Deficiencies per Year
24
18
12
6
0
Severe
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Jun 26, 2025
Visit Reason
This visit was for the investigation of Complaint IN00461802.
Findings
No deficiencies related to the allegations in Complaint IN00461802 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00461802 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 5
Medicaid census: 38
Other payor census: 25
Inspection Report
Re-Inspection
Census: 71
Capacity: 72
Deficiencies: 0
May 7, 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 03/17/25 and 03/18/25.
Findings
At this Post Survey Revisit, Restoracy of Carmel was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare and Medicaid. The facility consists of six one-story cottages, each fully sprinklered with fire alarm systems and smoke detectors. The facility had a census of 71 residents and a total capacity of 72 beds at the time of the survey.
Report Facts
Certified beds: 72
Census: 71
Building capacity: 12
Building census: 12
Building 06 census: 11
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 10, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on February 26, 2025.
Findings
Restoracy of Carmel 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 for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 71
Capacity: 72
Deficiencies: 12
Mar 18, 2025
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).
Findings
The facility was found not in compliance with Life Safety Code requirements including failure to inspect and test sprinkler systems quarterly in multiple buildings and failure of one resident room door to close and latch properly.
Severity Breakdown
SS=C: 5
SS=F: 7
SS=E: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan that was reviewed and updated at least annually. | SS=C |
| Failed to develop and implement emergency preparedness policies and procedures that were reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and was reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness training and testing program that was reviewed and updated at least annually. | SS=C |
| Failed to conduct exercises to test the emergency plan at least biennially, including unannounced staff drills. | SS=C |
| Failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters in Building 01 (Cottage #2). | SS=F |
| Failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters in Building 02 (Cottage #3). | SS=F |
| Failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters in Building 03 (Cottage #1). | SS=F |
| Failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters in Building 04 (Cottage #4). | SS=F |
| Failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters in Building 05 (Cottage #5). | SS=F |
| Failed to ensure 1 of 72 sets of resident room doors to the corridor would close completely and latch into the door frame (resident room J, Cottage #5). | SS=E |
| Failed to provide written documentation or other evidence the sprinkler system components had been inspected and tested for 1 of 4 quarters in Building 06 (Cottage #6). | SS=F |
Report Facts
Facility certified beds: 72
Census: 71
Deficiencies cited: 13
Resident room doors: 72
Residents affected by door deficiency: 12
Staff affected by door deficiency: 6
Visitors affected by door deficiency: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Andi Denbo | Assist Administrator | Signed report on page 1 |
| Maintenance Director | Interviewed regarding emergency preparedness and sprinkler system deficiencies; acknowledged missing documentation and door issue | |
| Executive Director | Informed of findings during discovery and exit conference |
Inspection Report
Renewal
Census: 70
Capacity: 70
Deficiencies: 3
Feb 26, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaints IN00444413 and IN00444369.
Findings
The facility was found deficient in several areas including failure to ensure urinary catheter bags had dignity covers, failure to follow physician's orders regarding medication administration, and failure to ensure catheter bags were not touching dirty surfaces and were disposed of properly. No deficiencies were cited related to the investigated complaints.
Complaint Details
Complaints IN00444413 and IN00444369 were investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure urinary catheter bags had dignity covers in place for 2 of 3 residents reviewed. | SS=D |
| Failed to ensure staff followed the physician's orders regarding medication administration for 2 of 2 residents reviewed. | SS=D |
| Failed to ensure catheter bags were not touching a dirty surface and catheters were disposed of properly for 3 of 5 residents reviewed for infection control. | SS=D |
Report Facts
Census: 70
Total Capacity: 70
Medicare Census: 5
Medicaid Census: 37
Other Payor Census: 28
Medication administration errors: 12
Medication administration errors: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chelsea Knox | RN DON | Named as Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 4 | Indicated catheter bags did not have dignity covers and need for education on catheter bag placement | |
| Director of Nursing | Director of Nursing | Provided interviews regarding medication administration errors and education plans |
| Registered Nurse 3 | Observed used catheter bags and indicated proper disposal needed |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Sep 16, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00441699 and IN00441876.
