The Pines on Carmel Senior Living

The facility failed to provide adequate supervision for a resident at moderate risk for elopement, resulting in the resident exiting the building via an emergency release button and being found in the parking lot. Although the resident's care plan identified wandering behaviors and elopement risk, there were no specific interventions documented to prevent elopements.

The facility failed to provide adequate supervision for a resident in the Special Care Unit, resulting in the resident eloping to the parking lot and walking toward a nearby street. Although the resident was redirected, the resident's care plan and elopement risk evaluations lacked documented interventions to prevent such wandering and elopement behaviors.

The facility failed to ensure physician notification for a resident with blood sugar levels greater than 350. Specifically, multiple instances in February and March 2025 were identified where finger stick blood sugars exceeded the prescribed threshold without documented notification to the Primary Care Provider or hospice provider.

The facility failed to ensure Primary Care Provider (PCP) notification for a resident with type 2 diabetes. Specifically, there was no documentation that the physician was notified of multiple finger stick blood sugar readings greater than 350 between February and March 2025.

The facility failed to provide adequate supervision to two residents in the Special Care Unit, resulting in both individuals eloping from the unit without staff knowledge. Specifically, the resident's care plan lacked an elopement risk evaluation score, specific interventions to prevent elopement, and documented safety instructions beyond general policy references.

The facility failed to provide adequate supervision to two residents in the Special Care Unit, resulting in both residents eloping from the unit without staff knowledge. A review of the facility's wandering and elopement prevention plan revealed inconsistencies in implementing required interventions and monitoring.

The facility failed to supervise a resident with a known history of wandering and exit-seeking behaviors, resulting in the resident eloping from the building without staff knowledge. Additionally, the facility failed to complete a required elopement risk evaluation for the resident and lacked secure exit door controls, as doors could be opened from the inside by anyone.

The facility failed to provide adequate supervision for a resident with a known history of wandering and exit-seeking behaviors, resulting in the resident eloping from the facility. During maintenance on the maglock system, the security system was disabled, allowing the resident to walk out of the front door unnoticed.