Deficiencies (last 8 years)
Deficiencies (over 8 years)
20.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
280% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
74% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Census: 143
Deficiencies: 6
Date: 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.
Deficiencies (6)
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.
Failure to provide bathing assistance twice weekly as per facility policy for two residents, resulting in inadequate personal care.
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.
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.
Failure to offer suitable food substitutes and honor resident food preferences, resulting in resident dissatisfaction and inadequate nutrition.
Failure to consistently provide snacks to residents on the long term care unit as scheduled, limiting resident access to nourishment between meals.
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
Date: 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.
Deficiencies (2)
Failed to ensure the dignity of one sampled resident (Resident #104).
Failed to ensure hot foods on room trays were served at or close to 120°F during lunch and breakfast.
Report Facts
Residents affected: 1
Residents affected: 60
Facility census: 158
Inspection Report
Complaint Investigation
Census: 158
Deficiencies: 17
Date: 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.
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.
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.
Deficiencies (17)
Failed to ensure dignity of Resident #104 during smoking incident involving staff contact on head.
Failed to obtain physician order and evaluate ability for self-administration of medication for Resident #96.
Failed to notify residents and representatives of transfer to hospital and bed hold policies for Residents #137 and #109.
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.
Failed to update care plan for anticoagulant medication for Resident #110.
Failed to document discharge planning and discharge summary for Resident #201 discharged to home.
Failed to provide treatment and monitoring orders for head laceration with staples for Resident #45.
Failed to supervise, assess, and investigate a burn related to smoking for Resident #104.
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.
Failed to ensure medication error rate under 5% for Resident #96 due to failure to watch resident take inhaler.
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.
Failed to ensure expired medications and medical supplies were removed and medications were properly labeled and stored in medication carts and storage rooms.
Failed to ensure routine and emergency dental services were offered and provided to Residents #14 and #98.
Failed to ensure residents were provided food at safe and appetizing temperatures for Residents #109, #91, and #139.
Failed to ensure proper use of enhanced barrier precautions (EBP) and hand hygiene to prevent cross contamination for multiple residents.
Failed to properly screen new employees for tuberculosis (TB) including documentation of test reading dates for five sampled employees.
Failed to ensure pneumococcal and influenza vaccinations were offered, administered, or documented for Residents #95 and #48.
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
Date: 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.
Deficiencies (2)
Failed to document discharge planning prior to resident discharge and failed to complete a discharge summary for one discharged resident.
Failed to ensure residents were provided food that was at a safe and appetizing temperature for three sampled residents.
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
Life Safety
Census: 151
Capacity: 202
Deficiencies: 2
Date: Nov 19, 2024
Visit Reason
A Life Safety Code Survey was conducted by Healthcare Management Solutions, LLC on behalf of the State of Missouri, Department of Health and Senior Services to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found to be noncompliant with several Life Safety Code requirements including delayed egress locking arrangements and fire alarm system testing and maintenance. Deficiencies had the potential to affect all 151 residents.
Deficiencies (2)
K222 Egress Doors: The facility failed to ensure that delayed egress signs were employed with delays notices of 15 seconds on the front exit door and Renew 500 wing exit door. The deficient practice had the potential to affect 32 residents.
K345 Fire Alarm System - Testing and Maintenance: The facility failed to conduct a sensitivity test for all 81 photo electric smoke detectors in the corridor and common area as required. This deficient practice had the potential to affect all 151 residents.
Report Facts
Facility census: 151
Total licensed beds: 202
Photo electric smoke detectors: 81
Residents potentially affected by delayed egress deficiency: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding door release and fire alarm system | |
| Regional Director of Maintenance Services | Interviewed regarding fire alarm system testing |
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 1
Date: Oct 16, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding missing narcotic medication (Oxycodone) at Carmel Hills Wellness & Rehabilitation.
Complaint Details
The complaint investigation was substantiated as the facility census was 159 residents and 47 pills of Oxycodone were missing from the licensed nursing cart for Resident #1. The facility conducted interviews and investigations but could not locate the missing narcotic count sheets.
Findings
The facility was found not free from misappropriation/exploitation as 47 pills of Oxycodone were missing for one sampled resident. The facility had policies for controlled substances, but the narcotic count sheets for deliveries could not be located and the medication was missing despite investigations.
Deficiencies (1)
F 602: The resident was not free from misappropriation/exploitation as 47 pills of Oxycodone were missing. The facility failed to maintain accurate narcotic count sheets and secure medication properly.
