Deficiencies (last 4 years)
Deficiencies (over 4 years)
18.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
143 residents
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 143
Deficiencies: 6
May 21, 2025
Visit Reason
Routine inspection of Carmel Hills Wellness & Rehabilitation to assess compliance with regulatory requirements including resident care, safety, and food service.
Findings
The facility was found deficient in timely notification of legal guardians after a resident's death, failure to provide adequate bathing assistance, inadequate supervision and safety during resident smoking, improper food temperature maintenance, failure to accommodate resident food preferences, inconsistent snack provision, and deficiencies in food service sanitation and handling.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to notify the legal guardian of a resident's death in a timely manner and failure to notify the Business Office Manager, resulting in delayed financial processing. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide bathing assistance twice weekly as per facility policy for two residents, resulting in inadequate personal care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to supervise a resident during smoking, resulting in the resident's hair catching fire and delayed burn treatment; failure to safely store and restrict use of electronic smoking materials. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to maintain food safety and sanitation standards including dust and grease on sprinkler heads, grime under dishwasher, unrefrigerated items, unwashed fruit, improper food temperatures, and improper food handling. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to offer suitable food substitutes and honor resident food preferences, resulting in resident dissatisfaction and inadequate nutrition. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to consistently provide snacks to residents on the long term care unit as scheduled, limiting resident access to nourishment between meals. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 143
Resident sample size: 19
Days delayed notification: 14
Bathing frequency: 2
Burn size: 1.2
Burn size: 0.9
Food temperature: 111.4
Food temperature: 106.3
Food temperature: 124.5
Food temperature range: 104-107
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| HA B | Hospitality Aide | Failed to report resident's hair fire incident immediately, resulting in delayed burn treatment; received corrective action memo and suspension. |
| LPN B | Licensed Practical Nurse | Notified of resident's burn on 5/17/25 and assessed injury; received physician orders for burn treatment. |
| DA B | Dietary Aide | Handled French Toast without gloves; unaware of fruit washing procedures. |
| DM | Dietary Manager | Informed staff to use gloves when handling food; expected fruit washing; reported cleaning needs to maintenance. |
| Administrator | Facility Administrator | Notified late of smoking incident; expected staff to report incidents immediately and ensure resident safety. |
| DON | Director of Nursing | Notified of smoking incident; responsible for staff education and resident safety protocols. |
Inspection Report
Annual Inspection
Census: 158
Deficiencies: 2
Jan 16, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights and food service quality.
Findings
The facility failed to ensure the dignity of one sampled resident and failed to serve hot foods at a safe and appetizing temperature during meals, potentially affecting at least 60 residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the dignity of one sampled resident (Resident #104). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure hot foods on room trays were served at or close to 120°F during lunch and breakfast. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 60
Facility census: 158
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 17
Nov 25, 2024
Visit Reason
The facility conducted a complaint investigation related to an allegation of staff to resident abuse involving Resident #104 and Hospitality Aide B, and other compliance concerns including medication self-administration, transfer notifications, care planning, medication errors, infection control, and vaccination documentation.
Findings
The facility failed to ensure dignity for Resident #104 during a smoking incident, failed to obtain physician orders for medication self-administration, failed to notify residents and representatives of transfers and bed holds, failed to ensure accurate Minimum Data Set (MDS) assessments and care plans, failed to document discharge planning, failed to provide appropriate treatment orders for a head laceration, failed to ensure comprehensive physician orders and care plans for suprapubic catheter care, failed to maintain respiratory equipment properly, failed to perform gradual dose reductions for psychotropic medications, failed to maintain medication error rates below 5%, failed to ensure proper medication storage and labeling, failed to provide routine and emergency dental services, failed to ensure food was served at safe and appetizing temperatures, failed to implement infection prevention and control including enhanced barrier precautions, failed to ensure appropriate hand hygiene and glove use, and failed to provide and document COVID-19 and pneumococcal vaccinations.
