‘Problems everywhere you look’: State reports confirm families’ fears of poor conditions, management at Green House Cottages of Carmel


Lisa Fisher couldn’t have been happier when she learned her mother, Charlene, had been accepted to live at Green House Cottages in Carmel.

“I felt like our family had won the lottery, because it was such a beautiful place and all these promises were made about the level of care,” Fisher said. “I actually cried when the admissions person hugged me, and I told her, ‘I’m so grateful.’”

But less than two years later, Fisher is leading the charge to expose what she sees as poor management and unsafe conditions at the long-term care facility. As president of the Family Council of Green House Cottages of Carmel, which she founded in January 2021 in response to several troubling incidents, she’s learned that more than a dozen other people with loved ones at the facility share many of her concerns.

So do public health officials.

Since October 2020, state surveyors have identified more than 30 violations of federal or state regulations, ranging from medication errors to failure to follow COVID-19 protocols to not adequately supervising a resident, which led to a fall, and then failing to accurately assess the resulting injury that required staples in the emergency room. Green House Cottages has been fined at least $86,000 during that time.

Officials from Green House Senior Living LLC, which manages the facility, declined to respond to specific incidents or allegations, citing HIPPA and other privacy laws. However, they responded by email to questions from Current and said the COVID-19 pandemic has caused stress throughout the industry and led to high employee turnover and staffing shortages in Carmel, forcing the company to hire temporary nurses and assistants to keep the facility running.

“We are proud of our team and continue to attempt to deliver the best care possible,” they stated. “The fact that we continue to be one of the safest nursing facilities with one of the lowest (COVID-19) infection rates in the state is a testimony to our model and staff and the very reason why even some of our detractors continue to want their loved ones to remain at Green House Cottages of Carmel.”

But for Pat Abbott, whose mother has lived at Green House Cottages since November 2018,  the pandemic isn’t the source of most of the problems. Rather, it was in the fall of 2020, when new leadership took over the facility, that the most troubling issues began to occur.

“You have management who I’m not sure they can find their way out of a box. It’s evident through their emails, through their responses or nonresponses,” said Abbott, who worked as a nurse for 42 years before retiring in 2017 to help care for her mother. “I have been in other situations where you have to work with difficult management, management who doesn’t know what they’re doing, but I’ve really never dealt with management who were so uncaring, so careless and neglectful and bullying and spiteful.”

A pandemic problem?

Green House Cottages opened in 2016 as the state’s first long-term care facility to be part of the Green House Project, which, according to the project’s website, provides guidance for senior living providers to offer a “radically non-institutional” model of service in a home-like setting. The six 8,000-square-foot cottages in Carmel each have 12 private bedrooms, an open kitchen and dining area, a physical therapy center, library and salon.

The model appealed to Abbott, who said initially the Carmel facility was generally adhering to the Green House Project standards. She said she enjoyed getting to know the staff — most of whom worked full time at the facility — and visiting with them as they prepared meals for the residents.

She no longer had those opportunities when the COVID-19 pandemic hit, as Green House Cottages and all other long-term care facilities across the state halted visitation to prevent the spread of the disease, which is especially dangerous to the elderly population.

During the lockdown, a new management team led by Executive Director Tammy Bledsoe began working at the facility. Bledsoe brought two administrators who had previously worked with her at Carmel Health & Living, and during their tenure there — which included a COVID-19 outbreak early in the pandemic — families of residents expressed similar concerns about poor management.

Abbott said she has no reason to believe matters will improve with the current management team in place.

“There is no one who is showing leadership to solve any problems or to implement the correct policies and procedures that a facility needs to run properly,” Abbott said. “There’s no one trying to solve any problems, and you see problems everywhere you look.”

Most troubling, she said, is the constantly changing staff who don’t appear to receive proper training and usually aren’t around long enough  to build familiarity with the residents, which is especially important for those who have Alzheimer’s disease with dementia.

Bledsoe did not respond to multiple requests for comment.

State inspection reports document several instances of staff members not knowing or following policy, such as a certified nursing assistant (CNA) who removed a face covering to eat with residents, a qualified medication aide charting a medication that wasn’t given and employees not using proper techniques for moving residents.

One troubling incident uncovered by the state involved a previously cooperative resident who cried out in pain whenever anyone tried to touch her, at one point grabbing a cushion so tightly she ripped into its foam filling. A Green House Cottages medication aide told the state investigator she thought the resident’s screams were a “behavior symptom of resisting care and not related to pain,” the report states.

The investigator found that the resident had a prescription for a pain-relief patch and other pain-relief medications that were not consistently administered. When a hospice nurse later restarted the patch, the resident’s pain disappeared.

Officials from Shelbyville-based Major Hospital, the licensed operator of Green House Cottages of Carmel, did not respond to a request for comment.

Green House Senior Living officials stated in an email that the facility has “not been perfect” since the COVID-19 pandemic started, as the staff has had to quickly adapt to constantly changing public health guidelines to keep residents healthy and safe.

