Inspection Report Summary
The most recent inspection on July 8, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving staff training and certification, documentation of orientations, fire and disaster drills, food safety practices, and tuberculosis testing. Prior reports also cited issues with resident dignity and property security, which led to staff terminations, but no fines or enforcement actions were listed in the available reports. Most complaint investigations were unsubstantiated, with the exception of some substantiated complaints related to resident rights and property misappropriation in 2024. The facility’s inspection history shows some improvement over time, with fewer deficiencies noted in the most recent visits.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
38% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
70 residents
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 70
Deficiencies: 0
Date: Jul 8, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00461993.
Complaint Details
Complaint IN00461993 - No deficiencies related to the allegations are cited.
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.
Report Facts
Residential Census: 70
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 7
Date: Apr 7, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00453792.
Complaint Details
Complaint IN00453792 was investigated and no deficiencies related to the allegations were cited.
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.
Deficiencies (7)
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
| Name | Title | Context |
|---|---|---|
| Dana Larson | Executive Director | Interviewed regarding facility policies and deficiencies |
| Maintenance Director | Interviewed about fire drill invitations to local fire department | |
| Assistant Director of Health | Interviewed regarding medication aide certification and resident health information | |
| Executive Chef | Interviewed regarding kitchen food safety deficiencies | |
| Property Administrator | Interviewed regarding staff orientation documentation |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Date: 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.
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.
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.
Deficiencies (2)
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
| Name | Title | Context |
|---|---|---|
| Dana Larson | Executive Director | Signed the report and involved in investigation and corrective actions. |
| CNA 1 | Terminated for handling Resident C inappropriately during personal care. | |
| Dietary Server 5 | Terminated for misappropriation of Resident D's credit card. | |
| Dietary Server 6 | Terminated for involvement in theft of Resident D's credit card. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 3
Date: Apr 24, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaint IN00422623.
Complaint Details
Complaint IN00422623 was investigated and no deficiencies related to the allegations were cited.
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.
Deficiencies (3)
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
| Name | Title | Context |
|---|---|---|
| Dana Larson | Executive Director | Signed the report. |
| Director of Nursing | Indicated no documentation of job specific orientation for employees; provided facility policies and corrective action plans. | |
| QMA 4 | Indicated medication refrigerator temperatures were to be checked every other shift. | |
| QMA 5 | Indicated medication refrigerator temperatures were to be checked and documented on temperature logs. | |
| Setting Support Specialist | Indicated no documentation of annual HVAC inspection and that inspection should have been completed. |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Date: May 30, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00408949 and IN00408782.
Complaint Details
Complaint IN00408949 and Complaint IN00408782 were investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Residential Census: 48
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 11
Date: Oct 6, 2022
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00381347, IN00376114, and IN00374357.
Complaint Details
Complaint IN00381347 was substantiated with no deficiencies cited. Complaints IN00376114 and IN00374357 were substantiated with state deficiencies cited at R216 and R217.
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.
Deficiencies (11)
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
| Name | Title | Context |
|---|---|---|
| Erin Beiriger | Executive Director and RCA | Named as Executive Director responsible for facility operations and plan of correction. |
| Executive Director 2 | Interviewed regarding survey results binder location, fire drills, employee orientation, dementia training, tuberculosis testing, and resident evaluations. | |
| Cook 11 | Cook | Observed not wearing mask properly in kitchen. |
| Kitchen Staff 12 | Observed not wearing mask properly in kitchen. | |
| Kitchen Staff 13 | Observed not wearing mask properly in kitchen. | |
| Sous Chef 8 | Sous Chef | Observed not wearing mask properly in kitchen. |
| Speech Therapist 14 | Speech Therapist | Observed wearing mask under chin while interacting with resident. |
| Clinical Specialist | Provided information on employee orientation, dementia training, tuberculosis testing, and resident evaluations. | |
| LPN 15 | Licensed Practical Nurse | Observed medication administration without observing resident take medication. |
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