Complaint Details
The complaint investigation involved allegations of staff to resident abuse and multiple compliance concerns including medication administration, care planning, infection control, and vaccination documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 17
Deficiencies (17)
| Description | Severity |
|---|---|
| Failed to ensure dignity of Resident #104 during smoking incident involving staff contact on head. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to obtain physician order and evaluate ability for self-administration of medication for Resident #96. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify residents and representatives of transfer to hospital and bed hold policies for Residents #137 and #109. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accuracy of Minimum Data Set (MDS) assessments for Residents #14 and #98, including dental status and BiPAP usage, and failed to update care plans for falls for Resident #109. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to update care plan for anticoagulant medication for Resident #110. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document discharge planning and discharge summary for Resident #201 discharged to home. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide treatment and monitoring orders for head laceration with staples for Resident #45. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to supervise, assess, and investigate a burn related to smoking for Resident #104. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure suction and oxygen equipment were kept covered to prevent cross contamination for Residents #95, #126, #19, #14, #98, and failed to follow physician orders for tracheostomy care for Resident #116. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rate under 5% for Resident #96 due to failure to watch resident take inhaler. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate hand hygiene, glove usage, and barrier placement during medication administration, blood glucose testing, and insulin administration for Residents #84 and #132. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure expired medications and medical supplies were removed and medications were properly labeled and stored in medication carts and storage rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure routine and emergency dental services were offered and provided to Residents #14 and #98. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were provided food at safe and appetizing temperatures for Residents #109, #91, and #139. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure proper use of enhanced barrier precautions (EBP) and hand hygiene to prevent cross contamination for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly screen new employees for tuberculosis (TB) including documentation of test reading dates for five sampled employees. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pneumococcal and influenza vaccinations were offered, administered, or documented for Residents #95 and #48. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 158
Facility census: 151
Medication error rate: 8
Scheduled dialysis visits: 14
Scheduled dialysis visits: 12
Scheduled dialysis visits: 11
Scheduled dialysis visits: 13
Scheduled dialysis visits: 10
Scheduled dialysis visits: 12
Scheduled dialysis visits: 11
Scheduled dialysis visits: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hospitality Aide B | Hospitality Aide | Named in dignity and abuse incident involving Resident #104 |
| Registered Nurse A | Registered Nurse | Provided statements and assessments related to Resident #104 and medication administration |
| Assistant Director of Nursing A | Assistant Director of Nursing | Provided statements related to dignity incident, medication self-administration, and infection control |
| Administrator | Provided statements related to dignity incident | |
| Certified Medication Technician B | Certified Medication Technician | Provided statements related to medication self-administration and medication cart checks |
| Registered Nurse B | Registered Nurse | Provided statements related to transfer notifications, dialysis, and medication administration |
| Director of Nursing | Director of Nursing | Provided statements related to multiple findings including medication errors, infection control, and vaccination |
| Licensed Practical Nurse B | Licensed Practical Nurse | Provided statements related to anticoagulant care plan and infection control |
| Certified Nurse Assistant K | Certified Nurse Assistant | Provided statements related to dignity incident |
| MDS Coordinator A | Provided statements related to MDS accuracy and dental care | |
| MDS Coordinator B | Provided statements related to MDS accuracy and dental care | |
| Social Worker | Provided statements related to discharge planning for Resident #201 | |
| Regional Social Worker | Provided statements related to discharge planning for Resident #201 | |
| Licensed Practical Nurse G | Licensed Practical Nurse | Provided statements related to head laceration care |
| Certified Nursing Assistant H | Certified Nursing Assistant | Provided statements related to infection control and personal care |
| Certified Nursing Assistant J | Certified Nursing Assistant | Provided statements related to infection control and personal care |
| Certified Medication Technician C | Certified Medication Technician | Provided statements related to oxygen equipment storage and infection control |
| Licensed Practical Nurse A | Licensed Practical Nurse | Observed and interviewed regarding medication administration and infection control |
| Certified Nurse Assistant C | Certified Nurse Assistant | Observed and interviewed regarding infection control |
| Certified Nurse Assistant D | Certified Nurse Assistant | Observed and interviewed regarding infection control |
| Certified Nurse Assistant E | Certified Nurse Assistant | Observed and interviewed regarding infection control |
| Human Resources Coordinator | Provided statements related to employee TB testing | |
| Central Supply Manager | Provided statements related to oxygen equipment cleaning and storage | |
| Dietary Manager | Provided statements related to food service and temperature monitoring |
Inspection Report
Routine
Census: 151
Deficiencies: 2
Nov 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to discharge planning and food service quality at Carmel Hills Wellness & Rehabilitation.