“(We) acknowledge that since March 2020 when this pandemic started our focus has been on infection control and attempting to prevent the spread of COVID, limiting deaths and subsequent fatal illnesses while giving the best care possible in this difficult time,” officials stated. “Our efforts have led to Green House Cottages of Carmel having one of the lowest COVID infection rates and number of fatalities in the state.”

According to a document provided by Green House Senior Living, since the pandemic began, Green House Cottages has reported 17 COVID-19 cases among its staff and seven cases among residents, with one resident death.

The facility closed for visitation beginning Aug. 21 because of at least one resident testing positive for COVID-19.

‘It wasn’t just me’

At first, Fisher, a Carmel resident, was satisfied with the care her mother received at Green House Cottages. She said that changed in October 2020 when a nurse called to report that her mother had fallen and cut her head.

Fisher’s visits with her mother had been limited primarily to brief video chats during the previous months because of the COVID-19 pandemic, and what she saw at the hospital shocked her.

“I found lots of signs of neglect. She had the gash over her eye, which made me wonder about supervision and whether it was adequate,” Fisher said. “This was late October, and she was not wearing socks, the clothes she was wearing were not her own, she had feces-encrusted fingernails that were jagged and crooked, and she was dehydrated.”

Fisher said she was surprised by the management’s lack of concern when she reported the issues. So, she began to educate herself on her rights and the process for holding long-term care facilities accountable. That’s when she learned about family councils, which are comprised of family members and friends of nursing home residents who advocate on their behalf. So, she decided to start one.

The council gave its members a place to share their concerns, which is when Fisher said she realized the scope of the problems. She soon connected with many others who felt the same way she did.

“It’s sad to say, but I was excited to find out it wasn’t just me, that there were lots of similar issues,” Fisher said.

A former entrepreneur and marketing professional, Fisher essentially turned her leadership of the council into a full-time job, spending four to six hours a day learning about how long-term care facilities operate and are monitored and advocating for Green House Cottages residents and their families.

Fisher said the group’s efforts paid off in mid-May, when the council and its attorney convinced Green House Cottages administrators to write a visitation policy and allow families back into the facility. Fisher said she discovered by calling all long-term care facilities in the county that Green House Cottages was the last one to begin allowing visits again.

Still, not everyone has had a negative experience with Green House Cottages. Once a member of the family council, Lisa Boland recently left the group because of what she viewed as constant negativity and complaining instead of attempting to work with facility staff to address problems. Boland said she feels like her mother is living “in a different place from what (the family council is) describing.”

“I think it’s been great. The place is beautiful, and every single person I’ve talked to when I go in and visit my mom has been super friendly,” Boland said. “They seem to understand everything she likes and dislikes. They’ve got stories about her, so I know they’re paying attention to what she’s doing.”

Missed opportunity

Family council members Debbie Frazer and her sister, Teresa Nourse, began noticing problems before the hiring of the current management team. Their aunt moved to Green House Cottages in December 2016, followed by their mother in April 2017. In August 2020, it became clear their aunt didn’t have much longer to live.

Visitation was restricted at the time because of the COVID-19 pandemic, but end-of-life visits were permitted. However, Frazer and Nourse never got the opportunity to say a final goodbye to their aunt because the facility never notified them that her medication had been discontinued and that she was actively dying.

The sisters were furious and reported the incident to state health officials, who investigated and substantiated the complaint. The report states that on the day before and morning of the resident’s death, a nurse told the director of nursing that the family should be notified. The director of nursing told them she would later assess the resident, and if she concurred, she would contact the family.

“The (director of nursing) got busy and did not see the resident,” the report states.

With their mother still living at Green House Cottages, Frazer and Nourse said they’ve developed several other concerns, from the constantly rotating staff to a lack of supervision of the residents. They wonder if they’ll get a chance to say goodbye to their mother when the time comes.

“Are we not going to get in again when she dies? I don’t know,” Nourse said. “I hope they do the right thing next time. Everything is a crapshoot over there.”

Lisa Fisher left a box of food to feed her mother and others in the cottage with a sign stating, “Please feed Miss Charlene.”

‘Please feed Miss Charlene’

Many of Fisher’s concerns also have been confirmed by state surveyors during their investigations.

Fisher’s mother had been losing weight, and Fisher began to doubt she was receiving proper nutrition. So, she filed a complaint with the state, which sent investigators to visit four cottages in December 2020 to observe preparations for two meals. They found problems in each cottage at both meals.

Of particular concern to Fisher was the preparation of her mother’s lunch, which must be pureed. In front of the inspector, the CNA placed a sandwich in a blender and added an unmeasured amount of water. The report states that the CNA said she didn’t have or need a recipe because she had been preparing pureed foods “for a long time.”

“(The two CNAs preparing lunch) indicated they had not received training on how to prepare the meals, including how to prepare pureed and other mechanically altered food, did not have recipes to follow and were not aware of portion sizes to offer the residents,” the report states.

