Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carmel Health & Living Community during CMS and state inspections, most recent first.
A resident with left-sided weakness and requiring total assistance for bed mobility fell from bed during incontinence care when an LPN left the room, leaving a CNA alone to assist. The resident, weighing over 300 pounds, was on a bariatric bed that staff reported was too small. The resident rolled off the bed and sustained multiple skin tears and a subdural hematoma, requiring hospitalization.
A resident with ESRD and hemodialysis was prescribed full-dose valacyclovir for shingles after a telehealth visit, even though the EHR generated severe kidney-related alerts. After starting the medication, the resident developed confusion, hallucinations, and insomnia, received additional sedating meds, and was transferred to the hospital, where she was diagnosed with toxic metabolic encephalopathy from the high-dose Valtrex in the setting of renal failure.
Incomplete narcotic count documentation, missed medication availability, and inconsistent controlled substance records were found. Multiple medication carts lacked required nurse signatures on shift count sheets, a resident admitted with benzodiazepine dependence missed Valium doses because the ordered dose was unavailable and the admission order was entered incorrectly, and another resident with chronic pain had repeated gaps and unclear documentation for Fentanyl patch availability, removal, and destruction. Staff interviews confirmed the expected sign-on/sign-off process and the need for two nurse signatures for controlled substance destruction.
Medication labeling and storage were inconsistent across several med carts and a med refrigerator. Surveyors found multiple open meds, including morphine, eye ointment, eye drops, and tuberculin solution, without open dates, one damaged morphine label, and pills for a resident stored outside original pharmacy packaging. For one resident on oxycodone, the MAR and controlled drug record did not match the current order, and an ADON stated staff were using a PRN dose from the scheduled med card and were unsure how the 5 rights were being verified.
Failure to assess and document self-administration of nebulizer treatments: A resident with COPD, pneumonia, and anxiety was observed with a nebulizer machine set up in her room, and she stated it had been prepared for her because she forgot to do it. Although she had an order for albuterol inhalation treatments, the record lacked an assessment, physician order, and care plan for self-administration, and an RN and Clinical Support Nurse confirmed the needed assessment and care planning were not in place.
Blood pressure medications were not administered according to physician orders for two residents. One resident received midodrine when SBP was above the ordered hold parameter and also had doses held when SBP was below the parameter without refusal documentation. Another resident received PRN clonidine when SBP was below the ordered threshold. Staff interviews confirmed the orders should have been followed as written, and facility policy stated medications must be given only as prescribed.
Respiratory care was not fully managed for multiple residents receiving oxygen and nebulizer therapy. Two residents had oxygen and nebulizer tubing that was not dated, and one resident had a nebulizer mask stored outside a bag. Another resident was observed on oxygen at 3 L/min, but no physician order for oxygen was found in the chart. Staff acknowledged that oxygen use should be supported by a physician order and that tubing should be dated.
A resident with ESRD and dependence on renal dialysis was receiving hemodialysis, but the EHR did not contain an active MD order for dialysis or the required pre- and post-dialysis assessments. Although the resident returned from the hospital with discharge paperwork indicating dialysis was needed and was observed going to and returning from dialysis, the dialysis orders were missed during readmission order review.
Unnecessary Drug Regimen Due to Unsupported Diagnoses: The facility failed to ensure medication orders had diagnoses that supported the documented indications for use for two residents. One resident received sennosides-docusate sodium ordered for unsteadiness on feet even though the drug is used for constipation, and the DON stated the diagnosis did not match. Another resident received cephalexin ordered for UTI with no end date, while staff later stated the medication was actually being used for a non-healing foot wound and that UTI was an incorrect diagnosis. The record also showed the pharmacy reviewed the medications with no recommendations.
A facility failed to ensure proper documentation of narcotic administration for two residents. RN 1 signed out narcotics in the count book but did not document their administration in the EMAR. Resident F, with severe pain conditions, had no PRN doses documented despite multiple sign-outs. Resident G, with severe dementia, had only one documented dose despite several sign-outs. All medications were accounted for, but RN 1 was terminated for not following policy.
The facility failed to follow physician orders for several residents, including inappropriate administration of insulin and blood pressure medications, delayed treatment for a UTI due to poor communication, and continued administration of discontinued medications. Additionally, daily weights and as-needed medications were not managed according to orders, highlighting significant lapses in care and communication.