Findings
The facility failed to document discharge planning and complete a discharge summary for one discharged resident, and failed to ensure residents were provided food at safe and appetizing temperatures, with multiple residents reporting cold food and observations confirming food temperatures below acceptable levels.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to document discharge planning prior to resident discharge and failed to complete a discharge summary for one discharged resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were provided food that was at a safe and appetizing temperature for three sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident sample size: 35
Facility census: 151
Food temperature: 100
Food temperature: 114
Food temperature: 101
Food temperature: 100
Food temperature: 120
Food temperature: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse F | Licensed Practical Nurse | Provided information about resident behaviors and discharge process |
| Director of Nursing | Director of Nursing (DON) | Provided information about discharge planning expectations and food service policies |
| Social Worker | Social Worker | Discussed discharge planning efforts and documentation deficiencies |
| Regional Social Worker | Regional Social Worker | Commented on discharge planning documentation and facility expectations |
| Certified Nurse Assistant E | Certified Nurse Assistant (CNA) | Reported resident complaints about food temperature and lack of monitoring |
| Registered Nurse A | Registered Nurse (RN) | Reported resident complaints about food temperature and warming food for residents |
| Assistant Director of Nursing A | Assistant Director of Nursing (ADON) | Discussed food tray delivery times and resident complaints |
| Dietary Manager | Dietary Manager | Described food service procedures and monitoring of room tray temperatures |
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 1
Oct 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding missing narcotic medication (Oxycodone) for a sampled resident (Resident #1).
Findings
The facility failed to ensure the security of narcotics, resulting in 47 pills of Oxycodone missing on 9/11/24. The investigation revealed missing narcotic count sheets, misplaced empty medication cards, and staff issues including resignation of a nurse involved. The facility provided education and policy changes to prevent recurrence.
Complaint Details
The complaint investigation was substantiated with findings that narcotics were missing after access by Licensed Practical Nurse (LPN) B, who resigned and refused to give a statement. The facility found empty medication cards in the shred box and missing narcotic count sheets. Prior complaints existed about narcotic administration during overnight shifts when LPN B worked.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure one sampled resident's narcotics were secure, resulting in 47 pills of Oxycodone missing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents census: 159
Missing Oxycodone pills: 47
Oxycodone tablets delivered: 20
Oxycodone tablets delivered: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Had access to narcotics before missing medication was discovered; resigned and refused to give statement |
| LPN A | Licensed Practical Nurse | Notified DON of missing narcotics and participated in narcotic counts |
| LPN C | Licensed Practical Nurse | Last counted narcotics with LPN B and reported concerns about narcotic administration |
| DON | Director of Nursing | Responsible for monitoring narcotic logs and adherence to policy |
| ADON | Assistant Director of Nursing | Located empty medication cards and responsible for daily narcotic log checks |
| Regional Nurse Consultant | Conducted investigation using shift to shift log and confirmed missing medications |
Inspection Report
Complaint Investigation
Census: 160
Deficiencies: 1
Jun 28, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely notification and an appropriate immediate discharge letter for one sampled resident (Resident #5).
Findings
The facility failed to provide timely notification to the resident and relevant parties before transfer or discharge. Resident #5 was discharged to a hospital due to aggressive behavior and threats, but the facility did not agree to re-admit the resident despite the hospital clearing him/her to return. The facility cited safety concerns and inability to find appropriate placement as reasons for the emergency eviction.
