Restoracy Of Carmel
RESTORACY OF CARMEL in CARMEL, IN — inspection on February 20, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
(injury/decline/room, etc.) that affect the resident.
three (3) pound weight gain according to the physician's order for 1 of 3 residents reviewed for
on 2/17/26 at 3:10 p.m.
The diagnoses included, but were not limited to, heart failure, stage 3 chronic kidney disease, and type 2 diabetes.A care plan indicated Resident 4 was at risk for potential alteration of nutrition and weight status.
Interventions included, but were not limited to, obtain and evaluate weights as ordered and notify the physician and family of any significant changes.A physician's order, with a start date of 10/3/24 and an end date of 1/7/26, indicated to weigh Resident 4 every Monday and Thursday and to notify the Nurse Practitioner (NP) for a weight increase of three (3) pounds.The following weights were documented in the clinical record:a. On 9/22/25, the weight was 239 pounds. On 9/25/25, the weight was 242.2 pounds.
This was a gain of three (3) pounds or more.b. On 10/16/25, the weight was 241 pounds. On 10/20/25, the weight was 248.3 pounds.
This was a gain of three (3) pounds or more.c. On 12/1/25, the weight was 227 pounds. On 12/3/25, the weight was 230.2 pounds.
This was a gain of three (3) pounds or more.During an interview, on 2/19/26 at 9:51 a.m., Licensed Practical Nurse (LPN) 2 indicated the weight gain notification to the provider would be documented in the progress notes and she could not find the documentation in the clinical record.
During an interview, on 2/19/26 at 3:38 p.m., the Director of Nursing (DON) indicated the facility could not find the notifications for Resident 4's weight gain and it should have been documented in a progress note.
The facility could not find the documentation. A current facility policy, titled Weight and Height of Resident, dated as approved 5/20/20 and received from the Executive Director on 2/20/26 at 9:42 a.m., indicated .Report significant weight loss/weight gain to the nurse supervisor.Report other information in accordance with facility policy and professional standards of practice.3.1-5(a)(2)3.1-5(a)(3)
155846 02/20/2026
Restoracy of Carmel 616 Green House Way Carmel, IN 46032
receiving health care facility or provider.When a resident is transferred or discharged from the facility,
date and time of the transfer or discharge.The new location of the resident.The mode of
of personal effects.Disposition of medications.Others as appropriate or as necessary and.The signature of the person recording the data in the medical record.Should the resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider.The basis for the transfer or discharge.All special instructions or precautions for ongoing care.comprehensive care plan goals.All other necessary information, including a copy of the residents discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.3.1-12(a)(6)(A)(i)3.1-12(a)(6)(B)
155846 02/20/2026
Restoracy of Carmel 616 Green House Way Carmel, IN 46032
for services as needed.
Resident Review (PASSAR) level I screen contained current mental health diagnoses and mental
was corrected on 2/12/26, prior to the start of the survey, and was therefore past noncompliance.Findings include:The clinical record for Resident 75 was reviewed on 2/19/26 at 8:48 a.m.
The diagnoses included, but were not limited to, depression, anxiety, insomnia, and dementia.A PASSAR level I screen, dated 7/9/25, indicated no current or past mental health diagnoses were known or suspected.
The current or past mental health medications were buspirone (an anxiety medication) and trazodone (used to treat insomnia and sometimes used to treat depression).
The diagnosis for both medications was listed as unknown.
The level I screen indicated there was no evidence of an intellectual/developmental disability or a serious behavioral health condition and if changes occurred or new information refutes the findings, a new screen must be completed.The PASSAR level I did not include accurate diagnoses of depression, anxiety or dementia and did not include accurate medication dosage or accurate prescribed mental health medications.A physician's order, dated 7/11/25 and discontinued 1/15/26, indicated Resident 75 received buspirone 5 milligrams (mg) twice a day related to anxiety. A physician's order, dated 7/21/25, indicated Resident 75 received duloxetine (an antidepressant medication) 60 mg related to depression.The care plans, dated 7/14/25, indicated Resident 75 received an antianxiety medication related to anxiety and an antidepressant medication related to depression.
During an interview, on 2/19/26 at 12:19 p.m., the Executive Director (ED) indicated the facility had conducted an audit on PASSAR's earlier in the month (February) and found several level I screenings had not been updated.
During an interview, on 2/19/26 at 3:27 p.m., the Social Service Director (SSD) indicated she had conducted an audit for level I PASSAR's to ensure all the information on the PASSAR's was correct and had found several which needed to be resubmitted.A current facility policy, titled Preadmission Screening and Resident Review (PASSR)/(LOC), dated 4/25/24 and received from the ED on 2/19/26 at 12:28 p.m., indicated .ensure all residents have the required screenings.