Findings
No deficiencies related to the allegations in Complaints IN00441699 and IN00441876 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00441699 and IN00441876 found no deficiencies related to the allegations.
Report Facts
Census payor type - Medicare: 11
Census payor type - Medicaid: 36
Census payor type - Other: 23
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 1
Aug 7, 2024
Visit Reason
This visit was for the investigation of Complaint IN00439367 regarding allegations of misappropriation of resident property.
Findings
No deficiencies related to the complaint allegations were cited; however, unrelated deficiencies were cited involving misappropriation of residents' credit cards by a CNA. The CNA was terminated for fraudulent use of residents' credit cards, and corrective actions including staff in-servicing and QAPI inclusion were implemented.
Complaint Details
Complaint IN00439367 was investigated with no deficiencies related to the allegations cited. The complaint involved fraudulent use of Resident B's and Resident C's credit cards by CNA 1, who was terminated for the misconduct. Resident B's son and police were involved in the investigation. Resident C reported missing credit cards and fraudulent charges totaling approximately $798.09, which were reimbursed by credit card companies.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' credit cards were kept safe and secure during admission for 2 of 3 residents reviewed for misappropriation of property. | SS=D |
Report Facts
Census SNF/NF beds: 66
Medicare census: 5
Medicaid census: 43
Other payor census: 18
Fraudulent charges on Resident C's credit cards: 705.09
Fraudulent charges on Resident C's other credit card: 93
Fraud amount threshold: 750
Number of suspicious charges on Resident B's credit cards: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in fraudulent credit card use and terminated for theft and fraud |
| Executive Director | Interviewed regarding discovery and termination of CNA 1 for credit card fraud | |
| Officer 3 | Police Officer | Interviewed and involved in investigation of credit card fraud |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 0
Jun 18, 2024
Visit Reason
This visit was for the investigation of complaints IN00435358, IN00436327, and IN00436743.
Findings
No deficiencies related to the allegations in complaints IN00435358, IN00436327, and IN00436743 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00435358, IN00436327, and IN00436743 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 70
Total Capacity: 70
Census Payor Type Medicare: 8
Census Payor Type Medicaid: 40
Census Payor Type Other: 22
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
May 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaints IN00433332 and IN00433662.
Findings
No deficiencies related to the allegations in Complaints IN00433332 and IN00433662 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00433332 and IN00433662 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census: 68
Total Capacity: 68
Medicare Census: 6
Medicaid Census: 41
Other Payor Census: 21
Inspection Report
Re-Inspection
Census: 71
Capacity: 72
Deficiencies: 0
Apr 22, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey that exited on 03/08/24, to verify compliance with federal and state regulations.
Findings
At this PSR Emergency Preparedness survey and Life Safety Code survey, Restoracy of Carmel was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare and Medicaid. The facility consists of six one-story cottages, all fully sprinklered except a separate detached administration building, with fire alarm systems and smoke detectors in place.
Report Facts
Certified beds: 72
Census: 71
Building 01 capacity: 12
Building 01 census: 12
Building 02 capacity: 12
Building 02 census: 11
Building 03 capacity: 12
Building 03 census: 12
Building 04 capacity: 12
Building 04 census: 12
Building 05 capacity: 12
Building 05 census: 12
Building 06 capacity: 12
Building 06 census: 12
Inspection Report
Life Safety
Census: 71
Capacity: 72
Deficiencies: 7
Mar 8, 2024
Visit Reason
Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with Life Safety from Fire and related requirements. Deficiencies included obstructed exit discharge paths, lack of annual fire door inspections, failure to conduct required emergency generator four-hour run tests, and issues with oxygen transfilling room ventilation and door latching.
