Inspection Reports for The Restoracy of Carmel

The facility was found not in compliance with Life Safety Code requirements including failure to inspect and test sprinkler systems quarterly in multiple buildings and failure of one resident room door to close and latch properly.

The facility was found deficient in ensuring urinary catheter bags had dignity covers for residents, following physician's medication orders for two residents, and proper infection control practices related to catheter bag placement and disposal for three residents. Deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.

Complaints IN00444413 and IN00444369 were investigated with no deficiencies related to the allegations cited.

The facility was found deficient in several areas including failure to ensure urinary catheter bags had dignity covers, failure to follow physician's orders regarding medication administration, and failure to ensure catheter bags were not touching dirty surfaces and were disposed of properly. No deficiencies were cited related to the investigated complaints.

Complaint IN00439367 was investigated with no deficiencies related to the allegations cited. The complaint involved fraudulent use of Resident B's and Resident C's credit cards by CNA 1, who was terminated for the misconduct. Resident B's son and police were involved in the investigation. Resident C reported missing credit cards and fraudulent charges totaling approximately $798.09, which were reimbursed by credit card companies.

No deficiencies related to the complaint allegations were cited; however, unrelated deficiencies were cited involving misappropriation of residents' credit cards by a CNA. The CNA was terminated for fraudulent use of residents' credit cards, and corrective actions including staff in-servicing and QAPI inclusion were implemented.

The complaint investigation was substantiated with evidence that CNA 1 fraudulently used Resident B's credit cards for multiple unauthorized charges, including a Door Dash order. Resident C also reported missing credit cards with fraudulent charges totaling $798.09, which were reimbursed by credit card companies. CNA 1 was terminated and police involvement was ongoing.

The facility failed to ensure residents' credit cards were kept safe and secure, resulting in fraudulent charges made by a certified nursing assistant (CNA 1). CNA 1 was terminated for theft and fraud after investigations confirmed unauthorized use of residents' credit cards. The facility implemented corrective actions including staff abuse in-servicing and inclusion of misappropriation of property in the QAPI program.

The facility was found not in compliance with Life Safety from Fire and related requirements. Deficiencies included obstructed exit discharge paths, lack of annual fire door inspections, failure to conduct required emergency generator four-hour run tests, and issues with oxygen transfilling room ventilation and door latching.

The facility was found deficient in multiple areas including failure to honor residents' rights to dignity, incomplete PASARR screenings, inadequate care planning, failure to provide recommended oral care, insufficient cognitively stimulating activities, improper use and documentation of assistive devices, failure to notify physicians of significant weight loss and abnormal blood sugar readings, lack of documentation for pharmacist recommendations, food safety violations, and lack of a qualified infection preventionist onsite.

The facility was found deficient in multiple areas including resident rights, PASARR screening, care planning, ADL care, activities, quality of care, colostomy care, nutrition and hydration, drug regimen review, food safety, and infection preventionist qualifications.

The facility failed to timely renew its license to operate as a health care facility before the expiration date of December 31, 2023. The renewal application and payment were received postmarked January 8, 2024, which was not at least 45 days prior to license expiration as required.

This Federal tag relates to Complaint IN00413720. The complaint involved allegations of rough handling and improper transfer techniques by a CNA, resulting in injury to Resident B. The complaint was substantiated by interviews and record review.

The facility failed to ensure proper transfer techniques were used, causing injury to Resident B, who exhibited bruising and swelling after a rough transfer by a CNA. The CNA was reeducated and reassigned, and the resident's care plan was updated to reflect proper transfer methods.

Complaint IN00413720 was substantiated with federal/state deficiencies cited related to allegations of improper transfer technique causing injury to Resident B.

The facility failed to ensure a proper transfer technique was used during a transfer, resulting in injury to one resident. The resident exhibited bruising and swelling consistent with improper handling. Staff education and corrective actions were implemented.

Complaint IN00411683 relates to pressure ulcer care deficiencies for Resident B. Complaint IN00407963 relates to fall supervision deficiencies for Resident H.

The facility failed to ensure physician's pressure ulcer orders were transcribed and treatments completed for Resident B, resulting in infection and hospital admission. Additionally, the facility failed to provide adequate supervision to Resident H, a high fall risk, who fell off the toilet when left unattended by a CNA.

Complaint IN00407963 involved failure to ensure a resident with dementia and high fall risk was free from injury after being left unattended on the toilet. Complaint IN00411683 involved failure to ensure physician's pressure ulcer orders were transcribed and treatments completed as ordered.

The facility was found deficient in ensuring proper transcription and completion of physician orders for pressure ulcer treatment for one resident, and in providing adequate supervision to prevent injury for another resident at high risk for falls. Both deficiencies were substantiated with detailed findings and corrective actions.

This Federal tag relates to Complaint IN00404058.

The facility failed to ensure accurate and complete documentation of deaths for 4 of 4 residents reviewed. Progress notes lacked critical information such as date and time of death, name and title of the person pronouncing death, notification of MD, family, and Executive Director, and documentation of the mortician and person removing the deceased. The attending physician did not document the cause of death in progress notes.

Complaint IN00404058 was investigated. The complaint alleged incomplete documentation of resident deaths, which was substantiated by findings.

The facility failed to ensure that residents' deaths were accurately and completely documented in the medical records for 4 of 4 residents reviewed. Documentation lacked key information such as date and time of death, name and title of the person pronouncing death, notification of family and medical staff, and cause of death by the attending physician.

The facility was found not in compliance with Life Safety Code requirements including failure to ensure semiannual inspection of kitchen fire suppression systems in all six cottages, lack of quarterly sprinkler system inspection reports for the second and third quarters of 2022, and failure to conduct quarterly fire drills for multiple quarters.

The complaint investigation included multiple allegations of failure to honor advance directives, failure to notify physicians of changes in condition, failure to identify and report injuries of unknown origin as abuse, failure to provide accurate assessments and appropriate care, failure to provide meaningful activities, failure to maintain a safe environment and medication security, failure to provide safe respiratory and pain management care, failure to maintain infection prevention and control, failure to ensure adequate RN coverage, failure to post daily staffing information, failure to ensure staff COVID-19 vaccination compliance, and failure to establish an antibiotic stewardship program.

The facility was found deficient in multiple areas including failure to honor residents' advance directives, failure to notify physicians of changes in condition, failure to identify and report injuries of unknown origin as possible abuse, failure to provide accurate assessments and appropriate care, failure to provide meaningful activities, failure to maintain a safe environment and medication security, failure to provide safe and appropriate respiratory and pain management care, failure to maintain infection prevention and control programs, failure to ensure adequate RN coverage, failure to post daily staffing information, and failure to ensure staff COVID-19 vaccination compliance.

Complaint IN00388052 was unsubstantiated due to lack of evidence. Complaint IN00393166 was substantiated with federal/state deficiencies cited.

The facility was found to have multiple deficiencies including failure to ensure advance directives were reviewed and updated, failure to notify physicians of significant changes, failure to identify and report injuries of unknown origin as possible abuse, failure to investigate such injuries, inaccurate MDS assessment coding, incomplete care plans for antipsychotic use, failure to provide ADL assistance, lack of meaningful activities, failure to identify and respond to change of condition, medication errors, unsafe storage of chemicals and medications, infection control deficiencies, lack of RN coverage for 8 hours on some days, failure to post nurse staffing data timely, unnecessary antibiotic use, improper medication crushing, unsecured medications, unsafe environment with flooring gaps, incomplete employee records, and failure to implement COVID-19 vaccination policies and reporting.