A resident's mail from Medicaid was opened by facility staff without permission, despite the resident's explicit refusal to authorize such actions. The Business Office Manager opened the mail under corporate direction due to issues at other facilities. The facility lacked a specific mail delivery policy, and this action violated the resident's rights to privacy and confidentiality as outlined in the facility's Resident Rights policy.
The facility failed to ensure accurate and updated PASARR documentation for two residents. One resident's PASARR Level I did not list an antidepressant medication they were taking, while another resident's PASARR Level I failed to recognize a bipolar disorder diagnosis, missing the need for a Level II screen. The social service department was responsible for updating PASARRs, but the facility lacked a specific PASARR policy.
A facility failed to include a resident's insomnia diagnosis and related medications in their care plan. The resident, who had dementia and heart failure, was prescribed melatonin, trazodone, and Seroquel for insomnia. Staff interviews indicated that the social services department was responsible for updating care plans, but this was not done. The facility did not have a specific care plan policy and followed the RAI manual.
A resident was observed with a vape in their room, contrary to the facility's smoke-free policy. The CNA was unsure about the policy, and both the Unit Manager and Executive Director confirmed that vapes should not be in residents' rooms. The resident's medical history included opioid dependence and anxiety disorder.
The facility failed to administer the correct oxygen levels for two residents, with one receiving 3L instead of the ordered 2L, and another receiving 5L instead of 2L. Staff interviews confirmed the discrepancies, highlighting a lapse in verifying physician orders for oxygen administration.
The facility failed to ensure proper narcotic count procedures were followed, with numerous missing signatures from both on-coming and off-going staff in the 700-unit and 400-unit narcotic log count sheets. The facility's policy requires that outgoing and oncoming licensed nurses count and account for all scheduled drugs together and complete the Nurse's Narcotic Sign In/Sign Out sheet, which was not adhered to, leading to the observed deficiencies.
The facility failed to properly label, date, and store medications and supplements across three units, affecting two residents. An open insulin pen and liquid protein were found unlabeled, and medications were improperly stored. Two residents had unauthorized Diclofenac Sodium gel in their rooms, with one lacking a physician's order. Facility policies on drug storage and bedside medications were not followed.
A resident with a history of Alzheimer's and other conditions was observed with missing front teeth, and the facility failed to ensure her partial dentures were repaired or replaced. Despite a policy requiring prompt referral for dental services, there was no documentation of dental visits or attempts to address the issue, and staff interviews revealed confusion and lack of follow-up.
The facility failed to serve food at a safe and appetizing temperature for residents receiving room trays. Several residents reported that their food was cold, and a resident council meeting confirmed that room trays were sometimes cold. An observation showed that food items were served below the required temperature, and the Assistant Dining Services Supervisor acknowledged the need for reheating. The facility's policy requires reheating food to an internal temperature of 165 F for 15 seconds or replacing it.
The facility failed to maintain a safe and sanitary environment in five rooms, with issues such as exposed wires, ceiling stains, improperly fitted light switch covers, and food debris. A resident's room had persistent cleanliness issues, and opened wound supplies were left in another room. The maintenance supervisor and administrator were unaware of some deficiencies.
The facility failed to ensure that a resident was clinically appropriate to self-administer medications. An LPN left the resident alone with medication cups and a nebulizer vial within reach, without a documented assessment, physician's order, or care plan for self-administration. The facility's policy requires interdisciplinary team approval for self-administration, which was not followed.
An LPN failed to follow infection control practices by using her fingers to remove a medication capsule from the bottle for a resident with vascular dementia, chronic kidney disease, and insomnia, despite facility procedures prohibiting such actions.
Resident Fall During Incontinence Care Due to Inadequate Supervision and Bed Size
Penalty
Summary
A resident with a history of cerebral infarction, hemiplegia, and hemiparesis, who was dependent on staff for all activities of daily living and required a two-person physical assist for bed mobility, experienced a fall during incontinence care. The resident, who weighed over 300 pounds and had left-sided weakness from a previous stroke, was being cared for by a CNA and an LPN. During the care, the LPN left the room to obtain cream for the resident's excoriated skin, leaving the CNA alone with the resident. While the CNA was positioned on one side of the bed, the resident rolled over and fell off the bed onto the floor. The bed in use was a collapsible bariatric bed extended to 42 inches, but staff reported that the bed was still too small for the resident to fit comfortably. The resident was partially clothed and incontinent at the time of the fall. The CNA was unable to reach the other side of the bed to assist the resident as she rolled off. The fall was witnessed, and emergency services were called to assist in transferring the resident from the floor to a stretcher. As a result of the fall, the resident sustained multiple skin tears and was hospitalized with an eight-millimeter right frontal convexity subdural hematoma, as confirmed by a CT scan. The incident occurred while the resident was being prepared for dialysis, and the lack of adequate supervision and appropriate bed size contributed to the accident. The facility's documentation and interviews confirmed that staff did not remain with the resident throughout care and that the bed may not have been suitable for the resident's size.