Complaint Details
The complaint involved the facility's failure to provide an appropriate immediate discharge letter for Resident #5 and improper handling of the resident's discharge to a hospital despite the resident being cleared to return. The Ombudsman noted the disposition to a hospital was incorrect. The facility Administrator confirmed the resident was discharged due to threats and aggressive behavior, and the facility did not agree to re-admit the resident.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide timely notification to the resident and applicable parties before transfer or discharge, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 9
Facility census: 160
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Facility Administrator | Spoke with hospital nurse about resident threats and discharge decision | |
| Corporate Nurse | Spoke with hospital nurse regarding resident assessment | |
| Hospital Employee | Provided information about psychiatric evaluation and clearance of resident | |
| Ombudsman | Reviewed Emergency Discharge and noted disposition error |
Inspection Report
Complaint Investigation
Census: 154
Deficiencies: 3
Feb 1, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to provide timely assistance with hearing aids for Resident #1 and failure to ensure resident safety during transfers and transportation for Residents #1 and #3.
Findings
The facility failed to ensure timely assistance in obtaining hearing aids for Resident #1, resulting in communication difficulties. Resident #1 also suffered a fall during an unsafe transfer causing multiple fractures and bruising, with inadequate post-fall assessment and reporting. Resident #3 was left unattended in a hospital lobby overnight after dialysis due to lack of coordinated transportation. The facility failed to follow transfer policies and ensure safe transportation for residents.
Complaint Details
The investigation was complaint-driven, triggered by allegations of failure to provide hearing aids and safe transfers for Resident #1, and failure to coordinate transportation for Resident #3 after dialysis. Immediate Jeopardy was identified related to unsafe transfer and lack of supervision, which was removed after corrective actions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to provide timely assistance in obtaining hearing aids for Resident #1. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure safe transfer of Resident #1 resulting in fall, fractures, bruising, and inadequate post-fall assessment. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure Resident #3 was safely transported after dialysis, resulting in resident being left unattended overnight in hospital lobby. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents affected: 6
Units of packed red blood cells: 5
Facility census: 154
Dates with no hearing aid applied: 2
Dates with code 9 (unknown): 4
Date of Immediate Jeopardy start: Jan 5, 2024
Date of Immediate Jeopardy removal: Jan 7, 2024
Dialysis days per week: 3
Missed medication dates: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Involved in unsafe transfer of Resident #1 resulting in fall and injuries |
| CNA B | Certified Nurse Assistant | Assisted CNA A in lifting Resident #1 from floor to bed after fall |
| LPN A | Licensed Practical Nurse | Charge nurse during incident; not notified of fall; assessed Resident #1 during night |
| CNA C | Certified Nurse Assistant | Notified nurse of Resident #1's change in condition and bruising |
| CNA D | Certified Nurse Assistant | Noticed bruising on Resident #1 and assisted with care |
| Assistant Director of Nursing | Assistant Director of Nursing | Responded to Resident #1's condition change and coordinated hospital transfer |
| Administrator | Facility Administrator | Provided statements on hearing aid issues and transfer policies |
| Nurse Practitioner | Nurse Practitioner | Provided medical opinion on Resident #1's condition and transfer incident |
| LPN B | Licensed Practical Nurse | Received call about Resident #3's rapid response at dialysis |
| CNA E | Certified Nurse Assistant | Provided information on Resident #1's transfer needs and behavior |
| CNA F | Certified Nurse Assistant | Provided information on Resident #1's transfer needs and behavior |
| Dialysis Social Worker | Social Worker | Reported on Resident #3's dialysis and transportation issues |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 3
Sep 7, 2023
Visit Reason
The inspection was conducted due to complaints regarding improper discharge and failure to allow a resident to return after hospitalization, as well as concerns about elopement and door security on the memory care unit.
Findings
The facility failed to provide appropriate discharge notice and improperly discharged a resident to a hospital without valid consent. The resident was not allowed to return after hospitalization despite no medical or psychiatric reason. Additionally, the facility failed to maintain secure doors on the memory care unit, resulting in a resident eloping from the unit.
