Carmel Hills Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily staffing information posted was for the current day. This failure had the potential to result in nurse staffing misinformation to residents, families, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ the director of food and nutrition services when the registered dietician was only employed part-time. This failure had the potential to negatively impact on food quality, sanitation, meal service, and residents' nutritional status for 92 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation of two ice machines (one was in the utility room, one was in the hallway) when there was buildup around the ice dispenser chutes and ice discharge chutes of the two ice machines. These failures had the potential to increase the risk of food contamination to 92 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain respect and dignity for 9 of 18 sampled residents (Residents 61 69, 19, 95, 90, 3, 93, 54, and 39) when:1. Residents 61, 69, 19, 95, and 90's care instructions were posted above their head of bed's (HOB) wall, and other side of their room wall uncovered in a shared room;2. Residents 3, 93, and 54's care instructions were visibly posted; and,3. Resident 39's urine drainage bag (a pouch that attaches to a urinary catheter and collects urine) was not covered with a privacy bag. These failures had the potential to negatively affect residents' emotional and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for an advance directive (AD, a written instruction, such as a living will or durable power of attorney [a document that authorizes a person to act on behalf of resident] for healthcare when individual incapacitated) for 5 of 22 sampled residents (Resident 1, 9, 118, 121, and 6) and completion of physician orders for life-sustaining treatment (POLST, a document that specifies the medical treatments the resident wants to receive during serious illness) form for 4 of 22 sampled residents (Resident 3, 7, 19, and 95) when: There was no documentation of AD for Residents 1,9,118, 121, and 6; and,POLST forms for Residents 3,7,19, and 95 were incomplete. These failures could lead to the delivery of medical services against sampled residents' goals and wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 3 out of 5 sampled residents (Residents 4, 7, and 87) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when:1. Resident 4 received an order for PRN (as needed) lorazepam (an anti-anxiety medication) without a 14-day limit as required by the regulations and facility policy and procedures (P&P).2. Resident 7 received Seroquel (quetiapine- an antipsychotic medication) without documented evidence of attempted non-pharmacological (non-drug) interventions and without implementation of non-pharmacological interventions from the care plan.3. Resident 87 received citalopram (an antidepressant) and zolpidem (medication to manage insomnia) without evidence of non-pharmacological intervention implementation. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide restorative services for one of three residents (Resident 10) when documentation was missing or lacking regarding the service. This failure has the potential of the residents to experience a decrease in their range of motion (ROM) and possibly psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to provide renal dialysis (a life sustaining medical treatment that filters waste, excess fluids from blood when kidneys [bean shaped organ, responsible for removing waste products from blood, producing urine] failed to function) care and services consistent with professional standards of practice for two of two sampled residents (Resident 121 and 3) when dialysis follow up information forms were incomplete for 5 of 7 dialysis treatment days for Resident 121, and 7 of 10 dialysis treatment days for Resident 3. These failures had the potential to result in inappropriate follow-up care for Residents 121 and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate administration and disposal of medications when:1. An insulin pen (a pre-filled pen containing insulin- medication to lower blood sugar) was not correctly primed (the process of removing any air bubbles from the pen's needle and cartridge before an injection) during the medication administration observation for 1 of 1 resident (Resident 115). This had the potential for the resident to receive the incorrect amount of insulin for treatment.2. A nursing staff disposed of 3 medications in the sharps container instead of a designated pharmaceutical bin. This resulted in inappropriate waste of medications.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 19) was free from an unnecessary medication. Resident 19 has been receiving Prilosec (omeprazole, a medication in a class called proton pump inhibitors [PPI] to treat gastroesophageal reflux disease [GERD- condition where stomach acid flows back up into the esophagus and causes heartburn]) for approximately 3.5 years without documented risk versus benefit (R/B) assessment for continued, long-term use despite having osteoporosis (disease where decreased bone strength and mass significantly increase the risk of fractures), being at risk for osteoporosis-related fractures, and receiving multiple medications that increase fall risk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served at an appetizing temperature when 11 out of 92 residents (Resident 34, 68, 9, 54, 123, 36, 59, 16, 85, 46, 74) complained hot food was served cold to them. This failure had the potential to affect the amount of food residents consume, which could decrease their food intake and lead to poor nutrition and health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) was obtained prior to the administration of a psychotropic medication (drug that affect brain activities associated with mental processes and behavior) for 1 out of 7 residents (Resident 4). The failure had the potential for the resident/resident representative not being informed in advance of the risks and benefits of the medication, the treatment alternatives, or other options before making the decision for treatment. A review of Resident 4's clinical record indicated she was admitted to the facility with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and anxiety disorder. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure an even floor surface in facility's hallways. This failure presented a potential tripping hazard for residents who were using these hallways.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fluid restrictions were followed for one of five sampled residents (Resident 3) and failed to initiate a care plan (an individualized, collaborative document that focuses on a resident specific needs, goals, preferences and values) for restricted fluids for one of three sampled resident (Resident 54). These failures had the potential to negatively affect Resident 3 and Resident 54's fluid balance.