Fisher said the report confirmed her fears.

“My mom was given bread and water, and that’s what they were feeding her many times,” Fisher said. “People in prison eat better than that.”

At one point, Fisher became so concerned about the food offered in her mother’s cottage that she developed a menu and purchased enough groceries for all 12 people living there. She said no one answered the door when she delivered it, so she left it on the porch with a note that said, “Please feed Miss Charlene.”

She’s not sure what happened to the food.

‘Why should we leave?’

Fisher said she and the family council have exhausted every avenue for help.

“The owners have been unresponsive, and because it’s privately owned, there’s nowhere else to go. We’ve gone all the way up the chain and found a dead end,” she said. “Any issues that are addressed don’t seem to stay fixed. They keep popping up like whack-a-mole.”

On Aug. 21, the council sent a letter to the Green House Cottages ownership requesting the removal of the management team. She said they haven’t heard back.

Green House Senior Living officials stated that the Green House Cottages management team and staff continue to work with the family council to respond to specific concerns and rectify issues, as they are “best suited to resolve these day-to-day items.”

Some family members — like Kimberley Davis of Fishers — have chosen to move their loved ones elsewhere. Her aunt moved to Green House Cottages in December 2020, but after discovering that medication errors were happening not only to her aunt but others in the facility, she decided to move her out.

“There’s always an excuse,” Davis said. “I’m tired of the excuses.”

Fisher said she’s thought about moving her mother elsewhere, but change can be especially difficult, and even traumatic, for adults with dementia. Plus, she believes — with the right management — Green House Cottages could operate as advertised.

“Our feeling has always been, ‘Why should we leave?’ We didn’t do anything wrong. We were promised a level of care, and they have not delivered,” she said. “So, I’ve continued with my advocacy work trying to make changes, not just for my mother but for all the families.”

ISDH findings

Surveyors from the Indiana State Dept. of Health have visited Green House Cottages of Carmel multiple times in the last year to investigate complaints and make observations. Those visits resulted in citations that include:

  • December 2020 — Eight employees preparing food failed to wear hair nets
  • December 2020 — Residents and staffers not adequately screened for COVID-19; one CNA did not clean hands after touching contaminated face mask
  • December 2020 — Required clinical assessment not complete for resident with difficulty swallowing who aspirated and died
  • December 2020 — Failed to provide adequate supervision and assistive devices to prevent accidents, with one resident falling and suffering an orbital eye fracture
  • December 2020 — Failed to secure hazardous chemicals in laundry area
  • December 2020 — CNAs not showing competency in skills and techniques to assist residents with daily activities
  • December 2020 — Established menu or dietician-approved recipes not followed
  • December 2020 — Failure to confirm food kept at a safe and appetizing temperature
  • October 2020 — Ten randomly observed staff members failed to wear a surgical or N95 respirator face mask in all observed cottages, leading to a potential spread of infections that include COVID-19
  • November 2020 — Failure to maintain accurate medication administration records for 12 of 51 residents reviewed
  • March 2021 — Family not provided end-of-life visitation with resident
  • March 2021 –– Failure to notify resident’s representative of a significant change in physical status
  • March 2021 — Failure to ensure alleged violation of abuse, neglect or misappropriation was reported to the State Survey Agency
  • March 2021 — Failure to ensure alleged violation of abuse, neglect or misappropriation was thoroughly investigated
  • March 2021 — Activities based on comprehensive assessments and preferences of residents not provided
  • March 2021 — Failed to ensure a resident on a feeding tube maintained acceptable parameters of nutritional status by failing to weigh the resident as ordered and document nutrition intake
  • March 2021 — Nurse staffing data not posted in any examined cottage
  • March 2021 — Medication error rate above 5 percent (at nearly 14 percent during random observation)
  • March 2021 — Incomplete/inaccurate medical records
  • June 2021 — Privacy bag not provided for resident with catheter drainage bag
  • June 2021 — Required clinical assessment not complete for resident
  • June 2021 — Failed to provide oral hygiene services for resident
  • June 2021 — Resident’s antipsychotic medication not available or administered in accordance with professional standards
  • June 2021 — Three CNAs transferred residents without a gait belt designed to prevent injuries and accidents
  • June 2021 — Three CNAs failed to demonstrate competency in skills and techniques in transferring residents
  • May 2021 — Visitors not allowed, a violation of visitation rights
  • May 2021 — Failed to protect property of residents from loss or theft by not accurately doing an inventory and documenting personal belongings
  • May 2021 — Failed to provide written information on the facility’s bed-hold policy
  • May 2021 — Nurse staffing data not posted daily
  • May 2021 — Food not served in accordance with professional standards for food safety
  • May 2021 — CNA did not wear face shield or face mask while eating with residents
  • July 2021 — Resident not adequately supervised during toileting or accurately assessed for injuries in resulting fall, which required an emergency room visit and staples to a laceration