Carmel Home

In the surveyor’s words

From the most serious findings on record at Carmel Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF756May 7, 2026

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure the Pharmacist reviewed residents' drug regimens at least once a month for 4 of 5 residents sampled for Medication Regimen Review (MRR). Resident (R)4, R5, R10, and R18). The findings include:Review of the facility policy titled, Medication Regimen Review, undated, revealed, the facility ensured that all residents' medication regimens were regularly reviewed to optimize therapeutic outcomes, prevent adverse reactions, and comply with regulatory requirements. Per policy review, a pharmacist was to conduct periodic reviews of each resident's medication regimen to assess effectiveness, identify potential risks, and recommend necessary adjustments to enhance resident safety and care. […]

• No harm, potential for more than minimal, widespreadF851May 7, 2026

  Based on interview, review of the facility's documentation, and review of the Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ) Report, the facility failed to electronically submit to CMS complete and accurate direct care staffing information based on its payroll and other verifiable and auditable data in a uniform format according to specifications as established by CMS. The findings include:Review of the facility's Payroll-Based Journal (PBJ) Staffing Report for Fiscal Year (FY) Quarter 1 2026 (October 1 - December 31) revealed the facility failed to submit data for that quarter and indicated no data was submitted for the quarter. […]

• No harm, potential for more than minimal, widespreadF727Feb 15, 2024

  Based on interviews and record review, it was determined the facility failed to provide the services of a Registered Nurse (RN) at least eight (8) consecutive hours a day, seven (7) days a week from 07/01/2023 through 09/30/2023. The findings include: Review of the facility's policy titled, Staffing Policy, revealed it was the policy of the Center to ensure that sufficient qualified nursing staff were available daily to meet residents needs for nursing care and in a manner and environment which promotes each resident's physical, mental and psycho-social well-being thus enhancing their quality of life. Staffing was determined within the facility based on work assignments designed to meet the needs of residents as determined by the resident assessment and individual plans of care. […]

• No harm, potential for more than minimal, widespreadF812Feb 15, 2024

  Based on observations, interviews, and review of facility documents, it was determined the facility failed to store, label, and date food in accordance with professional standards for food service safety. The findings include: Review of a facility document titled, Labeling and Dating for Safe Storage of Food, dated 04/10/2023, revealed labeling and dating were critical in order to promote food safety. The use of use by dates would be reviewed. All products should be dated upon receipt. All products should be dated when opened, used by dates on all food once opened and stored under refrigeration. Observation of the kitchen on 02/14/2024 at 8:42 AM, revealed walk in cooler #1 contained a plastic container partially full of a brown substance that was not labeled or dated. […]

• No harm, potential for more than minimal, patternF605May 7, 2026

  Based on interview, record review, and review of the facility policy, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, for 4 of 5 sampled for drug regimen review out of the total of 8 sampled residents, (Resident (R)5, R8, R10 and R18).The findings include:Review of the facility policy titled, Unnecessary Medications, undated, revealed the facility was to ensure each resident was free from unnecessary medications. Per policy review, all medications, including psychotropic medications, must be clinically indicated; appropriately dosed; monitored for effectiveness and adverse consequences; and used in accordance with current standards of practice. […]