Carmel Manor

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Observation on 09/18/2025 revealed nursing staff instead of dietary staff took breakfast tray carts to the units and served the residents, and resident roommates were regularly served meals more than 27 minutes apart, which angered the resident who had to wait. Also, in an interview with the Dietary Manager on 09/18/2025, he stated he only had nine current dietary employees, and it took seven each day to perform the required dietary functions. This deficient practice affected 80 residents who received their meals from the kitchen.

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to provide meals at regular times comparable to normal mealtimes in the community or to which they were accustomed and preferred. Observations on 09/16/2025, 09/17/2025, 09/18/2025, and 09/19/2025 revealed breakfast, lunch, and dinner meals were delivered late, some an hour later than the expected time. During subsequent interviews with residents and families, they reported delayed meals negatively altered the remainder of the residents' day and evening routines, which upset the residents for 5 of 14 sampled residents, Resident (R) 26, R28, R51, R62, and R64.

Inspectors wroteBased on observation, interview, and review of the facility's document and policy, the facility failed to store and prepare food in a safe manner. Observation on 09/16/2025 and 09/17/2025 revealed uncovered kitchen utensils and equipment. Also, observation on 09/16/2025 of the resident kitchen unit refrigerators revealed two of the four had resident food products not labeled with the resident's name, date received, and the identity of the food product. The deficient practice had the capability of affecting 80 residents who received food from the kitchen or all residents that had additional food left in the unit kitchenette refrigerators.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 7 out of 52 sampled residents, Resident (R) 3, R15, R49, R55, R58, R68, and R82.

Inspectors wroteBased on observation, interview, and review of the facility's document and policy, the facility failed to provide food at safe serving temperatures. Observation on 09/16/2025 of residents' supper trays on the cart revealed the foods to be served were not at safe temperatures for 5 of 18 sampled residents, Resident (R)14, R46, R57, R63, and R81.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 of 29 sampled residents, Resident (R) 15, R16, and R80.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure that all residents were informed and provided written information concerning the right, at the resident's option, to formulate an advance directive for 2 of 29 sampled residents, Resident (R) 2 and R37. Review of the residents' electronic medical records revealed there was no advance directive information for R2 and R37, and the facility did not produce documentation demonstrating advance directive information had been provided.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to provide resolutions and/or provide documentation on resolutions related to reported missing items in the Resident Council meeting on 08/21/2025 for 2 out of 14 sampled residents, Resident (R) 52 and R57.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. Additional information the resident and the resident's representation were not given, and which should have been on the notice included the date, location for the transfer, the resident's appeal rights, and the contact information for the state Long-Term Care Ombudsman. This deficient practice affected 3 of 3 sampled residents, Resident (R) 6, R10, and R66.

Inspectors wroteBased on interview, record review, review of the facility's investigation, and review of the facility's policies, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 23 sampled residents, Resident (R) 7.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, including ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 1 residents sampled for dialysis services, Resident (R) 7.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with professional standards. This affected 2 of 5 medication carts.

Inspectors wroteBased on observation, interview, record review, review of the facility's investigation, and review of the facility's policy, the facility failed to take steps to prevent sexual abuse from occurring for 2 of 15 sampled residents, Resident (R) 2 and R3. R2 and R3, two cognitively impaired residents, were observed having intercourse. Instead of separating the residents, staff were told to close the resident's door and provide the cognitively impaired residents privacy. Staff stated the residents were not assessed to have the ability to consent to the sexual activity, and interviews with staff revealed they did not know what to do for R2 and R3. The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. [...]

Inspectors wroteBased on interview, record review, review of the facility's investigation, review of the facility's job descriptions, and review of the facility's policy, the facility failed to develop and implement policies and procedures to prohibit and prevent abuse and failed to establish policies and procedures to thoroughly investigate allegations of abuse for 2 of 15 residents, Resident (R) 2 and R3. R2 and R3, both cognitively impaired, were observed having sexual intercourse. Additionally, the facility failed to promote a culture of safety and open communication in the work environment through prohibiting retaliation against an employee for reporting abuse. The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. [...]