Severity Breakdown
SS=F: 5
SS=E: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 3 exit discharge paths that lead from the garage to the public way was readily accessible at all times due to vehicle obstruction. | SS=F |
| Failed to ensure annual inspection and testing of fire door assemblies at Oxygen Transfilling rooms for each of the 6 buildings. | SS=F |
| Failed to ensure a four-hour run test for the emergency generator was conducted within the last 36 months. | SS=F |
| Failed to ensure Cottage #1 and Cottage #5 Oxygen Transfilling storage room doors latched into the frame when tested. | SS=E |
| Failed to ensure Cottage #5 oxygen storage room mechanical ventilation fan was functioning properly. | SS=E |
| Failed to ensure Cottage #4 Mop Closet Door and Cottage #4 resident room B’s door latch positively into their respective door frames. | SS=F |
| Failed to ensure all corridor doors had no impediment to closing and latching into the door frame and would resist the passage of smoke. | SS=E |
Report Facts
Certified beds: 72
Census: 71
Exit discharge paths obstructed: 1
Fire door assemblies lacking annual inspection: 6
Emergency generators: 6
Oxygen transfilling rooms: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Levengood | Executive Director | Named in relation to findings and exit conference. |
| Maintenance Director | Involved in record review, interviews, and corrective actions related to emergency preparedness, fire door inspections, generator testing, and facility maintenance. |
Inspection Report
Renewal
Deficiencies: 0
Feb 23, 2024
Visit Reason
The visit was conducted as a paper compliance review for the Recertification and State Licensure Survey.
Findings
Restoracy of Carmel 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 for the Recertification and State Licensure Survey.
Inspection Report
Annual Inspection
Census: 64
Capacity: 64
Deficiencies: 12
Feb 23, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from February 19 to 23, 2024.
Findings
The facility was found deficient in multiple areas including resident rights, PASARR screening, care planning, ADL care, activities, quality of care, colostomy care, nutrition and hydration, drug regimen review, food safety, and infection preventionist qualifications.
Severity Breakdown
SS=D: 10
SS=E: 2
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to ensure a resident was asked or instructed prior to repositioning. | SS=D |
| Failed to ensure the Preadmission Screening and Resident Review (PASARR) were completed when new mental health diagnoses were added for residents. | SS=D |
| Failed to complete a Level 1 Preadmission Screening and Resident Review (PASARR) prior to admission for a resident. | SS=D |
| Failed to provide quarterly care plan conferences and failed to include the use of a positioning cushion in the comprehensive care plan. | SS=D |
| Failed to ensure a resident who was unable to carry out activities of daily living care received the oral care recommendations from the Registered Dental Hygienist. | SS=D |
| Failed to ensure cognitively stimulating activities were offered daily for residents reviewed for activities. | SS=D |
| Failed to ensure a resident had documentation for the use of a positioning device, to ensure residents had splints placed as ordered by the physician, to notify the physician of a blood sugar which was out of parameter and to ensure a resident's skin impairment was accurately assessed and documented. | SS=D |
| Failed to ensure a resident who had a colostomy had specific direction for colostomy care. | SS=D |
| Failed to recognize, provide interventions, and to notify the physician of a weight loss for residents reviewed for nutrition. | SS=D |
| Failed to ensure the provider documented the rationale for not agreeing with a pharmacist recommendation for gradual dose reductions and pharmacy reviews and failed to give rationale for not discontinuing the use of prophylactic antibiotics. | SS=E |
| Failed to ensure the refrigerators and freezers were clean, food was sealed, labeled, and dated, and expired foods were discarded for kitchens reviewed. | SS=E |
| Failed to ensure a designated Infection Preventionist was onsite to work within the facility and completed the qualifying training or certification. | SS=D |
Report Facts
Census: 64
Total Capacity: 64
Weight loss percentage: 10.98
Weight loss percentage: 6.18
Weight loss percentage: 7.82
Weight loss percentage: 10
Weight loss percentage: 5
Weight loss percentage: 7.5
Weight loss percentage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON 1 | Director of Nursing | Provided information about Infection Preventionist and other facility policies |
| DON 2 | Director of Nursing | Acting Infection Preventionist, provided interviews about multiple findings |
| CNA 6 | Named in repositioning deficiency and splint application | |
| QMA 4 | Interviewed regarding resident care and activities | |
| Lead PT | Physical Therapist | Provided information about positioning devices |
| Assistant Director of Nursing | Took Infection Preventionist certification | |
| Director of Nursing | Educated staff and monitored compliance |
Inspection Report
Renewal
Deficiencies: 1
Jan 23, 2024
Visit Reason
The inspection was conducted as an offsite Licensure Investigation Survey to review the facility's compliance with license renewal requirements.
