Carmel Richmond Healthcare and Rehabilitation Cent

In the surveyor’s words

From the most serious findings on record at Carmel Richmond Healthcare and Rehabilitation Cent, in the surveyor’s own words.

• Actual harm, isolatedF684Mar 25, 2026

  Based on record reviews and interviews during survey, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice to maintain their highest practicable physical wellbeing. This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, Resident #1 was admitted to the facility with intact skin to the sacrum (a triangular, shield-shaped bone at the base of the spine) and buttocks and subsequently developed moisture associated skin damage (erosion of the skin caused by prolonged exposure to urine, stool, sweat, or wound drainage.) Treatment was not initiated until [DATE] without documented evidence of the effectiveness of treatment between [DATE] and [DATE]. […]

• Actual harm, isolatedF710Mar 25, 2026

  Based on record reviews and interviews during a survey, the facility failed to ensure that medical care for each resident was effectively supervised by a physician. This was evident for one (1) out of four (4) residents (Resident #1) sampled. Specifically, 1) Resident #1 developed Moisture Associated Skin Damage (erosion of the skin caused by prolonged exposure to urine, stool, sweat, or wound drainage) to the sacrum (a triangular, shield-shaped bone at the base of the spine) and bilateral buttocks on 08/12/2025 and treatment was ordered on 08/14/2025 to be completed for 30 days. A Surgical Note by Physician Assistant #1 dated 12/17/2025 indicated wound deterioration. […]

• No harm, potential for more than minimal, patternF880Jan 19, 2021

  Based on observation, record review and interview conducted during the COVID-19 Focused Infection Control Survey completed on 1/19/21, the facility failed to establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. This was evident for 3 out of 5 units observed for Infection Control (Units 4, 5, and 6). Specifically, a staff member was observed providing resident care without donning (applying) a gown and eye protection for a resident on quarantine (Unit 6). Additionally, residents who were in contact with COVID-19 positive staff members were not placed on quarantine (Units 4 and 5). […]

• No harm, potential for more than minimal, isolatedF580Mar 25, 2026

  Based on record review and interviews conducted during an abbreviated survey (ID#2720832), the facility failed to ensure that a designated resident representative was notified of changes in the resident's condition. This was evident in one (1) out of four (4) residents sampled (Resident #1). Specifically, Resident #1 was assessed on 08/14/2025 to have developed moisture associated skin damage (caused by prolonged exposure to moisture from sources such as urine, stool, sweat or wound drainage) to sacrum and bilateral buttocks and treatment was ordered. Resident #1's designated representative was not notified of changes in Resident #1's skin condition. […]

• No harm, potential for more than minimal, isolatedF641Mar 25, 2026

  Based on observation, record review, and interviews during the Abbreviated Survey (ID #2720832) the facility failed to ensure the Minimum Data Set assessments accurately reflect each resident's status. This was evident in one (1) out of four (4) residents (Resident #1) sampled. Specifically, 1) Resident 1 was admitted to the facility from the hospital on [DATE] and was identified with Cellulitis (a common, potentially serious bacterial skin infection). The Minimum Data Set, dated [DATE] assessment did not reflect Resident #1's skin condition. 2) the hospital discharged , and Patient Review Instrument dated 12/30/2025, revealed Resident #1 was discharged to the facility with eight wounds to various body areas. […]