Report Facts
Missing narcotic pills: 47
Facility census: 159
Medication tablets: 20
Medication tablets: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Interviewed regarding missing Oxycodone and medication counts |
| Assistant Director of Nursing | Assistant Director of Nursing | Located empty medication cards in shred box and responsible for narcotic logs |
| Director of Nursing | Director of Nursing | Interviewed about notification and investigation of missing Oxycodone |
| Regional Nurse Consultant | Regional Nurse Consultant | Conducted shift to shift log investigation and confirmed missing medication |
| LPN C | Licensed Practical Nurse | Interviewed about last counting of Oxycodone and shift change details |
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 1
Date: 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).
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.
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.
Deficiencies (1)
Failed to ensure one sampled resident's narcotics were secure, resulting in 47 pills of Oxycodone missing.
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
Plan of Correction
Census: 160
Deficiencies: 2
Date: Jun 28, 2024
Visit Reason
The inspection was conducted to evaluate compliance with notice requirements before transfer or discharge of residents and emergency discharge procedures at Carmel Hills Wellness & Rehabilitation.
Findings
The facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties in a language they understood. Additionally, the facility did not provide an appropriate immediate discharge letter for one sampled resident, and the emergency discharge notice requirements were not met.
Deficiencies (2)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties in a language they understood. The facility also failed to provide an appropriate immediate discharge letter for one sampled resident.
A8018 Emergency Discharges: The facility did not submit a written notice of discharge to the resident or legally authorized representative as soon as practicable in emergency discharge situations.
Report Facts
Facility census: 160
Sampled residents: 9
Inspection Report
Complaint Investigation
Census: 160
Deficiencies: 1
Date: 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).
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.
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.
Deficiencies (1)
Failure to provide timely notification to the resident and applicable parties before transfer or discharge, including appeal rights.
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
Date: 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.
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.
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.
Deficiencies (3)
Failure to provide timely assistance in obtaining hearing aids for Resident #1.
Failure to ensure safe transfer of Resident #1 resulting in fall, fractures, bruising, and inadequate post-fall assessment.
Failure to ensure Resident #3 was safely transported after dialysis, resulting in resident being left unattended overnight in hospital lobby.
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: 154
Deficiencies: 4
Date: Feb 1, 2024
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations related to resident care and safety concerns.
Complaint Details
The complaint investigation substantiated violations related to protective oversight and accident hazards. The facility was found to have imminent danger class I violations due to failure in supervision and protective oversight for residents on voluntary leave and accident prevention.
Findings
The facility was found to have failed in ensuring timely assistance with hearing devices for a sampled resident and failed to prevent accidents for two sampled residents. The investigation revealed issues with supervision, use of assistive devices, and resident safety protocols.
Deficiencies (4)
F550 Resident Rights: The facility failed to ensure one sampled resident received timely assistance in obtaining a hearing device for communication.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to ensure residents were free from accidents, including improper transfer techniques causing injury to residents.
A4074 Protective Oversight, Voluntary Leave: The facility failed to provide adequate protective oversight and supervision for residents on voluntary leave, resulting in an imminent danger class I violation.
A8030 Dignity/Privacy: The facility failed to treat residents with full recognition of dignity and privacy, resulting in a class III violation.
Report Facts
Facility census: 154
Deficiencies cited: 4
Residents sampled: 6
Residents involved in accident hazard deficiency: 2
Units of packed red blood cells: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Assistant | Involved in improper transfer of Resident #1 leading to injury |
| CNA B | Certified Nurse Assistant | Involved in improper transfer of Resident #1 leading to injury and received corrective action |
| Nurse E | Nurse | Employment terminated related to resident care deficiencies |
| Regional Nurse Consultant | Nurse Consultant | Reviewed facility protocols and educated staff on corrective actions |
Inspection Report
Complaint Investigation
Census: 148
Deficiencies: 3
Date: 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.
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.
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.
Deficiencies (3)
Failed to provide timely notification to the resident and responsible party before transfer or discharge, including appeal rights.
Failed to permit a resident to return to the nursing home after hospitalization that exceeded bed-hold policy.
Failed to maintain memory care unit doors to properly close, allowing unauthorized exit by residents.
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
Complaint Investigation
Census: 148
Deficiencies: 3
Date: Sep 7, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide appropriate discharge notices and permitting residents to return to the facility after hospitalization.
Complaint Details
Complaints substantiated at F623 and F626 related to discharge notices and resident return to facility. The facility failed to provide proper discharge notice and failed to allow a resident to return after hospitalization.
Findings
The facility failed to provide appropriate discharge notices for one sampled resident and failed to allow one sampled resident to return to the facility after hospitalization. The facility census was 148 residents at the time of the survey.
