Carmel Hills Wellness & Rehabilitation
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 270 Google reviews

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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (1/5 stars)
- Low staffing rating (1/5 stars)
- Above-median deficiencies (30 vs median 10)
- High staff turnover (56%)
Bottom 25% in MO · Critically understaffed (RN) · Worst in EL DORADO NURSING AND REHABILITATION chain · $20,787 in fines
What this means for your family
While recent renovations and community engagement efforts have improved the facility's atmosphere, the reports of severe hygiene issues and medical neglect are critical red flags. If you choose to tour, pay close attention to the smell in the hallways and ask specific questions about the nurse-to-patient ratio and how they handle medication management for complex cases.
Google Reviews
Google Reviews
270 reviews on Google“Carmel Hills Wellness & Rehabilitation receives highly polarized feedback, with many families praising the recent management changes, facility renovations, and compassionate nursing staff. However, a significant number of reviewers report severe concerns regarding hygiene, including persistent odors, and critical lapses in medical care, communication, and responsiveness.”
Quality Themes
Tap a score for detailsStrengths
- Compassionate and attentive nursing staff
- Recent facility renovations and clean common areas
- Effective rehabilitation therapy team
- Welcoming and helpful administrative staff
Concerns
- Persistent, overwhelming odor of urine and feces (mentioned by 5 reviewers)
- Inadequate communication and failure to answer phones (mentioned by 4 reviewers)
- Neglect of basic medical needs and medication management (mentioned by 6 reviewers)
- High staff-to-patient ratios leading to slow response times (mentioned by 3 reviewers)
- Missing or stolen personal belongings (mentioned by 3 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 208 analyzed
How They Respond to Reviews
Questions for Your Tour
- 1Given the recent facility renovations, what specific protocols are currently in place to ensure that common areas and resident rooms maintain a consistently fresh and sanitary environment?
- 2Could you walk me through the current process for medication management and how the nursing team ensures that prescriptions are administered accurately and on time?
- 3What is your facility's policy regarding communication with families, and what is the best way to ensure we receive timely updates regarding our loved one's health and daily status?
- 4With your current staffing levels, what is the typical response time for call lights, and how do you prioritize assistance during peak hours?
- 5What measures are in place to secure personal belongings and ensure that residents' items are tracked and protected within their living spaces?
- 6How does your rehabilitation team integrate with the nursing staff to ensure that a resident’s medical needs are met while they are actively participating in therapy sessions?
Personalized based on this facility's data
Key Review Excerpts
“My husband and I came to visit a Friend. First time ever to come to this facility. My Friend needed to be hoisted from a chair to her bed. Three persons came and immediately took care of her. She needed a smaller wheelchair. A therapist got that for her.”
“My dad was placed in nursing care here at Carmel Hills. The staff was always kind and respectful of him and of us. Carrie and Sara in the business office were so helpful.”
“My mother was here 3 hrs and unexpectedly died in their care. Left st Joseph hospital laughing smiling talking n eating that morning to just die in 3 hrs of being there. Her money she transferred with Missing Stolen. Her belongings was rummaged through on the floor.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 17 measures
8
measures
6
measures
3
measures
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for pneumonia
Residents on antipsychotic medication
Residents whose walking got worse
Residents on anti-anxiety or sleep medication
Residents needing more daily help over time
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has significant ongoing concerns with families filing multiple complaints that triggered 25 deficiency citations across recent surveys. The most persistent problems involve food service quality and safety, accident prevention and supervision, and medication management errors. While all deficiencies show correction dates, the recurring nature of food service issues, safety hazards, and medication problems across multiple years suggests systemic challenges that families should carefully evaluate during visits.
Mar 31, 2026Complaint1
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
May 21, 2025Complaint7
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Nutrition and Dietary Deficiencies
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Jan 16, 2025Complaint2
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nov 25, 2024Routine23
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Nov 25, 2024Complaint2
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Resident Assessment and Care Planning Deficiencies
Plan the resident's discharge to meet the resident's goals and needs.
Oct 16, 2024Complaint1
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from the wrongful use of the resident's belongings or money.
Federal Penalties
Fine
Feb 1, 2024
$20,787
Ownership & Operations
Who Operates This Facility
Carmel Hills Wellness & Rehabilitation
for profit
Chain Affiliation
Opco Skilled Management
64 facilities nationwide
Chain avg rating: 1.5/5 · Rank 6 of 6 (Worst)
Ownership & Management
Owners
El Dorado Nursing and Rehabilitation LLC
Owner · Organization
Caliber Advisors LLC
Owner (parent company) · Organization
Crestview Trust
Owner (parent company) · Organization
First Sweetzer Holdings LLC
Owner (parent company) · Organization
Hatteras Investments LLC
Owner (parent company) · Organization
Rimpau Holdings Trust
Owner (parent company) · Organization
Sasem Investments LLC
Owner (parent company) · Organization
Hagins, Elizabeth
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Kaplan, Esther
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Kaplan, Mordechai
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Kaplan, Mosha
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Sternshein, Jennifer
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Unger, Jeffrey
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Zimmerman, Caroline
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Key personnel
Contact
Get in Touch
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References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
270 reviews from families & visitors
Official Website
Visit carmelhillswellness.com
Medicare data downloads
Original nursing home datasets
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Safer Alternatives Nearby
Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.
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