Significant Valacyclovir Dosing Error in Resident With ESRD
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error when Resident 7, who had end stage renal disease and was dependent on hemodialysis, was ordered valacyclovir 1 gram three times daily for shingles. The telehealth nurse practitioner entered the full-dose order after a video visit, and the electronic health record generated severe drug-to-condition interaction alerts related to chronic kidney disease stage 5 and the need for extreme caution, but the order was still acknowledged and transcribed. The record also showed the resident had ESRD and kidney function concerns that would have required dose reduction based on renal function. After starting valacyclovir, Resident 7 developed new confusion, anxiety, insomnia, giggling, and hallucinations. A second telehealth call documented that she seemed "drunk" and had an onset of confusion that was not baseline behavior, and she was given hydroxyzine and Benadryl for insomnia and anxiety. The resident continued to worsen, with nursing notes describing confusion, nonsensical speech, and visual hallucinations such as seeing colors and stripes on the walls. STAT labs were ordered, but before they were obtained at the facility, the resident's daughter requested transfer to the hospital because of the delay. The resident received five doses of valacyclovir before refusing the sixth dose, and hospital records showed she was admitted for hallucinations and confusion after being started on a full dose of Valtrex despite ESRD. The hospital documented toxic metabolic encephalopathy due to the high dose of Valtrex in the setting of end stage renal disease, and her encephalopathy slowly resolved after the medication was stopped. Later documentation noted she had been recently hospitalized for altered mental status after receiving full-dose Valtrex, which improved after discontinuation.
Incomplete narcotic counts and inconsistent controlled substance documentation
Penalty
Summary
The facility failed to ensure narcotic reconciliation was documented as completed for multiple medication carts, and the controlled substance count sheets were missing required nurse signatures on several shifts. The 500 Unit narcotic reconciliation document lacked signatures for the on-coming night shift on 9/10/25, 9/13/25, and 9/17/25, and for both the on-coming and off-going evening shift on 9/15/25. The 700-1 Unit document was missing signatures for the on-coming and off-going evening shift on 9/22/25, and the 800 Unit document was missing signatures for the on-coming and off-going evening shift on 9/1/25. Staff interviews confirmed that nurses were expected to sign the narcotic count sheet when taking over and surrendering the cart, and that the facility used sign on and sign off count sheets at the end of each shift. The facility also failed to ensure uninterrupted availability and accurate administration documentation for Resident 138, who had diagnoses including benzodiazepine dependence, congestive heart failure, fluid overload, and age-related debility. Resident 138 was admitted on 9/16/25, and the discharge summary and physician orders indicated Valium 5 mg twice daily, later corrected to Valium 5 mg one-half tablet twice daily. The MAR showed the morning dose was not given because a new script was needed, and the evening dose was unavailable. The resident missed 3 doses of Valium after admission. A nursing progress note documented that the resident requested Valium earlier in the shift, was told the medication would be delivered later that night, and stated she thought she was experiencing withdrawal symptoms and called 911 herself. Staff interviews indicated the facility did not have the prescribed dosage in the EDK and that the admission order had been entered incorrectly before being fixed. The facility also failed to maintain accurate controlled substance administration and destruction documentation for Resident 55, who had diagnoses including pain, opioid dependence, and long-term use of drug therapy. The resident had an order for a Fentanyl 50 mcg/hr patch every 72 hours, with instructions to remove the previous patch and destroy it with another nurse. The controlled drug records showed missing count records for two date ranges, and the MAR showed Fentanyl was unavailable on two dates. The record also lacked documentation of removal and/or second nurse witness signatures for numerous patch changes, and several entries stated the patch fell off without documentation of destruction. In addition, the July 2025 MAR contained inconsistent documentation about patch placement across shifts, and the June and August 2025 MARs also contained inconsistent patch documentation. After review of the progress notes, controlled drug records, and MAR, the actual time frame of Fentanyl unavailability and missed administrations could not be determined.