensure temperatures of medication refrigerators were checked and documented daily for 2 of 2 medication storage areas reviewed (Memory Care Unit and second floor Assisted Living Unit), with multiple missing temperature log entries.
Report Facts
Residential Census: 57 Missing temperature entries: 13 Missing temperature entries: 23 Missing temperature entries: 22 Missing temperature entries: 8 Missing temperature entries: 1 Missing temperature entries: 2 Missing temperature entries: 4
Employees Mentioned
NameTitleContext
Dana LarsonExecutive DirectorSigned the report.
Director of NursingIndicated no documentation of job specific orientation for employees; provided facility policies and corrective action plans.
QMA 4Indicated medication refrigerator temperatures were to be checked every other shift.
QMA 5Indicated medication refrigerator temperatures were to be checked and documented on temperature logs.
Setting Support SpecialistIndicated no documentation of annual HVAC inspection and that inspection should have been completed.
Inspection Report Complaint Investigation Census: 48 Deficiencies: 0 May 30, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00408949 and IN00408782.
Findings
No deficiencies related to the allegations in complaints IN00408949 and IN00408782 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Complaint Details
Complaint IN00408949 and Complaint IN00408782 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Residential Census: 48
Inspection Report Complaint Investigation Census: 46 Deficiencies: 11 Oct 6, 2022
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00381347, IN00376114, and IN00374357.
Findings
The facility had multiple deficiencies including failure to ensure the State Survey Results binder was accessible, incomplete fire drill documentation, insufficient CPR and First Aid certified staff coverage, lack of employee orientation documentation, incomplete dementia training, incomplete tuberculosis skin testing for employees, incomplete resident evaluations and service plans, improper food storage and labeling, and inadequate infection control practices including improper mask usage.
Complaint Details
Complaint IN00381347 was substantiated with no deficiencies cited. Complaints IN00376114 and IN00374357 were substantiated with state deficiencies cited at R216 and R217.
Deficiencies (11)
Description
Failed to ensure the State Survey Results binder was accessible to residents and visitors.
Failed to conduct required fire drills and document fire department involvement.
Failed to ensure one awake staff person certified in CPR and First Aid was on duty for 3 of 14 shifts.
Failed to provide documentation of general and job specific orientation for 4 of 5 new employees.
Failed to ensure 4 of 10 employees were current on dementia in-service training.
Failed to perform two-step Mantoux tuberculosis skin testing for several employees.
Failed to perform semi-annual resident evaluations for 3 of 7 residents and failed to assess self-administration of medications for 1 resident.
Failed to have signed service plans for 7 of 7 residents reviewed.
Failed to ensure proper food storage practices including labeling open dates, sealing food containers, and storing food off the floor.
Failed to implement infection control policies including improper mask usage by staff and failure to provide infection control training.
Failed to ensure residents had completed two-step tuberculosis testing upon admission.
Report Facts
Residents affected: 46 Fire drills missing: 6 Shifts without CPR certified staff: 3 Employees not current on dementia training: 4 Residents without semi-annual evaluation: 3 Residents without signed service plan: 7
Employees Mentioned
NameTitleContext
Erin BeirigerExecutive Director and RCANamed as Executive Director responsible for facility operations and plan of correction.
Executive Director 2Interviewed regarding survey results binder location, fire drills, employee orientation, dementia training, tuberculosis testing, and resident evaluations.
Cook 11CookObserved not wearing mask properly in kitchen.
Kitchen Staff 12Observed not wearing mask properly in kitchen.
Kitchen Staff 13Observed not wearing mask properly in kitchen.
Sous Chef 8Sous ChefObserved not wearing mask properly in kitchen.
Speech Therapist 14Speech TherapistObserved wearing mask under chin while interacting with resident.
Clinical SpecialistProvided information on employee orientation, dementia training, tuberculosis testing, and resident evaluations.
LPN 15Licensed Practical NurseObserved medication administration without observing resident take medication.

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