Deficiencies (3)
F623 Notice Requirements Before Transfer/Discharge: The facility failed to provide appropriate discharge notice for one sampled resident as required by regulation.
F626 Permitting Residents to Return to Facility: The facility failed to allow one sampled resident to return to the facility after hospitalization.
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to maintain memory care unit doors to properly secure residents, resulting in one resident eloping from the secured unit.
Report Facts
Facility census: 148
Deficiencies cited: 3
Inspection Report
Routine
Census: 148
Deficiencies: 18
Date: 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.
Deficiencies (18)
Failed to provide oversight for residents without orders for self-administration of medications when staff left medications at bedside without supervision.
Failed to accommodate eating and ambulation needs for a visually impaired resident, relying on another resident for assistance.
Failed to maintain oscillating fans, sprinkler heads, ceiling vents, and other environmental surfaces free from dust and grime.
Failed to reassess and revise care plans timely for six sampled residents, potentially affecting physical and mental well-being.
Failed to notify physicians of blood sugar levels outside prescribed parameters and ensure proper hand hygiene during medication passes.
Failed to ensure timely initiation and follow-up of restorative assistance orders for three sampled residents due to staffing shortages.
Failed to provide appropriate catheter care for one sampled resident, including proper placement of catheter drainage bag below bladder and off the floor.
Failed to provide appropriate care during tracheostomy care using sterile technique and hand hygiene.
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.
Failed to provide adequate pain management for four sampled residents, including delays in medication administration and inadequate pain relief.
Failed to follow physician's orders for monitoring dialysis fistula site and weights for one sampled resident receiving dialysis.
Failed to ensure accurate narcotic counts and documentation for two sampled residents and one supplemental resident.
Failed to follow menus by cooking meals according to the menu, ensure recipes were available, and document meal substitutions for dietitian review.
Failed to ensure food items brought by family were labeled and dated in the resident food refrigerator.
Failed to properly dispose of garbage and refuse by leaving kitchen trash container open and outdoor dumpster lids open.
Failed to repair two convection ovens and one regular oven for an unknown period of time.
Failed to ensure safe smoking practices by residents and staff, including unsupervised smoking by a visually impaired resident and smoking in resident's room.
Failed to provide competency evaluation program for Certified Nursing Assistants (CNA).
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
Date: 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.
Deficiencies (7)
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.
Facility failed to ensure bathing/showers were completed at least once weekly and at resident's preference for five sampled residents.
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.
Facility failed to have sufficient nursing staff on a 24-hour basis to meet resident needs and ensure resident safety.
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.
Facility failed to ensure resident medications were dated when opened and failed to keep staff personal items separate from resident medications in medication carts.
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.
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
Complaint Investigation
Census: 154
Deficiencies: 6
Date: Jan 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify responsible parties of incidents, abuse and neglect, and inadequate treatment and supervision of residents with dementia.
Complaint Details
Complaint was substantiated on F580, F600, F744, A4075, A4088, and A8023 as noted in the plan of correction and deficiency statements.
Findings
The facility failed to notify a resident's responsible party of an incident involving abuse, failed to ensure a resident was free from abuse, and failed to provide appropriate monitoring and supervision for a resident with dementia. Multiple deficiencies were substantiated related to notification, abuse prevention, and treatment for dementia.
Deficiencies (6)
F580 Notification of Changes: The facility failed to notify one sampled resident's responsible party of an incident where the resident was kicked and sent to the hospital. The facility census was 154 residents.
F600 Freedom from Abuse and Neglect: The facility failed to ensure one sampled resident was free from abuse when another resident kicked them multiple times. The facility census was 154 residents.
F744 Treatment/Service for Dementia: The facility failed to provide monitoring and supervision for one sampled resident with dementia who wandered into another resident's room and was kicked multiple times. The facility census was 154 residents.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with acceptable nursing practice. This regulation was not met as evidenced by deficiencies noted in F744.
A4088 Notify Responsible Party-Change in Condition: Facility staff failed to immediately notify the responsible party of significant changes in a resident's condition as required, referencing F580.
A8023 Develop/Implement Abuse and Neglect Policies: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, referencing F600.
Report Facts
Facility census: 154
Sampled residents: 8
Inspection Report
Plan of Correction
Census: 164
Deficiencies: 7
Date: Oct 25, 2022
Visit Reason
The inspection was conducted to investigate deficiencies related to abuse prevention, transfer and discharge requirements, and treatment/services for mental/psychosocial concerns at Polaris Health & Wellness of Carmel Hills.