Findings
The facility failed to timely renew its license to operate as a health care facility before the expiration date of December 31, 2023. The renewal application and payment were received postmarked January 8, 2024, which was not at least 45 days prior to license expiration as required.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure timely renewal of license to operate as a health care facility before license expiration on December 31, 2023. |
Report Facts
Days late for license renewal: 8
Days required for renewal submission: 45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Lindsay | Director of Operations | Signed as Laboratory Director's or Provider/Supplier Representative's Signature on the report. |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 0
Dec 13, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422705.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00422705 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 4
Medicaid census: 32
Other payor census: 33
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 19, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00413720 completed on August 3, 2023.
Findings
Restoracy of Carmel 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 complaint investigation.
Complaint Details
Investigation of Complaint IN00413720; paper compliance review completed with findings of compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 19, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00407963 and IN00411683 completed on July 5, 2023.
Findings
Restoracy of Carmel 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 investigations.
Complaint Details
The visit was related to the investigation of complaints IN00407963 and IN00411683. Compliance was found upon paper review.
Inspection Report
Complaint Investigation
Census: 70
Capacity: 70
Deficiencies: 1
Aug 2, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00413720 regarding allegations of improper transfer technique resulting in injury.
Findings
The facility failed to ensure a proper transfer technique was used during a transfer, resulting in injury to one resident. The resident exhibited bruising and swelling consistent with improper handling. Staff education and corrective actions were implemented.
Complaint Details
Complaint IN00413720 was substantiated with federal/state deficiencies cited related to allegations of improper transfer technique causing injury to Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a proper transfer technique was used during a transfer resulting in an injury. | SS=D |
Report Facts
Census: 70
Total Capacity: 70
Medicare Census: 5
Medicaid Census: 29
Other Payor Census: 36
Random transfer audits frequency: 5
Random transfer audits frequency: 3
Random transfer audits frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Levengood | Administrator | Signed the report |
| CNA 2 | Involved in improper transfer of Resident B | |
| Director of Nursing | Director of Nursing | Provided interview confirming gait belt use policy |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 2
Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00407963 and IN00411683 related to alleged deficiencies in care and safety at the facility.
Findings
The facility was found deficient in ensuring proper transcription and completion of physician orders for pressure ulcer treatment for one resident, and in providing adequate supervision to prevent injury for another resident at high risk for falls. Both deficiencies were substantiated with detailed findings and corrective actions.
Complaint Details
Complaint IN00407963 involved failure to ensure a resident with dementia and high fall risk was free from injury after being left unattended on the toilet. Complaint IN00411683 involved failure to ensure physician's pressure ulcer orders were transcribed and treatments completed as ordered.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the physician's pressure ulcer orders were transcribed to the ETAR and failed to ensure a resident's pressure ulcer treatment was completed as ordered by the physician (Resident B). | SS=D |
| Failed to ensure a resident with dementia and high fall risk was free from injury after being left unattended on the toilet by a CNA (Resident H). | SS=D |
Report Facts
Census: 71
Total Capacity: 71
Morse Fall Scale score: 65
Laceration size: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Lindsay | Administrator | Signed the report |
| CNA 1 | Named in fall incident involving Resident H; received teachable moment for leaving resident unattended on toilet | |
| Director of Nursing | Director of Nursing | Interviewed regarding wound care orders and deficiencies |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding transcription error of wound care orders |
| Executive Director | Executive Director | Provided education to CNA 1 after fall incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 25, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00404058 completed on March 23, 2023.
Findings
Restoracy of Carmel 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 complaint investigation.
Complaint Details
Investigation of Complaint IN00404058 completed on March 23, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 0
May 3, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00405607 and IN00406826.
Findings
Both complaints were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant federal and state regulations regarding the complaints investigated.
Complaint Details
Complaint IN00405607 and Complaint IN00406826 were both unsubstantiated due to lack of evidence.
Report Facts
Census: 64
Total Capacity: 64
Medicare Census: 6
Medicaid Census: 29
Other Payor Census: 29
Inspection Report
Complaint Investigation
Census: 62
Capacity: 62
Deficiencies: 1
Mar 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00404058 regarding concerns about incomplete documentation of residents' deaths.
