Carmel Hills Wellness & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Carmel Hills Wellness & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Feb 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from accidents for two sampled residents (Resident #1 and #3) out of six sampled residents. On 1/5/24 about 10:15 P.M., Certified Nurse Assistant (CNA) A transferred Resident #1 without using the Hoyer lift (a mechanical means to transfer a resident) from the wheelchair to the bed. During the transfer CNA A realized it was not safe to continue and lowered the resident to the floor. CNA A and CNA B then transferred the resident from the floor to bed by placing their arms under the resident's arms, one on each side and lifting the resident up. They did not use a gait belt or mechanical lift to transfer the resident back to his/her bed. […]

• Immediate jeopardy, isolatedF600Sep 1, 2022

  Based on observation, interview, and record review, the facility failed to ensure two residents (Resident #3 and #4) were free from verbal and physical abuse. Resident #4 hit Resident #3 multiple times with a cane on 8/29/22. Resident #4 had to be physically separated from Resident #3 by facility staff members. Resident #4 was sent to the hospital for psychological evaluation and returned back to the facility with no new orders and placed back in the same room with Resident #3. Resident #3 realized Resident #4 was back in the room, notified Family Member A. Family Member A contacted Family Member B. Family Member B arrived to the facility and went to the residents' room. Family Member B stood over Resident #4 and verbally abused and hit the resident with a cane. […]

• Immediate jeopardy, isolatedF600Mar 31, 2022

  Based on observation, interview, and record review, the facility failed to prevent staff to resident abuse for one sampled resident (Resident #1) out of three sampled residents, when Certified Nurse Aide (CNA) A admitted to hitting the resident several times in the face resulting in pain, swelling, and discoloration of the resident's left lateral (side) orbital (eye) area and a black eye. The facility census was 167 residents. On 3/31/22 at 12:57 P.M. the Administrator was notified of the past noncompliance immediate jeopardy (IJ) which occurred on 3/29/22. On 3/29/22 the facility administration was notified of the incident and the investigation was started. CNA A was suspended on 3/29/22 and terminated on 3/30/22. No employees were allowed to work prior to re-education. […]

• Immediate jeopardy, isolatedF689Jul 6, 2021

  Based on observation, interview, and record review, the facility failed to provide supervision and individualized interventions for one sampled resident (Resident #1) to address his/her exit seeking behavior. The resident was admitted to the facility on [DATE] with a history of wandering behaviors and no immediate care plan was developed to address the resident's wandering. The resident exited the unit five times prior to eloping from the building on 6/24/21. The resident was found by the local law enforcement near a busy traffic intersection and returned to the facility. The facility census was 161 residents. The Administrator was notified on 6/30/21 at 1:45 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on 6/24/21. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2025

  Based on observation and interview, the facility failed to maintain the sprinkler heads above the food preparation and food serving areas, free from dust and grease; maintain the oven mittens in good repair; maintain the drainage pipes, metal fixtures and walls under the dishwasher area, free of a buildup of grime and discarded dishes; ensure items (lemon juice and beef base), were refrigerated; maintain the handwashing sink free of obstructions; maintain hot foods ( pureed French Toast and regular French Toast) at or close to 135 ºF ( degrees Fahrenheit) at the steam table; to ensure that fresh fruits ( grapes) were washed prior to mixing them with the fruit salad for breakfast and to ensure Dietary Aide (DA) B use tongs or gloves while he/she handled French Toast from the steam table. […]