Findings
The facility was found not to have met requirements for freedom from abuse and neglect, appropriate transfer and discharge procedures, and adequate treatment and services for mental and psychosocial concerns. Specific incidents involving resident altercations and inadequate monitoring were documented.
Deficiencies (7)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent abuse for one sampled resident, resulting in an abrasion and inadequate monitoring of behaviors.
F622 Transfer and Discharge Requirements: The facility failed to provide an appropriate discharge plan and documentation for one sampled resident involved in an incident.
F742 Treatment/Services Mental/Psychosocial Concerns: The facility failed to ensure appropriate treatment and services to attain the highest practicable mental and psychosocial well-being for one sampled resident.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by Class II deficiency.
A8016 Reasons to Transfer/Discharge: A resident may be transferred or discharged only for medical reasons or welfare or nonpayment. This regulation was not met as evidenced by Class II deficiency.
A8018 Emergency Discharges: The facility must submit written notice of discharge and provide the resident the right to request an expedited hearing. This regulation was not met as evidenced by Class II deficiency.
A8023 Develop/Implement Abuse/Neglect Policies: The facility shall develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. This regulation was not met as evidenced by Class II deficiency.
Report Facts
Facility census: 164
Sampled residents: 14
Random audit residents: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager A | Nurse Manager | Notified of resident incident and involved in assessment and reporting |
| Director of Nursing | Director of Nursing (DON) | Involved in incident notification and plan of correction |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) | Completed assessments and assisted with resident incident |
| Certified Nursing Assistant A | Certified Nursing Assistant (CNA) | Witnessed resident incident and assisted resident |
| Certified Medication Technician A | Certified Medication Technician (CMT) | Witnessed resident incident and assisted resident |
| Administrator | Administrator | Provided interviews and signed plan of correction |
Inspection Report
Abbreviated Survey
Census: 166
Deficiencies: 4
Date: Sep 1, 2022
Visit Reason
The abbreviated survey was conducted due to an immediate jeopardy situation involving abuse and neglect between residents, as well as failure to investigate alleged abuse incidents.
Findings
The facility failed to ensure residents were free from verbal and physical abuse, including an incident where Resident #4 hit Resident #3 multiple times with a cane. The facility also failed to thoroughly investigate abuse allegations for two sampled residents. Immediate jeopardy was identified but later removed after corrective actions were implemented.
Deficiencies (4)
F600 Freedom from Abuse, Neglect, and Exploitation was not met as Resident #4 physically abused Resident #3 multiple times and the facility failed to protect residents from abuse by family members and staff.
F610 The facility failed to thoroughly investigate allegations of abuse for two sampled residents and did not prevent further potential abuse during the investigation.
A8022 Each resident shall be free from abuse including verbal abuse, corporal punishment, and involuntary seclusion. Refer to F600.
A8023 The facility failed to develop and implement written policies prohibiting mistreatment, neglect, and abuse of residents. Refer to F610.
Report Facts
Facility census: 166
Residents sampled for abuse: 10
Inspection Report
Plan of Correction
Census: 167
Deficiencies: 1
Date: Aug 10, 2022
Visit Reason
This document is a Plan of Correction related to a past non-compliance incident of misappropriation/exploitation at Polaris Health & Wellness of Carmel Hills.
Findings
The facility failed to protect a resident from misappropriation of property by a Certified Nurses Aide (CNA). The incident was investigated, and corrective actions including staff education and policy updates were planned and implemented.
Deficiencies (1)
F 602: The resident was not free from misappropriation of property as a CNA used the resident's credit devices without knowledge. The facility census was 167 residents at the time.
Report Facts
Facility census: 167
Monetary amounts taken: 11671.2
Monetary amounts taken: 1381.8
Monetary amounts taken: 10217.93
Unauthorized store credit card charge: 147.9
Unauthorized bank card charge: 720
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurses Aide | Named in misappropriation of resident property finding and investigation |
| Law Enforcement Officer A | Law Enforcement Officer | Interviewed regarding investigation and charges |
Inspection Report
Complaint Investigation
Census: 167
Deficiencies: 1
Date: Mar 31, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse of a resident by a Certified Nurse Aide (CNA).
Complaint Details
The complaint investigation substantiated abuse by CNA A against Resident #1. The facility took immediate action including suspension and termination of CNA A, notification of the Administrator, and involvement of local police.
Findings
The facility failed to prevent staff from abusing a resident, resulting in physical injuries including swelling and discoloration around the resident's eye. The investigation confirmed the abuse by CNA A, who admitted to hitting the resident multiple times.