Complaint Details
The complaint involved Resident #2 who was discharged to a hospital without proper consent and was not allowed to return to the facility despite no medical or psychiatric reason. The resident was found wandering outside the secured memory care unit due to malfunctioning magnetic locks and doors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide timely notification to the resident and responsible party before transfer or discharge, including appeal rights. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to permit a resident to return to the nursing home after hospitalization that exceeded bed-hold policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain memory care unit doors to properly close, allowing unauthorized exit by residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 148
Resident elopement risk score: 7
BIMS score: 2
Dates exit door not inspected: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager B | Nurse Manager | Instructed discharge of resident to hospital and signed Notice of Proposed Discharge |
| Administrator | Administrator | Acknowledged potential regulatory violation for discharge and stated following administration instructions |
| Social Service Designee | Social Service Designee | Sent referrals for residents and acknowledged discharge plans did not include hospital discharge |
| Hospital Social Worker | Social Worker | Reported improper discharge and no medical reason for resident not returning |
| Certified Nursing Assistant B | CNA | Last saw resident wandering before elopement and notified nurse |
| Licensed Practical Nurse A | LPN | Notified Administrator and DON of missing resident and called resident's spouse |
| Maintenance Director | Maintenance Director | Reported magnetic lock malfunction and door left open by unknown staff |
| Technician | Electrical Technician | Replaced malfunctioning magnetic lock on outer door |
| Dietary Aide A | Dietary Aide | Reported notification alarm was not working at time of elopement |
Inspection Report
Routine
Census: 148
Deficiencies: 18
Mar 29, 2023
Visit Reason
Routine inspection of Carmel Hills Wellness & Rehabilitation to assess compliance with healthcare facility regulations including medication administration, resident care, dietary services, and safety.
Findings
The facility had multiple deficiencies including failure to ensure proper medication administration oversight, inadequate bathing and restorative care services, improper infection control during tracheostomy care, insufficient staffing levels, failure to maintain food safety and dietary preferences, unsafe smoking practices, incomplete narcotic counts, and lack of competency evaluations for nursing assistants.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 18
Deficiencies (18)
| Description | Severity |
|---|---|
| Failed to provide oversight for residents without orders for self-administration of medications when staff left medications at bedside without supervision. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accommodate eating and ambulation needs for a visually impaired resident, relying on another resident for assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain oscillating fans, sprinkler heads, ceiling vents, and other environmental surfaces free from dust and grime. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to reassess and revise care plans timely for six sampled residents, potentially affecting physical and mental well-being. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physicians of blood sugar levels outside prescribed parameters and ensure proper hand hygiene during medication passes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure timely initiation and follow-up of restorative assistance orders for three sampled residents due to staffing shortages. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care for one sampled resident, including proper placement of catheter drainage bag below bladder and off the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate care during tracheostomy care using sterile technique and hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure oxygen equipment was stored properly, tubing and face masks changed weekly, and oxygen orders were in place for residents receiving oxygen therapy. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate pain management for four sampled residents, including delays in medication administration and inadequate pain relief. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow physician's orders for monitoring dialysis fistula site and weights for one sampled resident receiving dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate narcotic counts and documentation for two sampled residents and one supplemental resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow menus by cooking meals according to the menu, ensure recipes were available, and document meal substitutions for dietitian review. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food items brought by family were labeled and dated in the resident food refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly dispose of garbage and refuse by leaving kitchen trash container open and outdoor dumpster lids open. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to repair two convection ovens and one regular oven for an unknown period of time. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure safe smoking practices by residents and staff, including unsupervised smoking by a visually impaired resident and smoking in resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide competency evaluation program for Certified Nursing Assistants (CNA). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 148
Residents sampled: 30
Supplemental residents sampled: 9
Missed narcotic counts: 23
Missed narcotic counts: 25
Narcotic count sheets blank: 64
Narcotic count sheets blank: 61
Narcotic count sheets blank: 23
Narcotic count sheets blank: 22
Shower frequency: 5
Shower frequency: 5
Shower frequency: 5