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored according to accepted professional principles in multiple medication areas. On the 500 Unit medication cart, surveyors found three bottles of morphine with remaining medication that did not have open dates, and one bottle had a damaged label. On the 300 Unit medication cart, a clear plastic pouch labeled with Resident 3’s name and room number contained four pills that were not in the original pharmacy packaging, and another bottle of morphine with about 4 ml remaining was found without an open date. In the 300 Unit medication storage room refrigerator, one bottle of tuberculin solution was open and had no open date. On the 700 Unit medication cart, one tube of neomycin-bacitracin-poly-HC eye ointment and one bottle of olopatadine eye drops were both open without open dates, and the RN stated the date had been on the top of the lid of the medication container. The medication record for Resident 55 also did not match the pharmacy label for oxycodone. The resident’s clinical record listed diagnoses including pain, opioid dependence, and long-term use of drug therapy. Physician orders changed the oxycodone schedule from twice daily to three times daily, and the PRN order also changed, but the controlled drug record continued to reflect twice-daily administration. During interview, the ADON stated that when a PRN medication was ordered and the resident had a routine order for the same medication, nurses could use the PRN dose from the scheduled medication card, and she noted the label on the drug record did not match the MAR. She also stated she was unsure how nurses were verifying the 5 rights of administration without the correct label.
Failure to Assess and Document Self-Administration of Nebulizer Treatments
Penalty
Summary
The facility failed to ensure the interdisciplinary team determined that self-administration of medications was clinically appropriate and failed to document that determination in the resident’s medical record and care plan for one resident reviewed for self-administration of nebulizer treatments. During observation, the resident was seen in her room with a nebulizer machine containing fluid in the medicine cup, and she stated that the nebulizer was set up for her and that she forgot to do it. Her diagnoses included COPD, pneumonia, and generalized anxiety disorder, and a physician’s order directed albuterol sulfate inhalation treatments twice daily. At the time of record review, the resident did not have an assessment, physician order, or care plan for self-administering nebulizer treatments. An RN stated that the resident had an evening nebulizer treatment but had not yet been in the room and was not sure whether the resident could self-administer. A Clinical Support Nurse stated that the resident needed an assessment, a physician’s order to self-administer medications, and care planning for self-administration. The facility policy titled BEDSIDE MEDICATIONS AND SELF-ADMINISTRATION OF MEDICATIONS indicated that if a resident desires to self-administer, an assessment is conducted.
Blood Pressure Medications Given Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure blood pressure medications were administered according to physician orders for 2 residents. For one resident with diagnoses including hypotension, repeated falls, weakness, unsteadiness on feet, hypertensive heart disease without heart failure, and essential primary hypertension, an order directed staff to give midodrine 5 mg every 8 hours and hold it when systolic blood pressure was greater than 140. The MAR showed multiple administrations when systolic blood pressure was above 140, including readings of 152, 142, 145, 146, 154, 161, 157, 144, 153, and 155. The MAR also showed multiple held doses when systolic blood pressure was below 140 without documentation of refusal, and one administration note stated the blood pressure was too high for the medication. For another resident with diagnoses including peripheral vascular disease, diastolic congestive heart failure, tachycardia, chronic respiratory failure with hypoxia, stage 2 chronic kidney disease, and essential primary hypertension, physician orders directed clonidine 0.1 mg as needed twice a day for systolic blood pressure greater than 170. The MAR showed clonidine was administered on numerous occasions when systolic blood pressure was less than 170 across August and September 2025. During interview, the Clinical Support Nurse stated the clonidine order should have been PRN for systolic blood pressure greater than 170 and not given if the blood pressure was less than 170. Facility policy stated medications are to be administered only as prescribed by a physician. Another policy stated physician orders must be transcribed timely, completely, and accurately. The record review and staff interviews showed the blood pressure parameters in the orders were not followed for either resident, with medications given outside ordered limits and doses held without documented refusal.