Inspectors wroteBased on observation, interview, record review, review of the facility's job descriptions, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure, in response to an incident of witnessed sexual abuse, it had evidence of a thorough investigation, to include reporting the incident to the state agency timely, and protecting the residents during and after the investigation for 2 of 15 sampled residents, Resident (R) 2 and R3. On 06/30/2025, R2 and R3 were found by staff in R3's bed naked. The residents were not separated immediately, and based on interview, the room door was closed. Review of medical records and interviews revealed immediate assessments had not been performed. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, the facility failed to develop person-centered care plan interventions for 4 of 7 sampled residents, Resident (R) 1, R2, R3, and R11. 1. The facility failed to follow interventions placed on R1's Comprehensive Care Plan [CCP] and Kardex to prevent an accident on 06/19/2025, resulting in a compound fracture of R1's right lower extremity, which required surgical intervention.2. The facility failed to develop R11's CCP with person-centered interventions to prevent falls for R11. On 07/14/2025, R11 fell out of bed and sustained a right shoulder fracture.3. The facility failed to develop R2's and R3's CCP with person-centered interventions to address the residents' behaviors, assessments, ability to consent to sexual activity, or supervision needs following the sexual encounter. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident by failing to follow the abuse policy and procedures related to protecting residents and conducting a thorough investigation of abuse after two cognitively impaired residents were observed having sexual intercourse, Resident (R) 2 and R3. On 06/30/2025, R2 and R3 were found in R3's bed naked, engaging in sexual activity, and neither had been assessed for ability to consent to activity. The facility's failure to have an effective system in place to ensure residents were protected from sexual abuse is likely to cause serious injury, impairment, or death if immediate action is not taken. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed for accidents, Resident (R)1, R7, and R11.1) On 06/19/2025, R1 sustained a compound fracture to right lower extremity during a transfer, requiring surgical interventions. However, review of the facility's investigation, they determined it was an injury of unknow origin and the cause was unable to be determined.2) On 07/14/2025, R11 was found in her room on the floor and was transferred to local hospital. Hospital records revealed R11 sustained a broken shoulder.3) On 07/09/2025, observation during an interview with R7 revealed a medication cup with 2 pills in it on the overbed table. [...]

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 sampled residents, Resident (R) 27 and R28The

Inspectors wroteBased on interview, record review, review of the Centers for Medicare & Medicaid Services (CMS), Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's 'QSO-21-19-NH Memo''', and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current Coronavirus Disease 2019 (COVID-19) vaccination status for 3 of 4 sampled staff, Registered Nurse (RN) 7, Licensed Practical Nurse (LPN) 11, and LPN12.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident consistent with resident rights and provide services required to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 12 sampled residents, Resident (R)1 and R24. 1. On 02/25/2025, R1, who resided on the facility's locked Memory Care Unit (MCU), and was care planned to wear a wanderguard (a monitoring device that triggers door alarms to alert staff when a resident was near a door or going out a door) was observed entering the facility through the main door which was equipped with an alarming device. However, the door did not alarm when R1 entered the facility. [...]

Inspectors wroteBased on observation, interview, record review, review of the RoamAlert Resident Safety User Guide, and review of the facility's documents and policies, the facility failed to have an effective system in place to ensure each resident received adequate supervision and properly functioning assistance devices to prevent unsafe wandering, elopement, and falls for 3 of 11 sampled residents, Resident (R)1, R12, and R13. 1. R1's Clinical orders, initiated 05/20/2024, revealed orders for the resident to wear a wanderguard bracelet (an electronic device that caused an alarm to sound when the resident tried to exit a door that had an accompanying device installed) to his right wrist and to check every shift. Per R1's Progress Note, dated 06/25/2024, R1 was exit-seeking, went outside the exit door, and was brought back into the facility immediately. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for 2 of 12 sampled residents, Resident (R)12 and R13. 1. On 06/07/2024, R12 was transferred without the use of a gait belt, as per policy. The resident sustained wounds to the left knee, and left arm, and bruising with scratches on the left ribcage. Additionally, a CT of the Chest performed on 06/08/2024, revealed an age-indeterminate nondisplaced left 8th rib fracture. R12's care plan was updated on 06/08/2024 to state the resident required extensive assistance by two staff to move between surfaces; however, the CCP was not revised to include an intervention for the use of a gait belt during transfers. 2. [...]

Inspectors wroteBased on interview, record review, and review of the facility's documents and policies, the facility failed to ensure that all alleged violations involving misappropriation of the residents' property were reported to the State Survey Agency (SSA) and local law enforcement within 24 hours of when the misappropriation was suspected. This affected 1 of 12 sample residents, Resident (R)25.