Pain medication doses missed: 36
Pain medication doses given: 18
Pain medication doses given: 15
Pain medication doses given: 36
Pain medication doses given: 17
Pain medication doses given: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Observed and interviewed during tracheostomy care and medication administration |
| CMT B | Certified Medication Technician | Observed and interviewed regarding medication administration, oxygen equipment, and narcotic counts |
| DON | Director of Nursing | Interviewed regarding staffing, care plans, medication administration, and quality assurance |
| DM | Dietary Manager | Interviewed regarding food service, meal substitutions, and kitchen maintenance |
| RN D | Registered Nurse | Interviewed regarding medication administration, oxygen therapy, and restorative assistance |
| CNA C | Certified Nursing Assistant | Interviewed regarding bathing assistance and shower aide staffing |
| LPN B | Licensed Practical Nurse | Interviewed regarding medication administration, oxygen therapy, and smoking assessments |
| CMT C | Certified Medication Technician | Observed and interviewed regarding medication administration and hand hygiene |
| RN A | Registered Nurse | Interviewed regarding narcotic counts and medication administration |
| CNA L | Certified Nursing Assistant | Interviewed regarding staffing and training |
| LPN F | Licensed Practical Nurse | Observed narcotic count and interviewed |
| CNA J | Certified Nursing Assistant | Observed trash disposal and interviewed |
Inspection Report
Routine
Census: 148
Deficiencies: 7
Mar 29, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including medication administration, resident care, staffing, and dietary services.
Findings
The facility was found deficient in multiple areas including failure to ensure proper medication administration oversight, inadequate bathing and restorative services, insufficient staffing levels, improper narcotic count documentation, unsafe smoking supervision, and failure to assess and accommodate resident dietary preferences.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility failed to provide oversight for residents without orders for self-administration of medications when staff left medications at bedside and did not watch residents take them. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure bathing/showers were completed at least once weekly and at resident's preference for five sampled residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure residents were free from harm while outside smoking, failed to maintain hot water temperatures below 120°F, and failed to complete comprehensive fall investigations and post-fall monitoring for residents with falls. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to have sufficient nursing staff on a 24-hour basis to meet resident needs and ensure resident safety. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure proper narcotic count documentation and reconciliation for multiple residents, including pre-signing of narcotic count sheets and discrepancies between narcotic counts and medication administration records. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure resident medications were dated when opened and failed to keep staff personal items separate from resident medications in medication carts. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to assess dietary preferences of sampled residents and failed to provide appropriate food substitutes consistent with ordinary food items for residents who did not prefer offered items. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 148
Sampled residents: 30
Supplemental residents: 9
Narcotic count discrepancies: 53
Narcotic count discrepancies: 75
Narcotic count discrepancies: 78
Narcotic count discrepancies: 54
Narcotic count discrepancies: 23
Narcotic count discrepancies: 25
Narcotic count discrepancies: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN F | Registered Nurse | Interviewed regarding medication administration and resident medication self-administration policies |
| DON | Director of Nursing | Interviewed regarding medication administration, staffing, fall investigations, and narcotic count policies |
| CMT B | Certified Medication Technician | Interviewed regarding medication administration, narcotic counts, and smoking supervision |
| LPN A | Licensed Practical Nurse | Interviewed regarding narcotic counts and smoking assessments |
| CNA M | Certified Nursing Assistant | Interviewed regarding bathing assistance and staffing |
| LPN B | Licensed Practical Nurse | Interviewed regarding fall investigations and narcotic counts |
| CMT G | Certified Medication Technician | Interviewed regarding smoking assessments and supervision |
| LPN D | Licensed Practical Nurse | Interviewed regarding narcotic counts and smoking assessments |
| CNA C | Certified Nursing Assistant | Interviewed regarding bathing assistance and staffing |
| RA A | Restorative Aide | Interviewed regarding restorative services and staffing |
| Staffing Coordinator | Interviewed regarding staffing levels and scheduling | |
| Medical Director | Interviewed regarding smoking supervision | |
| Facility Nurse Practitioner | Interviewed regarding smoking supervision | |
| Social Services Director | Interviewed regarding smoking assessments | |
| Dietary Manager | Interviewed regarding dietary preferences and food availability | |
| Registered Dietitian B | Interviewed regarding dietary preferences and assessment policies | |
| Regional Director of Therapy | Interviewed regarding smoking assessments | |
| Physical Therapy Assistant | Interviewed regarding restorative assistance services |
Inspection Report
Routine
Census: 164
Deficiencies: 13
Mar 9, 2020
Visit Reason
The inspection was a routine survey of Carmel Hills Wellness & Rehabilitation to assess compliance with regulatory requirements including resident rights, restraint use, care planning, complaint investigations, pressure ulcer care, behavioral health care, food service, and equipment safety.