Findings
The facility failed to ensure that residents' deaths were accurately and completely documented in the medical records for 4 of 4 residents reviewed. Documentation lacked key information such as date and time of death, name and title of the person pronouncing death, notification of family and medical staff, and cause of death by the attending physician.
Complaint Details
Complaint IN00404058 was investigated. The complaint alleged incomplete documentation of resident deaths, which was substantiated by findings.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents' deaths were accurately and completely documented in the residents' records for 4 of 4 residents reviewed. | SS=D |
Report Facts
Census SNF/NF beds: 62
Census total residents: 62
Medicare residents: 6
Medicaid residents: 35
Other payor residents: 21
Residents reviewed for death documentation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Lindsay | Administrator | Signed the report |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 63
Deficiencies: 0
Mar 8, 2023
Visit Reason
This visit was for the investigation of complaints IN00398256, IN00399177, and IN00403160.
Findings
No deficiencies related to the allegations in complaints IN00398256, IN00399177, and IN00403160 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
Complaints IN00398256, IN00399177, and IN00403160 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 63
Total Capacity: 63
Medicare Census: 7
Medicaid Census: 37
Other Payor Census: 19
Inspection Report
Follow-Up
Census: 61
Capacity: 72
Deficiencies: 0
Mar 2, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey that exited on 01/11/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Restoracy of Carmel was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility consists of six one-story cottages, each fully sprinklered with fire alarm systems and smoke detectors. The entire facility had a capacity of 72 and a census of 61 at the time of the survey.
Report Facts
Building capacity: 12
Building census: 12
Building census: 7
Building census: 6
Inspection Report
Re-Inspection
Census: 59
Capacity: 59
Deficiencies: 0
Feb 7, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on December 8, 2022, which resulted in an Extended Survey for Substandard Quality of Care - Immediate Jeopardy. The visit also included a PSR to the Investigation of Complaint IN00393166 completed on December 8, 2022.
Findings
Restoracy of Carmel was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the Investigation of Complaint IN00393166. The complaint was corrected.
Complaint Details
Complaint IN00393166 was investigated and found to be corrected.
Report Facts
Census: 59
Total Capacity: 59
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 36
Census Payor Type - Other: 22
Inspection Report
Life Safety
Census: 63
Capacity: 72
Deficiencies: 3
Jan 10, 2023
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) on 01/10/23 and 01/11/23.
Findings
The facility was found not in compliance with Life Safety Code requirements including failure to ensure semiannual inspection of kitchen fire suppression systems in all six cottages, lack of quarterly sprinkler system inspection reports for the second and third quarters of 2022, and failure to conduct quarterly fire drills for multiple quarters.
Severity Breakdown
SS=F: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure kitchen fire suppression system was inspected semiannually for the kitchens in all six cottages. | SS=F |
| No quarterly sprinkler system inspection reports available for review in the second and third quarters of 2022. | SS=F |
| Failed to conduct quarterly fire drills for multiple quarters in 2022. | SS=F |
Report Facts
Certified beds: 72
Census: 63
Cottage capacity: 12
Cottage census: 63
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to deficiencies regarding fire suppression system inspections, sprinkler system inspections, and fire drills. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 64
Deficiencies: 24
Dec 8, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Complaints IN00388052 and IN00393166, resulting in an Extended Survey due to Substandard Quality of Care with Immediate Jeopardy.
Findings
The facility was found to have multiple deficiencies including failure to ensure advance directives were reviewed and updated, failure to notify physicians of significant changes, failure to identify and report injuries of unknown origin as possible abuse, failure to investigate such injuries, inaccurate MDS assessment coding, incomplete care plans for antipsychotic use, failure to provide ADL assistance, lack of meaningful activities, failure to identify and respond to change of condition, medication errors, unsafe storage of chemicals and medications, infection control deficiencies, lack of RN coverage for 8 hours on some days, failure to post nurse staffing data timely, unnecessary antibiotic use, improper medication crushing, unsecured medications, unsafe environment with flooring gaps, incomplete employee records, and failure to implement COVID-19 vaccination policies and reporting.