Inspectors wroteBased on interview and document review, the facility failed to conduct the Certified Nursing Assistant's (CNA) Annual Performance Evaluation (a formal, documented review of an employee's work over the past year, assessing their performance against established goals and expectations) for one (CNA M) of three sampled employees. This failure did not ensure CNA M had the necessary knowledge to provide safe resident care.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 6.06% when 2 medication errors occurred out of 33 opportunities during the medication administration for 2 out of 7 residents (Residents 18 and 61). For Resident 61, metformin (medication to manage diabetes) was not administered with a meal as per manufacturer's specifications. Resident 18's olanzapine (an antipsychotic medication) ODT (oral disintegrating tablet - a solid dosage form that dissolves rapidly on the tongue) was crushed, a practice contrary to the accepted standards of practice. The deficient practice had the potential for adverse effects (such as stomach irritation) and ineffective use of medications for the residents.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 inhalers and 3 insulin pens (pre-filled pen containing insulin - medication to lower blood sugar) were given the expiration date in accordance with the manufacturer's specifications, and an expired and discontinued insulin pen was removed, in 1 out of 2 inspected medication carts. The failure had the potential for medication errors or residents being administered expired medications or given beyond the effective period. During an inspection of the Station 2 Pebble Beach Medication Cart with Licensed Vocational Nurse (LVN) A and LVN B on 4/13/26 at 2:40 p.m., the following was identified and verified with both staff:a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow standard infection control practices when the following were observed:1. Undated nasal cannula (NC, light weight, flexible, medical device tube used to deliver oxygen [O2, a colorless, odorless and tasteless gas that is essential for life on earth, supplements for residents with breathing problem] for residents) for Resident 31,1, 44, 3, and 84;2. Undated nebulizer face mask (a medical device that fits over the nose and mouth to deliver liquid medication directly into the lungs [pair of organs, responsible to take O2 from air and transfer to blood] as a fine mist) for Resident 25 when not in use;3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and functional environment for kitchen staff when there was broken and buckled concrete flooring and condensed ice accumulation on the ceiling and on the floor in the walk-in freezer of the kitchen. These failures had the potential to create an unsafe environment for 23 staff in the kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food was thawed per the facility policy, there was not a crack in the kitchen floor, utensils were stored per the facility policy, the food drains were cleaned daily, there was not a build-up around the ice machine dispenser, and expired food items were discarded after their expiration date. These deficient practices had the potential to affect all residents who received food from the kitchen.

Inspectors wroteBased on interview, document review, and facility policy review, the facility failed to develop a water management program that specified a detailed description and diagram of the water system in the facility. This deficient practice had the potential to affect all 91 residents who currently reside in the facility.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure licensed staff locked 1 of 4 medication carts when the cart was not within the sight of the nurse during medication administration.

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure the Registered Dietitian comprehensively carried out the functions and evaluated the effectiveness of Food and Nutrition Services as evidenced by: Lapses in the delivery of services associated with: staff competency (cross-reference F802), following the menu (cross-reference F803), providing physician prescribed diet orders (cross-reference 808), food safety and sanitation (cross-reference F812), providing physician prescribed nutrition supplements (cross-reference F692), physical environment of the kitchen (cross-reference 908). [...]

Inspectors wroteBased on observation, interview, and facility document record review, the facility failed to ensure staff competency when: 1. The staff members were unable to properly test the dish machine's sanitizer and were not routinely testing the concentration of the dish machine's sanitizer and wash and rinse temperature. 2. Two of three staff members were unable to test the red bucket's sanitizer correctly and two red buckets' sanitizer concentration was not consistently tested for the month of March. 3. The FSW M did not follow the pureed preparation for vegetables. 4. The FSW M did not follow the recipes for the honey glazed pork and the fresh baked sweet potatoes served for lunch on 3/21/22. These failures had the potential to result in compromising the health and safety of the 71 residents in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. An ice machine was not kept in a sanitary condition; 2. Thawed meat was kept in the refrigerator for an extended period of time; 3. A red bucket with sanitizer was left on a food production surface; 4. A food contact surface sanitizer had inconsistent strength; 5. A protein based nutritional supplement was held above 41 degrees Fahrenheit (F, a temperature scale) for an extended period of time; 6. Food containers were stacked wet; 7. Kitchen floors had some black build up to corners of each storage area leading to the back door; 8. Spills of rice were found at the cart beside the rice container; 9. The lid of a flour container had a crack; 10. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures when: 1. The facility's screening process for Coronavirus disease (COVID-19, a disease caused by a contagious virus) was not in accordance with Centers for Disease Control and Prevention (CDC) guidelines; 2. The receptionist did not follow the facility's Screening Checklist when screening a visitor for COVID-19; 3. One dietary staff member was not screened for COVID-19 prior to entering the facility; 4. There were no receptacles (containers) inside the residents' rooms to dispose of used gowns in the yellow zone (area designated for resident with known or possible exposure to COVID-19); 5. One CNA did not use and dispose of personal protective equipment (PPE, mask, gown, gloves, eye protection) appropriately when providing care to Resident 3; 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability) to two of three residents (Residents 27 and 60). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform re-evaluation restraint assessments in a timely manner for three of five residents (Residents 62, 63, and 27), when restraint assessments were not performed on at least a quarterly basis. This failure had the potential of residents being physically restrained when not medically indicated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses (incoming shift nurse and outgoing shift nurse) consistently signed off the Correct Count Verification sheet/form for controlled medications that indicated they acknowledged accuracy and accountability of controlled drugs for two of four medication carts. This failure had the potential for inaccurate recording and accounting of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store medications in four of four medication carts and in one of two medication refrigerators when: 1. Multi-dose vials and liquid medications were not dated when opened and discarded when expired (beyond due date). 2. Expired medications were not disposed accordingly. 3. Multiple eyedrops/ointment opened and not dated, expired eyedrops not discarded and disposed. 4. Internal medications (oral medications) were mixed with external medications. These failures had the potential for administration of wrong and expired medications which could placed residents at risk for adverse drug reactions and possible complications.