This includes Level 1 PASSR, Level 2 PASSR, and Level of Care. It is the responsibility of the Business Office Manager, Social Service Director, MDS nurse, and/or designee to complete and/or track.ensuring new admission Level 1 PASSR are accurate.initiate a new Level 1, when a resident meets the qualifications.Level 1 completion procedure must be completed within 72 hours by the assigned or designated team member.Diagnosis-Assigned to Social Service Director.Mental Health Medications-Assigned to Social Service Director.This deficient practice was corrected by 2/12/26 after the facility implemented a systemic plan that included the following actions: an audit of all PASSARs were completed to ensure all information was correct, updated PASSARs were submitted if incorrect information was found, all new admission PASSARs are audited by the next business day to ensure the hospital or previous facility completed the PASSAR appropriately and are resubmitted if the previous facility information was incorrect, in-service education was conducted for all staff members responsible for ensuring PASSAR accuracy and completion.3.1-16(d)(1)(A)3.1-16(d)(1)(B)
155846 02/20/2026
Restoracy of Carmel 616 Green House Way Carmel, IN 46032
services of a licensed pharmacist.
free of expired medications for 1 of 3 medication carts reviewed for medication storage and labeling.
The following was observed:a. In the narcotic lock box, lorazepam (an antianxiety medication) with an unknown prescription filled date and a quantity of 30 out of 30 was past the expiration date of 1/15/26.b. In the narcotic lock box, lorazepam with an unknown prescription filled date and a quantity of 4 out of 30 was past the expiration date of 12/18/25.
During an interview, on 2/19/26 at 11:33 a.m., QMA (Qualified Medication Aide) 7 indicated pharmacy audited the medication carts monthly and the nurses would also monitor for expired medications.
During an interview, on 2/19/26 at 2:05 p.m., the Executive Director (ED) indicated the facility did not have a policy regarding medication cart audits.A current facility policy, titled Storage of Medications, dated 5/20/20 and received from the ED on 2/19/26 at 1:42 p.m., indicated .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.A current facility policy, titled Pharmacy services, dated 5/20/20 and received from the ED on 2/19/26 at 1:42 p.m., indicated .Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice.3.1-25(o)
155846 02/20/2026
Restoracy of Carmel 616 Green House Way Carmel, IN 46032
serve food in accordance with professional standards.
not expired and refrigerators were maintained at proper temperatures for food safety for 2 of 6
6)Findings include:The kitchen in Cottage 6 was reviewed on 2/16/26 at 10:05 a.m.
The following was observed:1.
Refrigerator 2 which contained, but were not limited to, dairy products and mayonnaise.a. A tub of ricotta cheese with an expiration date of 2/13/26 was opened and less than half of the ricotta cheese remained in the container.
Next to the opened and expired container was an unopened tub of Ricotta cheese with an expiration date not yet surpassed.b. An internal thermometer sat on the back of the top shelf and read fifty (50) degrees Fahrenheit.2.
Refrigerator 3 which contained, but were not limited to, milk and condiments.a. An internal thermometer sat on the back of the top shelf and read forty-eight (48) degrees Fahrenheit.
During an interview, on 2/16/26 at 10:09 a.m., the Dietary Manager (DM) indicated the meals prepared in Cottage 6 were served to both Cottage 6 and Cottage 1.
The Dietary Manager observed the expiration date and internal temperatures and indicated the tub of ricotta cheese was past the expiration date and should be discarded.
The elevated internal temperature was most likely due to the refrigerator doors being opened during breakfast clean up.After breakfast clean up and allowing the doors for Refrigerator 2 and Refrigerator 3 to remain closed, on 2/16/26 at 10:55 a.m., a second observation of the internal temperature was forty-six (46) degrees Fahrenheit in Refrigerator 2 and fifty-six (56) degrees Fahrenheit in Refrigerator 3.
During an interview, on 2/16/26 at 10:58 a.m., [NAME] 6 indicated the internal temperature of the refrigerators should be thirty-five (35) to forty (40) degrees Fahrenheit.The refrigerator temperature log for Cottage 6, for February 2026, was missing a documented p.m. (evening/night) temperature on 2/15/26. A documented a.m. (morning) temperature on 2/16/25 for refrigerators 2 and 3 indicated the internal temperature of both refrigerators was thirty-six (36) degrees Fahrenheit.A current facility policy, titled Refrigerators and Freezers, undated and received from the Director of Nursing on 2/17/26 at 11:01 a.m., indicated .This community will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.Acceptable temperature ranges are 35 degrees Fahrenheit to 41 degrees Fahrenheit.employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening.Supervisors will be responsible for ensuring food items in.refrigerators.are not expired.3.1-21(i)(1)3.1-21(i)(3)
include central lines (including PICC), urinary catheter, feeding tubes.Enhanced Barrier Precautions
wounds.
3.1-18(b)(1) 3.1-18(b)(2) 3.1-18(e)
155846 02/20/2026
Restoracy of Carmel 616 Green House Way Carmel, IN 46032