Carmel Health & Living Community

In the surveyor’s words

From the most serious findings on record at Carmel Health & Living Community, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 13, 2025

  Based on interview and record review, the facility failed to ensure a resident received supervision during incontinence care to prevent the resident from being rolled off the bed onto the floor for 1 of 3 residents reviewed for accidents. (Resident B) This deficient practice resulted in Resident B being hospitalized with an eight-millimeter frontal subdural hematoma.Findings include:During an interview, on 11/12/25 at 2:31 p.m., a family member of Resident B indicated she received a telephone call, on 10/1/25 at 6:00 a.m., Resident B had rolled out of bed when an aide was in the room. Typically, there were two staff members with her when care was provided due to Resident B's weight. She did not know where the other person was at the time of the fall. […]

• Actual harm, isolatedF760Sep 25, 2025

  Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error for 1 of 1 resident reviewed for medication errors. (Resident 7) This deficient practice resulted in Resident 7 being hospitalized for toxic metabolic encephalopathy due to a high dose of medication and her end stage renal disease.Findings include:During an interview, on 9/24/25 at 11:52 a.m., Resident 7 indicated she went to the hospital after receiving medication which caused her to see things that were not there. She did not remember a lot about the occurrence, but her daughter became very concerned and insisted she be sent to the hospital.The clinical record for Resident 7 was reviewed on 9/23/25 at 1:17 p.m. […]

• Actual harm, isolatedF689Apr 15, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 3 residents reviewed who were at risk for falling (Resident B). Resident B had an unwitnessed fall on the day of his admission, requiring hospitalization where he was diagnosed with a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain). Finding includes: Resident B's medical record was reviewed on 4/14/21 at 10:45 a.m. Diagnoses included, but were not limited to, end stage [CONDITION(S)], shortness of breath and spinal stenosis. Resident B's progress note, dated 04/10/21 at 3:30 p.m., entered by RN 1, reflected he arrived by EMS escorted by his family member. He was alert and oriented to self only. […]

• No harm, potential for more than minimal, patternF755Sep 25, 2025

  Based on observation, interview and record review, the facility failed to ensure narcotic reconciliation was documented as completed, medications were available without interruptions in administration, and to ensure accurate administration documentation and destruction by obtaining two nurse's signatures for 3 of 3 medication carts (500 Unit, 700-1 Unit, 800 Unit) and 2 of 2 residents (Resident 138 and 55) reviewed for pharmacy services.Findings include:1. A facility narcotic reconciliation document, for the 500 Unit, was missing signatures to indicate the narcotic reconciliation was completed on 9/10/25 for the on-coming night shift, on 9/13/25 for the on-coming night shift, on 9/15/25 for the on-coming and off-going evening shift, and on 9/17/25 for the on-coming night shift. […]

• No harm, potential for more than minimal, patternF761Sep 25, 2025

  Based on observation, interview and record review, the facility failed to ensure medications were dated when opened, were stored in the original pharmacy packaging, and a medication administration record matched the pharmacy label for a narcotic pain medication for 3 of 5 medication carts (500 Unit, 300 Unit and 700 Unit), 1 of 3 medication storage refrigerators (300 Unit), and 1 of 1 resident (Resident 55) reviewed for drug labeling and storage.Findings include:1. During an observation, on 9/23/25 at 8:17 a.m., with LPN 5 in attendance, the 500 Unit medication cart was found to have the following: a. One 30 milliliter (ml) bottle of morphine with approximately 15 ml left was found without an open date. b. […]