Deficiencies (1)
F 600: The facility failed to prevent abuse, neglect, and exploitation of a resident by staff, as evidenced by a CNA hitting a resident causing pain and bruising. The facility policy on abuse reporting and prevention was reviewed and corrective actions were planned.
Report Facts
Resident census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Admitted to hitting the resident multiple times and was suspended and terminated. |
| CNA B | Certified Nurse Aide | Reported the abuse and was involved in the investigation. |
| RN D | Registered Nurse | Reported the resident's injury and participated in the investigation. |
| DON | Director of Nursing | Assessed the resident, notified police, and participated in the investigation. |
| Regional Director of Operations | Interviewed CNA A and participated in the investigation. | |
| LPN C | Licensed Practical Nurse | Reported the resident's injury and participated in the investigation. |
| NP | Nurse Practitioner | Assessed the resident and gave orders for hospital evaluation. |
Inspection Report
Routine
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Plan of Correction
Census: 161
Deficiencies: 2
Date: Jul 6, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Redwood of Carmel Hills following a survey conducted on 07/06/2021. It addresses issues related to resident safety and medication administration.
Findings
The facility failed to provide adequate supervision and individualized interventions for a resident with wandering behavior, resulting in multiple elopements. Additionally, the facility failed to transcribe a new medication order and administer prescribed eye drops for another resident.
Deficiencies (2)
F 689 - The facility failed to provide supervision and individualized interventions to prevent accidents for a resident with wandering behavior, resulting in multiple elopements and a resident found near a busy traffic intersection.
F 760 - The facility failed to transcribe a new medication order and administer prescribed eye drops for a sampled resident, resulting in medication errors.
Report Facts
Facility census: 161
Sampled residents: 6
Medication administration opportunities missed: 22
Inspection Report
Routine
Deficiencies: 0
Date: Jan 20, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness survey was conducted to assess compliance with 42 CFR 483.73 related to emergency preparedness. Additionally, a COVID-19 Focused Infection Control Survey was conducted to evaluate compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the emergency preparedness regulation 42 CFR 483.73 and with CMS and CDC recommended infection control practices for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Dec 11, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 26, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with related regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: May 27, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with related federal regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Census: 164
Deficiencies: 7
Date: Mar 9, 2020
Visit Reason
The inspection was conducted as a complaint investigation triggered by grievances regarding resident care, including concerns about staff behavior, resident safety, and care planning.
Complaint Details
The complaint investigation was substantiated with findings of multiple deficiencies affecting resident care and safety, including grievances about staff behavior, restraint use, pressure ulcer management, and food safety.
Findings
The investigation found multiple deficiencies related to resident rights, care planning, use of restraints, pressure ulcer care, behavioral health management, and food safety. Several residents experienced inadequate care and monitoring, and the facility failed to meet regulatory requirements in multiple areas.
Deficiencies (7)
F585 Resident rights grievance procedures were not fully implemented, including failure to ensure residents could file grievances anonymously and timely resolution of complaints.
F604 Restraints were used improperly on a sampled resident without proper assessment, consent, or monitoring, violating residents' rights and safety.
F641 Assessments for residents did not accurately reflect their conditions, including failure to complete federally mandated assessments and care planning.
F684 Quality of care was deficient, including failure to identify and respond to changes in residents' conditions and inadequate management of pressure ulcers.
F686 Baseline care plans were incomplete and did not include all necessary information to meet professional standards of quality care.
F740 Behavioral health services were inadequate, with failure to assess and monitor residents' mental health needs and behaviors properly.
F812 Food safety violations were noted, including improper food storage temperatures and inadequate sanitation practices in the kitchen.
Report Facts
Facility census: 164
Deficiency count: 7
Inspection Report
Life Safety
Census: 164
Capacity: 194
Deficiencies: 4
Date: Mar 9, 2020
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility failed to conduct quarterly fire drills on all shifts with required documentation and components, and failed to provide complete, comprehensive, and verifiable documentation and testing of the facility's electrical main and branch circuit breaker panels. Additional deficiencies were noted in oxygen storage room fire resistance and electrical equipment compliance.
Deficiencies (4)
K712 Fire Drills: The facility failed to conduct quarterly fire drills on all shifts with required documentation and components as specified by NFPA standards, affecting staff preparedness and resident safety.
K918 Electrical Systems - Essential Electric System: The facility failed to provide complete and verifiable documentation and testing of the electrical main and branch circuit breaker panels annually as required by NFPA standards.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility allowed use of relocatable power tap outlets and extension cords in patient care areas contrary to National Electrical Code requirements, risking electrical hazards.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to properly maintain fire resistive qualities of the oxygen storage room, compromising fire safety and resident protection.
