Carmel Hills Wellness & Rehabilitation
CARMEL HILLS WELLNESS & REHABILITATION in INDEPENDENCE, MO — inspection on March 31, 2026.
Found 1 citation. 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
During an interview on 3/30/26 at 12:11 P.M., the DON said:-Prior to the elopement the door would alarm after pushing on the release bar 20 seconds.-The administrative staff were notified, and contacted the police department and the hospitals.-He/She and the Regional Nurse Consultant (RNC) and did the sweep of the outside grounds and drove up and down the streets trying to find the resident. -The Administrator remained at the facility.-Staff continued to actively look for the resident. -The resident was found a local hospital without injury.-The hospital called the facility and Licensed Vocational Nurse (LVN) C took the call.-All staff were educated about the elopement and door alarms before coming back to the next shift.
During an interview on 3/30/36 at 2:36 P.M., the Administrator said:-Prior to the elopement the doors were set up to push and hold for 15 seconds then it will open, and alarm would sound. -Staff did not hear the alarm.-When FT A used the code to get off the unit the door did not sound.-FT A received education and a corrective action plan. -FT A was newer to working on that unit.
During an interview on 3/30/26 at 6:21 P.M., FT A said:-He/She was working on the secured unit.-He/She left the unit using the code and didn't check to see if anyone was following him/her.-He/She did not listen for the door to click shut once he/she passed through it. -Prior to the incident he/she had received training to watch the door for anyone trying to leave behind him/her.-Now, he/she made sure the door was closed correctly, and no one was following him/her.-He/She reported he/she was not paying attention and did not intentionally let the resident off the unit.-He/She was unsure of what time he/she came through the door, maybe around 8:15 and 8:30 P.M.
During an interview on 3/30/26 at 6:26 P.M., LVN C said:-The door used to sound about 15-20 seconds after pushing on it. -It was enough time for the person to go through the door if no one was paying attention.-To his/her knowledge the door alarm was working correctly.-Staff were trained not to allow residents out to make sure the door closes behind you.
During an interview on 3/30/26 at 6:59 P.M., Certified Nurses Aide (CNA) A said:-He/She was working the night of the elopement.-He/She remembered seeing the resident around 8:00 P.M. to 8:10 P.M -The resident was following him/her around and the last place the resident was seen was in the dining room.-The alarm did not go off the night the resident eloped.-If staff pushed on the door for a few seconds the door would open.
During an interview on 3/31/26 at 9:14 A.M., the facility's Nurse Practitioner said:-The resident was fairly new to the facility.-He/She was aware the resident had eloped.-The facility physician was in the building the next day and saw the resident.-He/She adjusted one of the resident's medications that caused restlessness.-The resident had no recollection of eloping.-He/She expected the staff to check on the resident every hour to two hours.-The resident was not exit-seeking but liked to wander.-He/She expected the staff to know he was a wanderer as that was the reason the resident was on the secure unit. 2978949