Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Restoracy Of Carmel during CMS and state inspections, most recent first.
The facility failed to complete TB skin test readings within the required 48-to-72-hour window for multiple residents, including residents with significant neurologic, cardiac, and urinary conditions. The facility also failed to follow EBP during direct care: an LPN did not wear a gown during wound care for a resident with a stage 3 pressure ulcer and a catheter order, and a QMA wore a cloth gown instead of a disposable gown during catheter care for a resident on EBP.
The facility failed to notify the provider of a resident’s 3-pound weight gains as ordered. The resident had HF, stage 3 CKD, and type 2 DM, and the care plan called for monitoring weights and notifying the physician/family of significant changes. The record showed multiple weight increases of 3 pounds or more, but an LPN and the DON could not find documentation that the NP was notified.
Incomplete Transfer and Discharge Documentation: The facility failed to document required transfer/discharge information for three residents sent to the hospital. Records lacked evidence that report was called to the receiving facility, special instructions or precautions were provided, discharge summaries were included, and bed hold policies were given at discharge. Staff interviews indicated the facility relied on progress notes and transfer paperwork, but the EHR did not contain the required documentation.
A resident’s PASSAR Level I screen did not include current mental health diagnoses or accurate mental health medication information. The resident had documented depression, anxiety, insomnia, and dementia, and was receiving buspirone, trazodone, and duloxetine, but the screen listed no known mental health diagnoses and recorded the medication diagnoses as unknown. Facility leaders later noted that several PASSAR Level I screenings had not been updated.
Expired lorazepam was found in the Cottage 3 med cart narcotic lock box during survey. Two doses with unknown fill dates were past expiration, and staff stated pharmacy audited carts monthly while nurses also monitored for expired meds. The ED said the facility did not have a policy for med cart audits, although facility policies required meds to be stored safely and outdated drugs to be returned to the dispensing pharmacy or destroyed.
Expired Food and Improper Refrigerator Temps: In Cottage 6, surveyors found an opened tub of ricotta cheese past its expiration date stored with an unopened tub, and two refrigerators holding milk, condiments, and dairy products were above the facility’s stated safe range. The DM said the expired ricotta should be discarded and noted the higher temps may have been related to breakfast clean up, while a staff member stated refrigerators should be kept between 35 and 40 degrees Fahrenheit. The temperature log was also missing a p.m. entry for one day.
The facility failed to provide dignity covers for urinary catheter bags for two residents, compromising their dignity. One resident with benign prostatic hyperplasia and other conditions was observed without a cover, despite a care plan indicating its necessity. Another resident with chronic kidney disease and other diagnoses was also seen without a cover. An LPN confirmed the absence of covers, which contradicted the facility's dignity policy.
The facility failed to follow physician's orders for two residents, leading to improper medication administration. A resident with diabetes and hypertension did not receive hydralazine as ordered for high systolic blood pressure. Another resident received sacubitril-valsartan and metoprolol succinate despite blood pressure and heart rate being below the hold parameters. The DON confirmed these discrepancies in the MAR.
The facility failed to ensure proper infection control practices for three residents with catheters. A resident's catheter bag was improperly placed on a wheelchair footrest, another resident had a used catheter bag in a trash can without proper documentation of a change, and a third resident had used catheter bags hanging in their bathroom. These actions were not in line with the facility's infection prevention and control policies.
The facility failed to secure residents' credit cards, resulting in a CNA fraudulently using the cards of two residents. One resident's son discovered unauthorized charges, leading to an investigation involving the ED and police. Another resident found her cards missing post-discharge, with fraudulent charges linked to the same CNA. The facility's policy on property misappropriation was not effectively enforced.