Respiratory Equipment Not Dated and Missing Oxygen Order
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for residents receiving oxygen and nebulizer treatments. During observation, Resident 12 was receiving oxygen via nasal cannula, but the oxygen line was not dated to show when it was last changed. The resident also had a nebulizer machine on a dresser, and the nebulizer mask was stored next to the machine rather than in a storage bag. Resident 12’s record included diagnoses of COPD, cough, and age-related debility, and the physician’s order directed staff to change and date the oxygen tubing, humidified bottle, and nebulizer tubing every week on Sunday and as needed. Resident 113 was observed receiving oxygen and had a nebulizer machine with fluid in the medicine cup, but the oxygen line and nebulizer line were not dated. The resident’s diagnoses included COPD, pneumonia, and generalized anxiety disorder, and the physician’s order also directed weekly changing and dating of the oxygen tubing, humidified bottle, and nebulizer tubing. Resident 138 was observed receiving oxygen at 3 liters per minute on two occasions, but the clinical record contained no physician’s order for oxygen. RN 20 stated she did not see an oxygen order and that there should be one, and RN 21 stated a resident should have a physician’s order for oxygen use.
Missing dialysis order and monitoring orders for resident receiving hemodialysis
Penalty
Summary
The facility failed to ensure an active physician's order for hemodialysis and required monitoring before and after dialysis for one resident who required dialysis services. The resident had diagnoses including end stage renal disease, chronic kidney disease stage 3, and dependence on renal dialysis, and the care plan indicated she received hemodialysis for ESRD. A physician's order dated 7/12/25 directed midodrine before dialysis every Monday, Wednesday, and Friday, but no active physician's order for dialysis was found in the electronic health record. The prior dialysis-related orders, including pre-dialysis and post-dialysis assessments, had been discontinued on 7/6/25 when the resident was discharged to the hospital. The resident returned to the facility on 7/12/25, and the hospital discharge document indicated dialysis was needed after discharge for post-acute services. During observations, the resident was seen leaving for dialysis on 9/19/25 and 9/22/25, and on 9/24/25 she had just returned from dialysis and was eating lunch in her room. The ADON reviewed the orders and stated the resident did not have an active physician's order for dialysis or adequate monitoring in place. The Administrator stated that hospital discharge papers were reviewed on readmission, the nurse entered orders into the EHR, and a readmission meeting was held the following day, but the dialysis orders were missed. The Clinical Support Nurse 2 stated the facility did not have a policy for physician order reconciliation and that nursing managers should have reviewed all orders the morning after the resident returned.
Unnecessary Drug Regimen Due to Unsupported Diagnoses
Penalty
Summary
The facility failed to ensure that residents’ drug regimens were free from unnecessary drugs because the diagnoses used did not support the documented indications for medication use for 2 of 6 residents reviewed. For Resident 3, the clinical record showed diagnoses including constipation, anxiety disorder, and pain. A physician order dated 8/19/25 directed sennosides-docusate sodium twice daily for unsteadiness on feet, even though the medication is used for constipation. The pharmacy medication regimen review dated 8/26/25 noted the medications were reviewed with no recommendations. During interview, the DON reviewed the order and stated the medication did not have the correct supporting diagnosis, and Clinical Support Nurse 2 stated the pharmacy reviewed medications, allergies, diagnoses, and interactions. For Resident 11, the clinical record included diagnoses such as orthopedic aftercare following surgical amputation, cellulitis of the left lower limb, and UTI. A physician order dated 8/1/25 directed cephalexin 500 mg once daily for a UTI, with no end date listed. During interview, Clinical Support Nurse 2 stated the resident was receiving cephalexin for a non-healing foot wound, below-the-knee amputation, and chronic UTI, and also stated the facility nurse practitioner did not note the chronic UTI and would contact the physician. In a later interview, Clinical Support Nurse 2 stated UTI was an incorrect diagnosis and that it should have been prophylaxis for a wound. The facility policy on transcribing orders stated medication orders require the drug and associated diagnosis.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation and administration of narcotic medications for two residents, leading to a deficiency in pharmaceutical services. RN 1 was reported by a Qualified Medication Aide for potentially taking residents' narcotic medications, as she signed them out in the narcotic count book but did not document their administration in the residents' medical records. An investigation confirmed that all narcotic medications were accounted for, but RN 1 was terminated for not following the facility's policy and procedure. Resident F, diagnosed with conditions including malignant neoplasm of the rectum and cerebral infarction, had a physician's order for Oxycodone 10 mg as needed for severe pain. However, the resident's Electronic Medication Administration Record (EMAR) for November 2024 showed no documentation of PRN doses administered, despite the narcotic count sheet indicating multiple doses signed out by RN 1. A handwritten note confirmed that the resident had not missed any doses and had not complained of pain. Resident G, with diagnoses including severe vascular dementia and malignant neoplasm of the prostate, had a physician's order for Hydrocodone-acetaminophen 5-325 mg for pain. The EMAR for December 2024 documented only one PRN dose, while the narcotic count sheet showed several doses signed out by RN 1. A note indicated that the resident was unable to be interviewed but had not complained of pain, and all medications were accounted for. The facility's policy required immediate documentation of medication administration, which RN 1 failed to comply with, leading to her termination.