Report Facts
Facility census: 164
Licensed capacity: 194
Date of survey completion: Mar 9, 2020
Inspection Report
Routine
Census: 164
Deficiencies: 13
Date: 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.
Deficiencies (13)
Failed to have grievance forms accessible for all residents and educate residents on grievance policy and procedures.
Failed to ensure one resident was free from physical restraints; used a locked Broda chair without proper assessment or consent.
Failed to accurately complete Minimum Data Set assessments for two residents.
Failed to provide residents and representatives with a summary of baseline care plans within 48 hours of admission for two residents.
Failed to develop and implement a comprehensive person-centered care plan for one resident, including smoking care plan.
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.
Failed to provide appropriate pressure ulcer care and maintain wound VAC per physician's orders for one resident.
Failed to provide adequate incontinence care for one resident who was visibly wet with urine odor and puddles under wheelchair.
Failed to meet behavioral health needs for one resident with increased depression and aggressive behaviors, including inadequate assessment, monitoring, and physician notification.
Failed to ensure hot foods were maintained at safe and appetizing temperatures and failed to maintain food temperatures on steam table within required range.
Failed to ensure ample amounts of food were prepared and regular food preference items were available for residents.
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.
Failed to ensure kitchen range hood exhaust fan was operational, risking smoke inhalation and fire hazard.
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 |
Inspection Report
Plan of Correction
Census: 148
Deficiencies: 2
Date: Dec 19, 2019
Visit Reason
This document is a Plan of Correction submitted by Redwood of Carmel Hills in response to deficiencies cited during a survey conducted on 12/19/2019.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment and in quality of care, including failure to prevent misappropriation of resident property and failure to ensure availability and proper administration of pain medication for residents.
Deficiencies (2)
F584 Safe/Clean/Comfortable/Homelike Environment. The facility failed to prevent potential misappropriation of property for two residents by not completing admission and discharge personal inventory forms. The facility census was 148.
F684 Quality of Care. The facility failed to assure necessary care and services for one resident with terminal cancer on hospice, including failure to follow physician's orders and ensure availability of Fentanyl pain medication.
Report Facts
Facility census: 148
Facility census: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding admission and discharge inventory forms and medication administration | |
| Licensed Practical Nurse (LPN) A | Named in medication administration and inventory findings | |
| Assistant Director of Nursing (ADON) | Interviewed regarding medication administration discrepancies |
Inspection Report
Annual Inspection
Census: 146
Deficiencies: 10
Date: Jan 16, 2019
Visit Reason
Annual state inspection survey conducted at Redwood of Carmel Hills nursing facility to assess compliance with federal and state regulations.
Findings
The facility was found deficient in multiple areas including resident rights to survey results, admissions policy, transfer and discharge notices, medication administration, restorative nursing, infection control, and antibiotic stewardship. Several residents' records and care plans lacked proper documentation and compliance with regulatory requirements.
Deficiencies (10)
F577 Resident rights to access survey results were not ensured; residents were unaware of location of State Agency Survey results. Facility census was 146 residents.
F620 Admissions policy deficiencies included failure to ensure residents signed admission agreements and proper documentation of admission processes. Facility census was 146 residents.
F623 Notice requirements before transfer or discharge were not met; residents and legal representatives were not properly notified in writing. Facility census was 146 residents.
F625 Bed hold policy deficiencies included failure to notify residents and representatives of bed hold and reserve bed payment policies. Facility census was 146 residents.
F658 Medication administration deficiencies included failure to accurately document narcotic pain medication administration and controlled substance counts for sampled residents.
F688 Restorative nursing services were not provided to prevent decline in range of motion for sampled residents. Facility census was 146 residents.
F693 Enteral nutrition deficiencies included failure to ensure proper bolus tube feeding and water flushes per physician orders for sampled residents. Facility census was 146 residents.
F695 Respiratory care deficiencies included failure to ensure manual resuscitator (Ambu bag) was at bedside for two sampled residents. Facility census was 146 residents.
F880 Infection control deficiencies included failure to maintain a safe environment, proper hand hygiene, and infection prevention practices for sampled residents. Facility census was 146 residents.
F881 Antibiotic stewardship program deficiencies included failure to ensure real-time monitoring of antibiotic use and education of nursing staff. Facility census was 146 residents.
