Restoracy of Carmel

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 8, 2022

  Based on interview and record review, the facility failed to identity injuries of unknown origin as possible abuse for 3 of 11 residents in Cottage 3 reviewed for injuries of unknown origin. (Resident 27, 5 and 46) The immediate jeopardy began on November 2, 2022, when Resident 27 was found to have a bruising on the right side of the forehead. On 11/8/22, Resident 5 was noted to have discoloration and a skin tear. On 12/2/22, Resident 46 was noted to have several bruises on her left arm. The Director of Nursing was notified of the immediate jeopardy on 12/5/22 at 4:02 p.m. The immediate jeopardy was removed on 12/07/22, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. […]

• Immediate jeopardy, isolatedF610Dec 8, 2022

  Based on interview and record review, the facility failed to thoroughly investigate injuries of unknown origin as possible allegations of abuse and report to the state agency potentially preventing further injury to a resident for 3 of 11 residents reviewed for injuries of unknown origin. (Resident 27, 5 and 46) The immediate jeopardy began on November 2, 2022, when Resident 27 was found to have a bruising on the right side of the forehead. On 11/8/22, Resident 5 was noted to have discoloration and a skin tear. On 12/2/22, Resident 46 was noted to have several bruises on her left arm. The Director of Nursing was notified of the immediate jeopardy on 12/5/22 at 4:02 p.m. […]

• Actual harm, isolatedF692Oct 4, 2021

  Based on observation, interview and record review, the facility failed to provide nutritional supplements as ordered by the physician and Registered Dietician and failed to follow-up on recommendations from the Registered Dietician to prevent further weight loss for 1 of 5 residents reviewed for nutrition. (Resident D) This resulted in Resident D having a decrease in weight of 12.9% in 180 days. Finding includes: During a dining observation, on 09/27/2021 at 12:24 p.m., Resident D did not receive yogurt for lunch. During a dining observation, on 09/29/2021 at 9:02 a.m., the resident was not given a straw or a Provale cup (a specialized cup used to deliver small amounts of liquid with every drinking motion used with swallowing disorders). […]

• Actual harm, isolatedF689Jul 7, 2021

  Based on observation, interview and record review, the facility failed to ensure a resident was adequately supervised during toileting and failed to accurately assess for injuries upon discovering the resident had fallen for 1 of 3 residents reviewed for accidents. (Resident B) Resident B required an emergency room visit and staple placement to a laceration sustained during the fall. During an observation of Cottage 4, on July 06, 2021 at 10:17 a.m., LPN 2 was observed in the nursing office on the phone. Resident B was in a wheelchair parked in the doorway facing into the office. LPN 2 hung up the phone and indicated she was going to do a treatment on the resident. The nurse walked over to the overhead cabinets, moved items around, then closed them. […]

• Actual harm, isolatedF697May 20, 2021

  Based on observation, interview and record review, the facility failed to provide effective pain management in accordance with the resident's comprehensive care plan for 1 of 3 cognitively impaired residents reviewed experiencing pain. (Resident D) This resulted in Resident D having impaired mobility, mood, poor quality of life and increased the risk of pressure ulcers. Finding includes: During a telephone interview, on 5/17/21 at 3:45 p.m., Resident D's friend indicated the resident had no family nearby. She was a long-time friend and the only person able to visit the resident on a regular basis. Since before 4/27/21, she observed Resident D had pain in her hips and knees from prior hip surgery. She would not unlock her knees because of her pain. […]