Failure to Follow Physician Orders and Communication Lapses
Penalty
Summary
The facility failed to adhere to physician's orders for multiple residents, leading to significant lapses in care. For Resident G, the facility did not follow orders to hold Humalog insulin when blood sugar levels were below 150, resulting in multiple instances of inappropriate administration. Additionally, the facility failed to administer clonidine as needed for elevated systolic blood pressure, despite clear physician instructions. Interviews with staff revealed a lack of adherence to these orders, contributing to the resident's chronic uncontrolled hypertension. Resident H experienced a delay in receiving treatment for a urinary tract infection due to poor communication between the facility and external healthcare providers. After an outpatient urology appointment, the facility did not receive or follow up on the necessary paperwork, resulting in a six-day delay in starting the prescribed antibiotic. Interviews indicated that the facility's standard practice of contacting providers within 24 hours was not followed, and there was no policy in place to ensure follow-up communication when residents returned without paperwork. For Resident F, the facility continued to administer medications that had been discontinued by hospice orders, including melatonin and lorazepam, while failing to start Seroquel as prescribed. This oversight persisted for several days, as hospice communication logs indicated the changes, but the facility did not update the orders in their system. Similarly, Resident 33 received metoprolol despite blood pressure readings that should have prompted the medication to be held. Lastly, Resident 105 did not have daily weights recorded as ordered, and Lasix was not administered according to weight gain parameters, with staff unable to provide reasons for these omissions.
Violation of Resident's Mail Privacy
Penalty
Summary
The facility failed to ensure that a resident's mail was delivered unopened, violating the resident's rights. During a resident council interview, a resident reported that her mail from Medicaid had been opened by the facility without her permission. The resident had explicitly indicated on a Permission & Acknowledgment form that she did not authorize facility personnel to open her mail, including Medicaid correspondence. Despite this, the Business Office Manager admitted to opening the resident's Medicaid approval letter and making a copy of her new Medicaid card before delivering it to her. This action was taken under the direction of the corporate office due to issues at other sister facilities where checks meant for the facility were delivered to residents. The facility lacked a specific policy regarding mail delivery or mail services, as confirmed by the Executive Director. The existing Resident Rights policy, dated 6/6/19, emphasized the resident's right to privacy and confidentiality, including communication by mail. The unauthorized opening of the resident's mail was a clear breach of this policy, as it violated the resident's right to privacy and confidentiality. The facility's actions were not aligned with the resident's expressed wishes and the facility's own policy on resident rights.
Inaccurate PASARR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that pre-admission screening and resident reviews (PASARR) were accurate and updated for two residents. For Resident 87, the clinical record review revealed that the PASARR Level I, dated August 2, 2024, did not list any mental health medications, despite the resident being on Amitriptyline, an antidepressant, since admission. The Clinical Support nurse confirmed that the medication should have been included in the PASARR. Social Services 14 indicated that the social service department was responsible for ensuring PASARRs were up to date, and they should be updated when a resident receives a new mental health medication. For Resident D, the PASARR Level I, dated August 13, 2024, incorrectly indicated that the resident did not have a serious mental health disability, and no Level II screen was required. However, the resident was admitted with a diagnosis of bipolar disorder, which was also present on the admission Minimum Data Set (MDS) assessment. Social Services 14 acknowledged that the bipolar diagnosis was missed, and a Level II screening should have been initiated. The Clinical Support nurse noted that the facility did not have a policy for PASARR and followed the resident assessment instructions (RAI).