TB Screening and Enhanced Barrier Precautions Not Followed
Penalty
Summary
The facility failed to ensure new residents were correctly screened for tuberculosis. Resident 18, whose diagnoses included hypertensive encephalopathy, hypertensive heart disease with heart failure, and hemiplegia and hemiparesis following a cerebral infarction, had a 2-step tuberculin skin test documented in the MAR. The first test was given on 1/6/26 but was not read within the 48-to-72-hour window because the resident was out of the facility on leave of absence with his son. The second step was administered on 1/20/26 and read on 1/22/26, which was also outside the 48-to-72-hour window. The ADON stated that a 2-step TB test was needed at admission and should be read within the 48-to-72-hour window. Resident 40, with diagnoses including traumatic hemorrhage of the left cerebrum, traumatic subdural hemorrhage, and paroxysmal atrial fibrillation, had a tuberculin test administered on 2/8/26 and read on 2/10/26, which was not within 48 to 72 hours. Resident 43, with Parkinson's disease, CHF, retention of urine, dysphagia, type 2 diabetes mellitus, and obstructive and reflux uropathy, had a tuberculin test administered on 2/2/26 and read on 2/4/26 outside the required window. The same resident's second-step test was administered on 2/16/26 and read on 2/18/26, also outside the required 48-to-72-hour timeframe. The facility also failed to ensure staff wore protective gowns for enhanced barrier precautions. During wound care for Resident 66, who had type 2 diabetes, chronic diastolic heart failure, long-term insulin use, and a stage 3 heel pressure ulcer, an LPN was observed not wearing a gown. Resident 66 had an order for enhanced barrier precautions due to a foley catheter, and the ADON stated staff were supposed to wear gowns during wound care for pressure ulcers. During catheter care for Resident 54, who had obstructive and reflux uropathy, benign prostatic hyperplasia, and other disorders of the kidney and ureter, a QMA wore a cloth hospital gown instead of a disposable gown. Resident 54 had an order and care plan for enhanced barrier precautions due to a suprapubic catheter, and the ADON stated staff were supposed to be wearing disposable gowns during catheter care.
Failure to Notify Provider of Significant Weight Gain
Penalty
Summary
The facility failed to ensure the physician was notified of a three-pound weight gain for Resident 4, who had diagnoses including heart failure, stage 3 chronic kidney disease, and type 2 diabetes. The resident’s care plan identified a risk for altered nutrition and weight status and included interventions to obtain and evaluate weights as ordered and to notify the physician and family of any significant changes. A physician’s order directed staff to weigh the resident every Monday and Thursday and to notify the NP for a weight increase of three pounds. The clinical record showed multiple weight increases of three pounds or more, including a gain from 239 pounds to 242.2 pounds, from 241 pounds to 248.3 pounds, and from 227 pounds to 230.2 pounds. During interviews, an LPN stated the weight gain notification to the provider would be documented in progress notes but could not find such documentation in the record. The DON also stated the facility could not find the notifications for the resident’s weight gain and that they should have been documented in a progress note, but the documentation was not found.
Incomplete Transfer and Discharge Documentation
Penalty
Summary
The facility failed to ensure proper discharge information was documented in the electronic health record for 3 of 6 residents reviewed for discharge. Resident 5 had diagnoses including repeated falls, traumatic subdural hemorrhage without loss of consciousness, and dementia, and was sent to the emergency room after a nursing order and EMT transport. Resident 6 had diagnoses including unsteadiness on feet, multiple right rib fractures, and a head laceration, and was sent to the hospital for treatment. Resident 77 had diagnoses including heart failure, COPD, and ALS, and was transported by EMT to the hospital. For each of these residents, the electronic health record did not contain documentation that a report was called to the receiving facility, that special instructions or precautions for ongoing care were provided, that a copy of the discharge summary was provided, or that a copy of the bed hold policy was provided at the time of discharge. During interviews, the ED stated the facility did not use the electronic health record transfer/discharge assessment, and the nurse would gather information, call report to the receiving facility, document required information in a progress note, and send appropriate paperwork with EMS. An LPN stated that when a resident was transferred or discharged to the hospital, the nurse would send a transfer sheet including the face sheet, medication list, last medication administration time, demographics, and bed hold policy with EMS, and that the facility did not have a specific assessment or document for what occurred with the resident, who report was given to, or where the resident was transferred. The ADON stated the discharge protocol included obtaining a physician order, informing the resident's family, contacting EMS, calling report to the receiving facility, sending the face sheet, medication list, POST form, bed hold, and other documents in the discharge packet, and documenting all of this in a progress note. The facility policy required documentation of the transfer or discharge details in the medical record and communication of the basis for transfer or discharge, special instructions or precautions, comprehensive care plan goals, and other necessary information, including a copy of the discharge summary.