Inspectors wroteBased on interview, record review, review of a surveillance video recording, review of the facility's job descriptions, and review of the facility's policies, the facility failed to ensure that services provided met professional nursing standards for 1 of 33 sampled residents, Residents (R) 24. Review, on 03/14/2025 at 3:35 PM, of a surveillance video of R24, provided by the resident's family, revealed video footage of the resident and her room. The video revealed the last staff member left R24's room at 6:03 PM on 03/11/2025. Following this departure, no facility personnel re-entered the room until 5:41 AM on 03/12/2025, approximately 11 hours and 38 minutes. During this time, R24 did not receive monitoring or physician-ordered care, including assessments and administration of pain medications.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure that residents who required pain management were provided such services, for 1 of 33 sampled residents, Resident (R) 24. Review, on 03/14/2025 at 3:35 PM, of a surveillance video of R24, provided by the family, revealed the resident in her room. The video confirmed the last staff member left R24's room at 6:03 PM on 03/11/2025 and re-entered the resident's room at 5:14 AM on 03/12/2025. During this time, R24 was not administered her scheduled pain medication or assessed for signs and symptoms of pain.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 33 sampled Residents (R) 8, R18, and R20. 1. Observation and interview on 03/11/2025 revealed State Trained Nurse Aide (STNA) 11 did not put on personal protective equipment (PPE) before providing care for R20's who was under contact isolation precautions. Additionally, STNA11 failed to perform hand hygiene before entering or after exiting the room. 2. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, it was determined the facility failed to ensure employees were properly screened prior to hire. Three (3) of seven (7) employees' files reviewed did not have abuse registry checks completed prior to hire.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a comprehensive, person-centered care plan to meet each of the medical, nursing, mental and psychosocial needs identified on the resident's comprehensive assessment. The facility also failed to ensure the care/services were furnished so that residents attained or maintained their highest practicable physical, mental and psychosocial well-being, for three (3) of twenty-three (23) sampled residents (Residents #41, #22 and #14). Resident #41's care plan instructed staff to use a mechanical lift for transfers, however a State Registered Nurse Assistant (SRNA) stated she transferred the resident with a stand and pivot transfer, instead of using a mechanical lift. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident received proper care and/or services to ensure he/she was free from accidents and hazards for two (2) of twenty-three (23) sampled residents (Resident #41 and Resident #22). The facility assessed Resident #41 to be an extensive assist of two (2) staff for transfers with a mechanical lift: However, State Registered Nurse Aide (SRNA) #10 used a stand and pivot, one (1) person transfer on 01/05/2022 which resulted in a laceration to Resident #41's left lower leg. Resident #41 was sent to the Emergency Department and received twelve (12) sutures. Resident #22 sustained a non-injury fall on 02/14/2022. Resident #22 had orders for his/her wheelchair to have a dycem cushion to prevent falls. [...]

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention's (CDC) guidelines, CDC website, review of the Lippincott Manual of Nursing Practice 11th Edition, and review of the facility's policies, it was determined the facility failed to establish and maintain an Infection Prevention and Control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, affecting twenty-five (25) residents on the Transitional Unit. Observations, on 03/14/2022 at 5:45 PM, revealed Dietary Aide #1 failed to perform hand hygiene multiple times during meal service. Observations, on 03/16/2022 at 8:19 AM, 8:35 AM, 8:45 AM, and 8:51 AM, during medication administration, revealed Licensed Practical Nurse (LPN) #3 failed to perform hand hygiene; [...]

Inspectors wroteBased on interview and record review, it was determined the facility failed to provide reasonable accommodations of needs for one (1) of twenty-three (23) sampled residents (Resident #14). The facility assessed Resident #14 for special accommodations of a call light and emergency kick pad to be placed at the foot of the resident's bed. Resident #14 lacked the use of his/her upper extremities and was unable to use a regular call light. The facility did not ensure that the kick pad was properly attached to the resident's bed. In addition, the facility failed to prevent the call light from falling off the resident's bed, resulting in the resident's inability to call for help throughout the night.

Inspectors wroteBased on interview and record review, it was determined the facility failed to timely report an injury of unknown source resulting in bruising for one (1) of twenty-three (23) sampled residents (Resident #295). Resident #295 was discovered to have an injury of unknown origin on the night of [DATE], per staff interview. However, staff failed to notify Resident #295's Physician of the injury of unknown origin until [DATE].

Inspectors wroteBased on observation, interview, record review, review of Lippincott Nursing Procedures (9th Edition), review of Lippincott Manual of Nursing Practice (11th Edition), and review of the facility's policies, it was determined the facility failed to ensure that services provided met professional nursing standards. Licensed Practical Nurse (LPN) #3 failed to don (put on) gloves before administering eye drops for one (1) of twenty-three (23) sampled residents (Resident #29).

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the medication error rate for the facility was not five (5) percent or greater. Observation of thirty (30) opportunities for administration of medication revealed there were two (2) opportunities in which medications were not administered according to the Physician's Order, which resulted in an error rate of six point six seven percent (6.67%). This affected two (2) of twenty-three (23) sampled residents (Resident #1 and #29).

Inspectors wroteBased on observation, interview, review of the Centers for Medicare and Medicaid Services (CMS) guidelines, review of the Manufacturer's Package Insert for Dorzolamide and website, and review of the facility's policy, it was determined the facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards to include the date opened and expiration dates. Facility staff failed to label nine (9) Docusate Sodium liquid medication bottles, with the date opened; and, failed to label one (1) bottle of Dorzolamide 2% (20 milligrams/milliliter (mg/ml)) ophthalmic solution eye drops with the expiration date.

Inspectors wroteBased on interview and record review, it was determined the facility failed to ensure medical records were accurately documented for one (1) of twenty-three (23) sampled residents (Resident #41). Resident #41 sustained a laceration to his/her left lower extremity, on 01/05/2022, but the wound was incorrectly documented as being on the resident's right lower extremity multiple times.

Inspectors wroteBased on interview, record review, review of the Centers' for Disease Control and Prevention (CDC) guidelines and recommendations, and review of the facility's policies, it was determined the facility failed to ensure two (2) of twenty three (23) sampled residents (Residents #10 and #21) received a pneumonia vaccine as required. Review of the records for Residents #10 and #21 revealed no evidence their recommended pneumococcal vaccine series was completed to include the pneumococcal polysaccharide vaccine (PPSV23).