Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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 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.
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.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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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 | — | 0 | 0 |
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