PASSAR Level I Screen Missing Current Mental Health Information
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASSAR) Level I screen for one resident contained current mental health diagnoses and mental health medications. The resident’s clinical record showed diagnoses of depression, anxiety, insomnia, and dementia, but the PASSAR Level I screen dated 7/9/25 stated that no current or past mental health diagnoses were known or suspected. The screen also listed buspirone and trazodone as current or past mental health medications, but the diagnoses for both medications were recorded as unknown. The record also showed physician orders for buspirone 5 mg twice daily related to anxiety and duloxetine 60 mg related to depression, and the care plan identified use of an antianxiety medication for anxiety and an antidepressant medication for depression. During interviews, the ED and SSD stated that audits had found several Level I screenings had not been updated and that several needed to be resubmitted. The facility policy assigned responsibility for diagnosis and mental health medication information to Social Service and required accurate Level I PASSAR completion.
Expired lorazepam found in medication cart narcotic lock box
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the Cottage 3 medication cart was found to contain expired medications in the narcotic lock box. On 2/19/26 at 11:33 a.m., surveyors observed lorazepam with an unknown prescription filled date and a quantity of 30 out of 30 that was past the expiration date of 1/15/26, and another lorazepam with an unknown prescription filled date and a quantity of 4 out of 30 that was past the expiration date of 12/18/25. During interview, QMA 7 stated pharmacy audited the medication carts monthly and nurses also monitored for expired medications. The ED later stated the facility did not have a policy regarding medication cart audits. Facility policies titled Storage of Medications and Pharmacy services stated that drugs and biologicals are to be stored in a safe, secure, orderly manner and that discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
Expired Food and Improper Refrigerator Temperatures
Penalty
Summary
The facility failed to ensure refrigerated food was not expired and that refrigerators were maintained at proper temperatures for food safety in Cottage 6, which supplied food to Cottage 6 and Cottage 1. During observation of Refrigerator 2, a tub of ricotta cheese with an expiration date of 2/13/26 was found opened with less than half remaining, and an unopened tub of ricotta cheese was stored next to it. An internal thermometer in Refrigerator 2 read 50 degrees Fahrenheit. Refrigerator 3 contained milk and condiments, and its internal thermometer read 48 degrees Fahrenheit. During interview, the Dietary Manager stated the expired ricotta cheese should be discarded and indicated the elevated temperatures were most likely due to the refrigerator doors being opened during breakfast clean up. After the doors were allowed to remain closed, a second observation showed Refrigerator 2 at 46 degrees Fahrenheit and Refrigerator 3 at 56 degrees Fahrenheit. A staff member stated the refrigerators should be maintained between 35 and 40 degrees Fahrenheit. The refrigerator temperature log for Cottage 6 was missing a documented p.m. temperature on 2/15/26, and the a.m. temperature entry on 2/16/25 for Refrigerators 2 and 3 documented both units at 36 degrees Fahrenheit. The facility policy stated acceptable refrigerator temperatures were 35 to 41 degrees Fahrenheit and that staff were to check and record temperatures daily, with supervisors responsible for ensuring food items were not expired.