Findings
The facility was found deficient in multiple areas including failure to provide accessible grievance forms and education, improper use of restraints, inaccurate resident assessments, incomplete care plans, failure to identify and respond to resident condition changes, inadequate pressure ulcer care, insufficient incontinence care, unmet behavioral health needs, food service deficiencies including improper food temperatures and insufficient food availability, and failure to maintain kitchen sanitation and equipment.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 12
Level of Harm - Actual harm: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to have grievance forms accessible for all residents and educate residents on grievance policy and procedures. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure one resident was free from physical restraints; used a locked Broda chair without proper assessment or consent. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately complete Minimum Data Set assessments for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide residents and representatives with a summary of baseline care plans within 48 hours of admission for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive person-centered care plan for one resident, including smoking care plan. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to identify and respond timely to a resident's change in condition including decreased alertness, low blood pressure, and oxygen saturation, resulting in hospital transfer and ICU admission. | Level of Harm - Actual harm |
| Failed to provide appropriate pressure ulcer care and maintain wound VAC per physician's orders for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate incontinence care for one resident who was visibly wet with urine odor and puddles under wheelchair. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to meet behavioral health needs for one resident with increased depression and aggressive behaviors, including inadequate assessment, monitoring, and physician notification. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure hot foods were maintained at safe and appetizing temperatures and failed to maintain food temperatures on steam table within required range. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure ample amounts of food were prepared and regular food preference items were available for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store food in refrigerated walk-in unit and practice sanitary procedures before food preparation tasks, including dirty equipment, sticky nozzles, and improper hand hygiene by staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure kitchen range hood exhaust fan was operational, risking smoke inhalation and fire hazard. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 164
Residents sampled: 32
Residents affected by grievance deficiency: 15
Residents affected by restraint deficiency: 1
Residents affected by MDS assessment deficiency: 2
Residents affected by baseline care plan summary deficiency: 2
Residents affected by care plan deficiency: 1
Residents affected by change in condition deficiency: 1
Residents affected by pressure ulcer care deficiency: 1
Residents affected by incontinence care deficiency: 1
Residents affected by behavioral health deficiency: 1
Residents affected by food temperature deficiency: 1
Residents affected by food availability deficiency: 4
Food temperature observed: 99.4
Food temperature observed: 161.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Involved in assessment and notification regarding Resident #316's change in condition and hospital transfer |
| LPN A | Licensed Practical Nurse | Reported incident between Resident #154 and Resident #137 |
| ADON A | Assistant Director of Nursing | Involved in behavioral health management and resident assessments |
| DON | Director of Nursing | Oversaw care planning, behavioral health, and resident condition changes |
| Dietary Manager | Dietary Manager | Provided information on food temperature and kitchen sanitation |
| Dietary [NAME] | Dietary Staff | Reported range hood exhaust fan non-functional |
| Certified Nursing Assistant A | CNA | Acknowledged food temperature issue with scrambled eggs |
| Certified Nurses Assistant J | CNA | Provided information on Resident #85's behavioral needs |
| Certified Nurses Assistant L | CNA | Provided information on incontinence care for Resident #316 |
| Certified Nurses Assistant E | CNA | Provided information on incontinence care frequency |
| Certified Medication Technician A | CMT | Provided information on incontinence care frequency |
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