Complaint Details
Complaint IN00388052 was unsubstantiated due to lack of evidence. Complaint IN00393166 was substantiated with federal/state deficiencies cited.
Severity Breakdown
SS=F: 6
SS=J: 2
SS=E: 3
SS=D: 11
SS=C: 1
Deficiencies (24)
| Description | Severity |
|---|---|
| Failed to ensure advance directives were reviewed, obtained, or updated to reflect residents' current wishes. | SS=D |
| Failed to notify physician of a change in resident's condition resulting in a facility acquired pressure ulcer. | SS=D |
| Failed to identify injuries of unknown origin as possible abuse and failed to report and investigate them properly. | SS=J |
| Failed to report injuries of unknown origin to the Indiana State Department of Health. | SS=D |
| Failed to thoroughly investigate injuries of unknown origin as possible abuse. | SS=J |
| Failed to accurately code MDS assessment for tube feeding status. | SS=D |
| Failed to document targeted behaviors in comprehensive care plan for resident receiving antipsychotic medication. | SS=D |
| Failed to provide assistance with activities of daily living related to shaving. | SS=D |
| Failed to provide meaningful activities, staff engagement, and assistance for residents dependent on staff for activity involvement. | SS=E |
| Failed to identify change of condition, ensure physician order was followed, and notify physician of change for a resident with skin tear. | SS=D |
| Failed to ensure adequate supervision to prevent accidents when kitchen chemicals and medication room chemicals were unlocked and unsecured and failed to supervise hot fireplace. | SS=E |
| Failed to properly handle and store potentially hazardous foods, maintain kitchen equipment and areas to prevent microbial growth and cross contamination, label and date refrigerated products, and wear proper hair restraints in kitchens. | SS=F |
| Failed to maintain an infection prevention and control program, failed to handle linens properly, maintain laundry rooms and equipment clean and in good repair, and failed to follow proper infection control measures including hand hygiene during resident care. | SS=F |
| Failed to ensure oxygen tubing was dated and nebulizer mask and tubing were stored in a sanitary manner. | SS=D |
| Failed to provide pain management consistent with professional standards of practice. | SS=D |
| Failed to assess, obtain physician order, care plan, and provide maintenance inspections for side rails. | SS=D |
| Failed to ensure a Registered Nurse was on site for 8 consecutive hours on some days. | SS=D |
| Failed to provide current daily nurse staffing postings for residents and visitors. | SS=C |
| Failed to reassess resident medication regimen prescribed prophylaxis antibiotic for history of urinary tract infections. | SS=D |
| Failed to ensure medication error rate less than 5% due to crushing extended release medications. | SS=D |
| Failed to ensure medications were secure and inaccessible to residents and staff. | SS=D |
| Failed to maintain a functional and safe environment related to gaps in flooring. | SS=D |
| Failed to ensure employees received required TB skin tests, physical exams, orientation, reference verification, dementia and resident rights training. | SS=D |
| Failed to implement COVID-19 vaccination policy and procedures including education, vaccination offering, and reporting vaccination status to NHSN. | SS=F |
Report Facts
Residents present: 64
Total licensed beds: 64
Medication error rate: 7.69
Staff partially vaccinated: 5
Staff fully vaccinated: 54
Staff not vaccinated without exemption: 2
Staff with exemption: 1
Days without 8 hour RN coverage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Lindsay | Administrator | Named in Plan of Correction and interviews |
| Paige Owens | Director of Nursing | Named in Plan of Correction and interviews |
| Tinesha Burroughs | Assistant Director of Nursing | Named in Plan of Correction and interviews |
| LPN 23 | Observed during wound care with improper glove use | |
| QMA 1 | Observed medication administration errors and hand hygiene lapses | |
| Nursing Assistant 4 | Interviewed about flooring and medication cart security | |
| Dietary Manager | Interviewed about kitchen hygiene and food handling | |
| Consultant Nurse | Provided expert input on infection control and antibiotic stewardship | |
| Memory Care Coordinator | Interviewed about activities and supervision | |
| Director of Nursing | Interviewed about multiple deficiencies and staffing | |
| Executive Director | Interviewed about staffing and safety concerns | |
| Nurse Practitioner | Provided medical orders and input on antibiotic use and pain management |
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