Inspection Report
Complaint Investigation
Census: 96
Capacity: 96
Deficiencies: 0
Jul 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460086.
Findings
No deficiencies related to the allegations in Complaint IN00460086 were cited during the investigation.
Complaint Details
Complaint IN00460086 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 96
Total Capacity: 96
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 1
Nov 8, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00427994.
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.
Complaint Details
Complaint IN00427994 was investigated and no deficiencies related to the allegations were cited.
Deficiencies (1)
| Description |
|---|
| 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
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.
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.
Complaint Details
Complaint IN00425179 and Complaint IN00425290 were both corrected.
Report Facts
Facility number: 13510
Residential census: 77
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 0
Jan 30, 2024
Visit Reason
This visit was for the investigation of Complaint IN00426856.
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.
Complaint Details
Complaint IN00426856-No deficiencies related to the allegations are cited.
Inspection Report
Complaint Investigation
Census: 77
Deficiencies: 2
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.
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.
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.
Deficiencies (2)
| Description |
|---|
| 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
Dec 13, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00417833 and IN00422697.
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.
Complaint Details
Complaint IN00417833 and Complaint IN00422697 were investigated with no deficiencies cited related to the allegations.
Inspection Report
Complaint Investigation
Census: 89
Deficiencies: 0
Jun 16, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00410234.
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.
Complaint Details
Complaint IN00410234 - No deficiencies related to the allegations are cited.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
May 3, 2023
Visit Reason
This visit was for a State Residential Licensure Survey, which included the investigation of Complaints IN00382525 and IN00404315.
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.
Complaint Details
Complaint IN00382525 and Complaint IN00404315 were investigated with no deficiencies related to the allegations cited.
Report Facts
Residential Census: 84
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