Inspection Report Summary
The most recent inspection on July 16, 2025, found no deficiencies related to the complaint investigated at that time. Earlier inspections showed mostly compliance, but a January 16, 2024, complaint investigation identified deficiencies involving inadequate supervision that led to a resident’s fall with serious injury and failure to notify a physician of the resident’s condition change; these complaints were substantiated. Prior reports noted a single deficiency in November 2024 where a licensed practical nurse worked with an expired license, but no enforcement actions or fines were listed in the available reports. Most complaint investigations were unsubstantiated, and the facility corrected the cited issues from earlier complaints by April 2024. The inspection history suggests improvement after the January 2024 findings, with more recent inspections showing fewer or no deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 0
Date: Jul 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460086.
Complaint Details
Complaint IN00460086 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00460086 were cited during the investigation.
Report Facts
Census: 96
Total Capacity: 96
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Date: Nov 8, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00427994.
Complaint Details
Complaint IN00427994 was investigated and no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the complaint allegations were cited. However, a deficiency was found where a Licensed Practical Nurse (LPN 2) worked with an expired license after its expiration date of 10/31/2024.
Deficiencies (1)
Facility failed to ensure a Licensed Practical Nurse (LPN 2) did not work with an expired license after 10/31/2024.
Report Facts
Residential Census: 85
License expiration date: Oct 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Halstead | Executive Director | Interviewed regarding LPN license expiration and facility license tracking |
Inspection Report
Re-Inspection
Census: 77
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00425179 and IN00425290 completed on January 16, 2024.
Complaint Details
Complaint IN00425179 and Complaint IN00425290 were both corrected.
Findings
Woodland Terrace 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 Investigation of Complaints IN00425179 and IN00425290.
Report Facts
Facility number: 13510
Residential census: 77
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Date: Jan 30, 2024
Visit Reason
This visit was for the investigation of Complaint IN00426856.
Complaint Details
Complaint IN00426856-No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. Woodland Terrace of Carmel was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-5 in regard to the investigation of Complaint IN00426856.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
Date: Jan 16, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00425179 and IN00425290 related to allegations of neglect and resident rights offenses at Woodland Terrace of Carmel.
Complaint Details
The investigation was triggered by complaints IN00425179 and IN00425290 alleging neglect. The complaints were substantiated with findings that the resident experienced an unwitnessed fall due to staff negligence, resulting in serious injury and death within 14 days. The facility did not notify the physician timely about the resident's pain and condition changes post-fall.
Findings
The facility failed to ensure adequate supervision and assistance to prevent falls for a cognitively impaired resident requiring mobility assistance, resulting in an unwitnessed fall causing multiple rib fractures, hemothorax, hospitalization, and subsequent death. Additionally, the facility failed to notify the physician of the resident's significant change in condition and pain.
Deficiencies (2)
Failure to ensure adequate supervision and assistance to prevent falls for a cognitively impaired resident requiring mobility assistance.
Failure to notify the physician of a resident's significant change in condition and pain following a fall.
Report Facts
Resident census: 77
Number of fractured ribs: 3
Days resident experienced unrelieved pain: 3
Days until resident death post-fall: 14
Date of survey completion: Jan 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HHA 1 | Home Health Aide | Named in the fall incident where she walked ahead of the resident and was distracted by her phone, contributing to the resident's fall. |
| Director of Nursing | Director of Nursing | Observed video of the fall and provided statements regarding expected staff behavior. |
| Executive Director | Executive Director | Present during interview and involved in policy review. |
| QMA 2 | Qualified Medication Aide | Provided information about resident's usual care and mobility assistance. |
| QMA 3 | Qualified Medication Aide | Described how he assisted the resident with mobility and balance. |
Inspection Report
Complaint Investigation
Census: 80
Deficiencies: 0
Date: Dec 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417833 and IN00422697.
Complaint Details
Complaint IN00417833 and Complaint IN00422697 were investigated with no deficiencies cited related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00417833 and IN00422697 were cited. The facility was found to be in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Date: Jun 16, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00410234.
Complaint Details
Complaint IN00410234 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations are cited. Woodland Terrace of Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the Investigation of Complaint IN00410234.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: May 3, 2023
Visit Reason
This visit was for a State Residential Licensure Survey, which included the investigation of Complaints IN00382525 and IN00404315.
Complaint Details
Complaint IN00382525 and Complaint IN00404315 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies related to the allegations in Complaints IN00382525 and IN00404315 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the State Residential Licensure Survey and complaint investigations.
Report Facts
Residential Census: 84
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