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to ensure the planned menu was followed and the nutrient needs were met when: 1. Milk was not served according to the menu for a random sample of 16 residents (Residents 61, 274, 275, 54, 19, 3, 53, 27, 276, 9, 10, 7, 42, 51, 22, 2); 2. Fourteen of 14 residents (Residents 22, 10, 17, 5, 61, 64, 38, 73, 40, 48, 25, 54, 34, 41) on CCHO regular texture diet (carbohydrate controlled diets, diets designed for people with diabetes that evenly spread carbohydrates throughout the meals) when they were served the wrong portion size for sweet potatoes; 3. Seven of seven residents (Residents 33, 45, 29, 27, 71, 63, 15) on puree diets (texture modified diets for people with chewing or swallowing difficulties) when they were served the wrong portion size for pork chop and zucchini, 4. [...]

Inspectors wroteBased on observation, staff interview, and facility document review, the facility failed to assure residents consistently received a fortified diet as prescribed by a physician when two out of 33 residents on a fortified diet did not receive any fortified foods, and six out of 33 residents on fortified diets received minimal extra calories at one meal. These failures had the potential to result in not meeting the nutritional needs and further compromising the nutritional status of the 33 residents on fortified diets.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Track, offer and administer pneumococcal vaccines (vaccines intended to prevent lung infection) according to Centers for Disease Control and Prevention (CDC) guidelines for three of five sampled residents (Residents 20, 26 and 27); and 2. Perform screening prior to administering the influenza (respiratory infection) vaccine for one of five sampled residents (Resident 43). These failures had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure the kitchen's physical environment was free from accident hazards and equipment was in good working condition when: 1. The magnetic mesh screen at the kitchen's back door was not fully closed, the kitchen floor had a tear, and the floor coving was completely detached from the bottom part of the wall; 2. The floor drains were not emptied and cleaned; and, 3. Residents' food trays were broken exposing the metal parts at the edge. These failures had the potential to affect the health and safety of staff and 71 residents at the facility by possible exposure to disease carrying pests, hazards and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the interdisciplinary team (IDT, facility staff members from different departments including nursing who coordinate care provided to residents) assessed whether it was safe for one of 19 sampled residents (Resident 36) to keep her medications at the bedside and had a physician's order to administer the medication. These failures had the potential for incorrect self-medication administration and wrong medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide physician ordered nutrition supplements (products that are used to complement a resident's dietary needs, a high calorie drink in this case) to one resident (Resident 71) with a history of weight loss and pressure injury. This failure had the potential to cause further weight loss and decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a licensed nurse and student nursing assistant (SNA) had the specific competencies necessary to care for two of 19 sampled residents (Residents 11 and 60) when licensed vocational nurse A (LVN A) did not correctly demonstrate the proper use of insulin syringe, and when SNA turned off Resident 60's oxygen without informing the charge nurse. These failures had the potential for Resident 11 and 60 to not attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow its antibiotic stewardship program (program intended to prevent the overuse of antibiotics) when antibiotics were prescribed for one of one sampled residents (Resident 8) without the use of the protocols outlining clinical symptoms to confirm the presence of an infection. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policies and procedures that were in accordance with the Centers for Disease Control and Prevention (CDC) recommendations when it allowed medical exemptions and deferments from Coronavirus disease (COVID-19, a disease caused by a contagious virus) vaccinations for two of two staff members who were pregnant. Both staff members worked in the facility under this exemption. As a result, the facility's staff vaccination rate was 98.2% on [DATE]. In addition, the facility failed to ensure staff who were not fully vaccinated adhered to appropriate precautions to mitigate risk for COVID-19 spread. These failures increased the risk for COVID-19 exposure and infection to residents and staff.