Failure to Include Insomnia in Resident's Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident diagnosed with insomnia. The resident, identified as Resident F, had multiple diagnoses including dementia, diastolic heart failure, and insomnia. Despite having physician's orders for melatonin, trazodone, and Seroquel to manage insomnia, these medications and the diagnosis were not included in the resident's care plan. Interviews with facility staff revealed that the social services department was responsible for ensuring diagnoses and medications were added to care plans, but this was not done for Resident F. Additionally, the facility lacked a specific policy for care plans and relied on the Resident Assessment Instrument (RAI) manual.
Resident Found with Vape in Room Against Facility Policy
Penalty
Summary
The facility failed to ensure that a resident did not have smoking articles in their room, which posed an accident hazard. During an observation, Resident 241 was found with an electronic cigarette (e-cigarette) or vape on his bedside table. When a CNA entered the room with the resident's lunch, the resident attempted to conceal the vape, but it remained visible. The CNA was unsure about the policy regarding vapes in residents' rooms. The resident's clinical record indicated diagnoses including opioid dependence, drug-induced constipation, unspecified pain, and anxiety disorder. Interviews with the Unit Manager and Executive Director confirmed that the facility was smoke-free and residents should not have vapes in their rooms. The facility's smoking policy stated that residents without independent smoking privileges may not keep smoking articles unless under direct supervision.
Failure to Administer Correct Oxygen Levels
Penalty
Summary
The facility failed to administer the correct amount of oxygen as ordered by the physician for two residents. Resident 10 was observed multiple times with their oxygen concentrator set at 3 liters per minute (L), despite a physician's order for 2L. This discrepancy was noted during observations on several dates, and interviews with staff confirmed the incorrect setting. The resident's medical history included heart failure, vascular dementia, type 2 diabetes, chronic pulmonary embolism, and respiratory failure, necessitating precise oxygen therapy management. Similarly, Resident 37 was observed receiving oxygen at 5L per minute, contrary to the physician's order of 2L. The Director of Nursing and a registered nurse confirmed the incorrect setting, emphasizing the responsibility of nursing staff to verify and maintain the correct oxygen flow rate. The facility's documentation on oxygen administration required verification of the physician's order prior to administering oxygen, which was not adhered to in these cases.
Failure to Adhere to Narcotic Count Procedures
Penalty
Summary
The facility failed to ensure proper narcotic count procedures were followed, as observed during a survey. Specifically, the narcotic log count sheets for the 700-unit and 400-unit were found to have numerous missing signatures from both on-coming and off-going staff. In the 700-unit, Book 1 was missing 31 signatures from off-going staff and 28 from on-coming staff, while Book 2 was missing 34 signatures from off-going staff and 33 from on-coming staff. Similarly, in the 400-unit, the narcotic log was missing 39 signatures from off-going staff and 30 from on-coming staff. These observations were made in the presence of Unit Manager 4 and LPN 19, who confirmed that staff were supposed to sign the narcotic log sheets at the beginning and end of each shift. The facility's current policy, titled 'Policy and Procedure for Scheduled Drugs' and dated March 2015, mandates that at the beginning and end of each shift, the outgoing and oncoming licensed nurse must count and account for all scheduled drugs together and complete the Nurse's Narcotic Sign In/Sign Out sheet. This policy was provided by the Corporate Support Nurse. The failure to adhere to this policy resulted in the observed deficiencies in narcotic count procedures, as confirmed by the interviews and record reviews conducted during the survey.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, dating, and storage of medications and supplements across three units, affecting two residents. On the 500-unit, an open Lantus insulin pen was found without a resident's name, and an anesthetic oral gel was improperly stored with ear drops. Additionally, a 30-ounce bottle of liquid protein was open and unlabeled. LPN 16 confirmed the insulin was expired and acknowledged the improper storage of the gel and ear drops. On the 800-unit, a 30-milliliter bottle of liquid protein was also found open and unlabeled, and a bottle of aplisol in the medication room refrigerator had a broken seal with no open date. Similarly, on the 700-unit, a bottle of aplisol was found with a broken seal and no open date, which Unit Manager 4 confirmed should have been dated upon opening. Resident 80 was observed with Diclofenac Sodium topical gel on his bedside table without a physician's order, and it remained there over consecutive days. Unit Manager 4 confirmed the resident should not have had the gel in his room. Resident 45 also had Diclofenac Sodium topical gel in his room with a label that did not appear to be from the facility's pharmacy. The facility's policies on drug storage and bedside medications were not adhered to, as expired medications were not removed, and unauthorized medications were found at residents' bedsides.