Report Facts
Facility census: 146
Sampled residents: 29
Deficiencies cited: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding resident awareness of survey results and discharge notifications |
| Administrator | Administrator | Interviewed regarding admissions and notification processes |
| Admissions Coordinator | Admissions Coordinator | Interviewed regarding admission agreement completion |
| Licensed Practical Nurse B | Licensed Practical Nurse (LPN) B | Interviewed regarding transfer/discharge notifications and resident medication |
| Certified Medication Technician B | Certified Medication Technician (CMT) B | Interviewed regarding pain medication administration |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding medication administration and nursing staff compliance |
| Licensed Practical Nurse A | Licensed Practical Nurse (LPN) A | Interviewed regarding bolus tube feeding and G-tube care |
| Certified Nursing Assistant B | Certified Nursing Assistant (CNA) B | Interviewed regarding resident care and infection control |
| Certified Nursing Assistant D | Certified Nursing Assistant (CNA) D | Interviewed regarding wound care and infection control |
| Physical Therapy Assistant | Physical Therapy Assistant (PTA) | Interviewed regarding resident therapy services |
| Occupational Therapy Assistant A | Occupational Therapy Assistant (OTA) | Interviewed regarding resident therapy services |
Inspection Report
Life Safety
Census: 146
Capacity: 194
Deficiencies: 3
Date: Jan 16, 2019
Visit Reason
The visit was a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility did not meet the applicable provisions of the 2012 edition of the Life Safety Code, specifically regarding the annual inspection, testing, and maintenance of fire doors and smoke barrier doors. Deficiencies were noted in the facility's failure to conduct required visual, functional, and technical assessments of smoke barrier and fire resistive corridor door assemblies.
Deficiencies (3)
K761: The facility failed to conduct annual visual, functional, and technical assessments of smoke barrier and fire resistive corridor door assemblies as required by NFPA 101 and CMS directives.
A2003: No Fire Hazard - A section of the building presented a fire hazard, not meeting Class II requirements as referenced to K761.
A2046: Corridor Requirements - Corridors were not maintained free of obstruction and doors to resident rooms improperly swung into corridors, not meeting Class III requirements as referenced to K761.
Report Facts
Facility census: 146
Licensed capacity: 194
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 1
Date: Jul 24, 2018
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a missing blood pressure machine reported by a resident's family member.
Complaint Details
The investigation was triggered by a complaint alleging the facility failed to investigate a missing blood pressure machine reported by Resident #2's family member. The investigation was incomplete and corrective actions were not fully implemented.
Findings
The facility failed to investigate a report of a missing blood pressure machine in a timely manner and did not notify the resident's spouse or properly document the investigation. The investigation was incomplete and corrective actions were not fully implemented at the time of the survey.
Deficiencies (1)
F610: The facility failed to investigate a report of a missing blood pressure machine for Resident #2 in a timely manner and did not notify the resident's spouse or properly document the investigation. The investigation did not prevent further potential abuse or neglect as required.
Report Facts
Resident census: 144
Inspection Report
Annual Inspection
Census: 128
Capacity: 193
Deficiencies: 19
Date: Mar 5, 2018
Visit Reason
The inspection was the annual survey of Redwood of Carmel Hills to assess compliance with federal and state regulations for nursing homes.
Findings
The facility was found to have multiple deficiencies related to resident care, medication management, safety, and facility maintenance. Several areas required corrective action plans to address issues such as safe use of stand-up lifts, care planning, medication administration, infection control, and environmental safety.
Deficiencies (19)
F584: The facility failed to maintain the base of two stand-up lifts free of dust and debris, posing a risk to residents using the lifts.
F657: The facility failed to ensure care plans were updated and comprehensive for residents with wandering behaviors and cognitive impairments.
F658: The facility failed to properly administer and monitor medications for residents, including documentation and supervision.
F661: The facility failed to provide a complete discharge summary for residents leaving the facility.
F677: The facility failed to provide adequate dining assistance and supervision for residents with swallowing difficulties.
F678: The facility failed to ensure adequate CPR-trained staff were available at all times and failed to maintain proper emergency procedures.
F689: The facility failed to assess and monitor residents' smoking behaviors and safety, including education and supervision.
F690: The facility failed to complete bowel and bladder assessments and provide appropriate care for residents with incontinence.
F693: The facility failed to provide adequate nursing care for residents with enteral nutrition and swallowing difficulties.
F695: The facility failed to provide adequate respiratory care and oxygen administration for residents.
F725: The facility failed to maintain sufficient nursing staff to meet residents' needs.
F732: The facility failed to maintain accurate and complete nursing staffing records.