Failure to Provide Dignity Covers for Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure that urinary catheter bags had dignity covers in place for two residents, compromising their dignity. Resident 40 was observed in the TV area without a dignity cover on his catheter bag. His clinical record indicated diagnoses of benign prostatic hyperplasia, other obstructive and reflux uropathy, and hypertension, with a physician's order for a urinary catheter starting from January 22, 2023. The resident's care plan included instructions to obscure the visibility of the drainage bag with a dignity cover. During an interview, an LPN confirmed the absence of the dignity cover. Similarly, Resident 52 was observed on two occasions in the TV area without a dignity cover for his urinary catheter. His clinical record showed diagnoses of chronic kidney disease, neuromuscular dysfunction of the bladder, and muscle weakness, with a physician's order for a Foley catheter due to urinary retention starting from January 21, 2025. An LPN acknowledged the lack of a dignity cover, which needed to be addressed. The facility's policy on dignity, approved in May 2020, explicitly prohibited practices that compromise dignity and required staff to assist residents in keeping urinary catheter bags covered.
Failure to Follow Physician's Orders in Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding medication administration for two residents, leading to deficiencies in quality of care. Resident 19, diagnosed with type 2 diabetes, heart failure, and hypertension, had a physician's order to receive hydralazine for systolic blood pressure (SBP) above 170. However, the medication was not administered on multiple occasions when the resident's SBP exceeded this threshold, as documented in the Medication Administration Record (MAR). The Director of Nursing (DON) confirmed that the medication should have been given and documented, but there was no evidence of administration in the MAR. Similarly, Resident 7, with diagnoses including hypertension and neuromuscular dysfunction of the bladder, was affected by improper medication administration. The resident had orders for sacubitril-valsartan and metoprolol succinate, both with specific parameters to hold the medication if the SBP or heart rate fell below certain levels. Despite these orders, the MAR indicated that sacubitril-valsartan was administered when the SBP was below the hold parameter, and metoprolol succinate was given multiple times when either the SBP or heart rate was below the ordered hold parameters. The DON acknowledged that the medications were administered contrary to the physician's orders, as evidenced by the MAR.
Infection Control Deficiencies in Catheter Management
Penalty
Summary
The facility failed to maintain proper infection control practices for three residents with catheters. Resident 52's catheter bag was observed resting on the footrest of his Broda chair, with his feet on top of it, for an extended period without staff intervention. This oversight occurred despite the resident's medical conditions, including chronic kidney disease and neuromuscular dysfunction of the bladder, which necessitated the use of a Foley catheter. LPN 4 acknowledged the need for staff education regarding the correct placement of catheter bags. Resident 7 had a used catheter drainage bag improperly disposed of in a trash can next to his bed, following a leak that occurred a few days prior. There was no documentation in the electronic medical record to confirm a catheter change after the leak, despite the resident's medical history of neuromuscular dysfunction of the bladder and benign prostatic hyperplasia. Additionally, Resident 44 had a catheter drainage bag with dried sediment and a used leg drainage bag hanging in her bathroom for an extended period. RN 3 confirmed that these bags should have been disposed of properly. The facility's policies on infection prevention and control, as well as resident rights, were not adhered to in these instances.
Failure to Protect Residents' Credit Cards from Misappropriation
Penalty
Summary
The facility failed to ensure the security of residents' credit cards during their admission, leading to the misappropriation of property for two residents. Resident B's son discovered fraudulent charges on her credit cards, which were traced back to a CNA employed at the facility. The CNA was found to have used Resident B's credit cards without authorization, resulting in multiple unauthorized transactions. The facility's Executive Director and the police were involved in the investigation, which confirmed the CNA's involvement in the fraudulent activities. Similarly, Resident C reported missing credit cards after her discharge from the facility, with subsequent fraudulent charges being investigated by her credit card companies. She identified the same CNA as the perpetrator of the theft and unauthorized use of her credit cards. The facility's policy on abuse and misappropriation of property was not effectively enforced, leading to these incidents of exploitation and mistreatment of residents' property.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 945 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carmel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carmel Health & Living Community | 0.9 mi | ★★★★★ | 17 | 0 |
| Barrington Of Carmel, The | 1 mi | ★★★★★ | 0 | 0 |
| Wellbrooke Of Carmel | 1.7 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Carmel | 1.7 mi | ★★★★★ | 0 | 0 |
| Bridgewater Healthcare Center | 2.3 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Restoracy Of Carmel.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.