Failure to Provide Dental Services for Denture Repair
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services to repair or replace partial dentures. The resident, who had a history of repeated falls, bipolar disorder, oral phase dysphagia, Alzheimer's dementia with behavioral disturbance, anxiety, depression, and impaired memory, was observed on multiple occasions with missing front teeth. The resident's clinical record indicated that she had upper partial dentures upon admission, and a physician's order allowed for dentistry services as needed. However, after the resident's front teeth fell out in early July, there was no documentation of any dental visits or attempts to repair or replace the dentures. Interviews with facility staff, including the Assistant Director of Nursing, CNA, Unit Manager, and Administrator, revealed that there was confusion and lack of follow-up regarding the resident's dental care. The facility's policy required that residents with lost or damaged dentures be referred for dental services within three days, but there was no evidence that this was done. The Administrator admitted that there were no notes on dental consultations or visits, and the facility could not provide any further documentation on the status of the resident's partial dentures.
Failure to Serve Food at Safe and Appetizing Temperature
Penalty
Summary
The facility failed to ensure that food was served at a safe and appetizing temperature for residents receiving room trays. Multiple residents, including Residents E, D, B, and C, reported that their food was cold, with Resident C also noting that the food lacked good flavor. During a resident council meeting, it was indicated that room trays were sometimes cold. An observation on 10/31/24 revealed that a lunch tray had food items, such as country fried steak, peas, and glazed carrots, served at temperatures below the facility's standard of at least 120 degrees. The Assistant Dining Services Supervisor acknowledged that the food should be reheated to meet the required temperature. The facility's policy mandates that hot food not served at a preferable temperature should be reheated to an internal temperature of 165 F for 15 seconds or replaced.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in five rooms, as observed during a survey. In one room, brown stains were noted on six ceiling tiles, and a telephone outlet was missing a cover, exposing wires. The unit manager was unaware of the reason for the missing cover. Another room had a large brown stain on the ceiling and a constantly dripping kitchenette sink faucet. Additionally, a room was found with an improperly fitted light switch cover, leaving a visible hole between the cover and the wall. In another instance, a resident's room had food drip stains on the wall and window, with dried debris stuck to the window and a cracked windowsill with a milky white substance. These conditions remained unchanged over several days. Furthermore, a room was observed with opened wound supplies left on a table, which the unit manager acknowledged should have been discarded. During an environmental tour, the maintenance supervisor and administrator were unaware of some of these issues, such as the brown stains on the ceiling and the missing telephone outlet cover. The facility's job description for the Environmental Services Supervisor outlines responsibilities for maintaining a clean and safe environment, which were not met in these instances.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined a resident was clinically appropriate to self-administer medications. During a random observation, a Licensed Practical Nurse (LPN) was found to have left a resident alone in their room with medication cups and a nebulizer vial within reach. The resident's clinical record did not contain an assessment for self-administration of medication, a physician's order, or a care plan for self-administration. The resident was cognitively intact according to a Brief Interview for Mental Status (BIMS) assessment conducted a few months prior, but no formal assessment for self-administration had been documented. The facility's policy on bedside medications and self-administration requires that the interdisciplinary team determine the safety of self-administration for each resident. However, this protocol was not followed for the resident in question. The LPN admitted to stepping out of the room to assist another resident, leaving the medications unattended. This oversight indicates a failure to adhere to the facility's own policies and procedures regarding medication administration and resident safety.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for one of the residents reviewed. During a medication pass observation, an LPN used her fingers to remove an Acidophilus/Pectin capsule from the medication bottle and placed it in a medication cup for administration to a resident. The resident's clinical record indicated diagnoses including vascular dementia, chronic kidney disease, and insomnia, with a physician's order for the probiotic. The LPN acknowledged that she should not have used her fingers and mentioned having a spoon available for such tasks. The facility's procedure explicitly stated that tablets and capsules should be handled without touching them with fingers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 924 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Barrington Of Carmel, The | 0.9 mi | ★★★★★ | 0 | 0 |
| Restoracy Of Carmel | 0.9 mi | ★★★★★ | 8 | 0 |
| Wellbrooke Of Carmel | 1.6 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Carmel | 2 mi | ★★★★★ | 0 | 0 |
| Mcgivney Health Care Center | 2.7 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.