F755: The facility failed to properly manage and document controlled substances, including fentanyl patches.
F804: The facility failed to maintain safe food temperatures and proper food handling procedures.
F805: The facility failed to provide food in a form consistent with residents' dietary needs and preferences.
F812: The facility failed to maintain clean and sanitary kitchen and food storage areas.
F814: The facility failed to properly dispose of garbage and refuse.
F838: The facility failed to conduct a comprehensive facility-wide assessment to determine resource needs for resident care.
F881: The facility failed to implement an effective antibiotic stewardship and infection control program.
Report Facts
Facility census: 128
Total capacity: 193
Deficiencies cited: 19
Inspection Report
Life Safety
Census: 128
Capacity: 193
Deficiencies: 15
Date: Mar 5, 2018
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and emergency preparedness requirements at Redwood of Carmel Hills.
Findings
The facility was found deficient in emergency preparedness, fire safety systems including sprinkler systems, emergency lighting, storage of flammable materials, smoking regulations, fire drills, and electrical equipment maintenance. Multiple areas potentially affected numerous residents across various smoke zones.
Deficiencies (15)
EP Program Patient Population CFR(s): 483.73(a)(3) Emergency preparedness plan failed to include a plan for residents requiring powered support systems and lacked mention of an emergency generator.
42 CFR 483.90(a) Building Construction Type and Height did not meet Life Safety Code requirements for sprinkler systems; walls and ceilings failed to resist smoke passage in the kitchen janitor closet.
Emergency Lighting CFR(s): NFPA 101 Emergency lighting did not illuminate sufficiently in the Mechanical Room and Spa on 600 Hall, potentially hampering evacuation efforts.
Laboratories CFR(s): NFPA 101 Flammable or combustible paints and substances were stored improperly in the storage room outside the 300 Hall, affecting at least 24 residents.
Subdivision of Building Spaces - Smoke Barrier CFR(s): NFPA 101 Facility failed to ensure smoke barriers were continuous and properly sealed, affecting 85 residents in five smoke zones.
Fire Drills CFR(s): NFPA 101 Facility failed to ensure fire drills were thoroughly documented and included simulated fire size and type, affecting all residents and staff.
Smoking Regulations CFR(s): NFPA 101 Facility failed to ensure table-top ashtrays were self-closing and outdoor smoking receptacles had interior metal liners; cigarette butts were improperly disposed.
Engineer Smoke Control Systems CFR(s): NFPA 101 Facility failed to ensure four-year testing of pneumatic smoke dampers was completed, affecting 85 residents in five smoke zones.
Electrical Systems - Essential Electric System CFR(s): NFPA 101 Facility failed to identify outlets powered by emergency generator and had electrical equipment plugged into extension cords, affecting 44 residents.
Electrical Equipment - Other CFR(s): NFPA 101 Facility failed to prevent use of extension cords and adapters for electrical equipment in resident rooms, creating potential fire hazards.
Combustible Materials CFR(s): NFPA 101 Facility stored unnecessary combustible materials improperly, creating a fire hazard.
Ashtrays Noncombustibles/Safe/Disposal CFR(s): NFPA 101 Facility failed to properly dispose of ashtray contents and ensure ashtrays were safe and noncombustible.
Substantially Constructed/Maintained CFR(s): NFPA 101 Facility failed to maintain building in good repair per construction standards.
Electrical Wiring & Equipment Maintained CFR(s): NFPA 101 Facility failed to maintain electrical wiring and equipment in accordance with NFPA 70 standards.
Policies/Procedures-Operational CFR(s): NFPA 101 Facility failed to develop policies and procedures to ensure resident health and safety, including emergency preparedness and infection control.
Report Facts
Facility census: 128
Licensed capacity: 193
Smoke zones affected: 10
Residents affected by smoke barrier deficiency: 85
Residents affected by combustible storage deficiency: 24
Residents affected by electrical outlet deficiency: 44
Residents affected by electrical equipment deficiency: 35
Residents affected by smoking regulation deficiency: 128
Residents affected by fire drill deficiency: 128
Residents affected by smoke damper testing deficiency: 85
Residents affected by emergency lighting deficiency: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Assistant A | Interviewed regarding smoke penetrations, storage room conditions, and smoke barrier observations | |
| Maintenance Director | Interviewed regarding emergency lighting, electrical outlets, fire drills, and maintenance logs | |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding smoking area conditions and cigarette butt disposal |
| Administrator | Interviewed regarding emergency preparedness and plan of correction approval | |
| Transportation Coordinator | Interviewed regarding space heater in office |
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