Mount Carmel Care Center

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that two Residents (#36 and #51) out of a total sample of 15 residents, and/or their Resident Representatives were afforded the right to participate in the scheduled interdisciplinary (IDT) care plan meetings. Specifically, for Resident's #36 and #51, the facility failed to ensure that a care plan meeting was rescheduled as requested by the Resident and/or Resident Representative.

Inspectors wroteBased on record review, and interview, the facility failed to notify the Physician/Nurse Practitioner (NP) timely of a change in condition for one Resident (#28) out of a total sample of 15 residents. Specifically, for Resident #28, the facility staff failed to notify the Physician/NP of a significant weight loss (greater than 5% in one month) that occurred on 4/2/25, resulting in a delay in the assessment and treatment of the weight loss, and the Resident continued to lose weight.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure one Resident (#56) out of a total sample of 15 residents, remained free from accidental hazards. Specifically, for Resident #56, the facility failed to evaluate and analyze hazards and risks, implement interventions to reduce hazards and risks, monitor the effectiveness and modify interventions relative to falls. Findsings include: Review of the facility policy titled Fall Prevention Program, dated 2/13/25, indicated the following: -Complete a fall risk assessment on admission, quarterly, and as indicated for significant condition changes and after each fall. -Provide additional interventions as directed by the resident's assessment, including but not limited to: i. Assistive devices ii. Increased frequency of rounds iii. Sitter if indicated iv. Medication regimen review v. Low bed vi. Alternate call system access vii. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that acceptable parameters of nutritional status were maintained for one Resident (#28), out of a total sample of 15 residents. Specifically, the facility failed to: -implement the Dietitian's recommendation for a nutritional supplement for Resident #28, who was identified as being at risk for inadequate intake of nutrition and hydration, and had experienced weight loss. -assess Resident #28 when he/she continued to experience unplanned, undesired weight loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure timely Physician visits for one Resident (#28) out of total sample of 15 residents. Specifically, the facility failed to ensure that Resident #28 was seen by a Physician as required after his/her admission to the facility in February 2025.

Inspectors wroteBased on record review, observation, and interview, the facility failed to adhere to infection control standards of practice for one Resident (#29) out of a total sample of 15 residents, and on one unit (St. Luke's) out of a total of two units. Specifically, 1) For Resident #29, the facility failed to ensure that staff wore the required Personal Protective Equipment (PPE: items such as gown and gloves worn by the staff member to decrease the spread of infection) while in the Resident's room when he/she was on Contact Precautions (interventions including use of PPE to prevent the spread of a communicable diseases). 2) For St. Luke's Unit, the facility failed to ensure that staff performed hand hygiene after removing gloves creating a risk for cross contamination.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that care and services to prevent and/or treat pressure ulcers were provided for two Residents (#57 and #15), out of three applicable residents reviewed, out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #57, ensure timely assistance with bedpan use to prevent the development of a pressure ulcer to his/her sacrum (triangular bone in the lower back) for the Resident who was at increased risk for pressure ulcers. 2. For Resident #15, ensure weekly skin assessments were completed as ordered by the Physician so that a resulting Stage 2 Pressure Ulcer (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) could have been identified earlier and prevented from progressing.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that there was sufficient nursing staff to assist residents in attaining and maintaining the highest practicable physical, mental, and psycho-social well-being on two out of two units observed (St. Louise and St. [NAME] Units) and six Residents (#16, #57, #62, #28, #2, and #32). Specifically, the facility staff failed to: -For Resident #16, answer the call light timely for assistance with toileting. -For Resident #57, respond to the call light timely to assist with bedpan use by the Resident, who was unable to independently use the bedpan due to a fractured hip. -For Resident #62, provide bathroom assistance to the Resident during meal times. -For Resident #28, provide liquids and assistance in the early morning hours. -For Resident #2, respond timely when the call light was activated. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one Resident (#60) who was receiving intravenous (IV) antibiotics, out of a total sample of 17 residents. Specifically, the facility failed to ensure that six Nurses ( #3, #8, #10, #11, #13 and #14) had the specific competencies and certification necessary to provide appropriate Central Venous Access Device (CVAD: [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure that one Resident (#25) out of a total sample of 17 residents, was provided privacy and dignity when assisting with personal care. Specifically, the facility staff failed to: -provide appropriate clothing or covering for the Resident's private areas while he/she was being transported to and from the shower.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure the Physician and the Resident Representative were notified of a change in skin condition for one Resident's (#60) out of a total sample of 17 residents. Specifically, the facility failed to notify the Physician and Resident Representative when Resident #60 was found bleeding from his/her left index finger and the Resident was on anticoagulant (medication that prevent blood from clotting) therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) Assessment was accurate for one Resident (#15) out of a total sample of 17 residents. Specifically, the facility failed to accurately code that Resident #15 had a pressure injury (localized damage to skin and/or underlying soft tissue, usually over a bony prominence or related to a medical or other device).

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide treatment and care in accordance with professional standards relative to monitoring and assessing the skin condition for two Residents (#60 and #15). The facility also failed to ensure care and services were provided that meet professional standards relative to a Central Venous Access Device (CVAD-long flexible tube that is inserted through one of the central veins found in the neck, chest or groin to allow access to the bloodstream to deliver medication) catheter used to administer Intravenous (IV) antibiotics for Resident #60. Specifically, the facility failed to: 1. For Resident #60, a. perform weekly skin assessments, notify and obtain orders from the Physician when a new skin area of concern was identified, and b. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to investigate accident/hazards incidents and implement interventions to the plan of care for two Residents (#60 and #57), out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #60, thoroughly investigate and add interventions when a new skin area was identified on his/her left index finger. 2. For Resident #57, thoroughly investigate and add interventions when a new pressure injury was identified.

Inspectors wroteBased on interview, record and policy review, the facility failed to perform a trauma assessment on admission to the facility and develop a trauma care plan for one Resident (#10) out of a total sample of 17 residents. Specifically, the facility failed to assess whether Resident #10, who was admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD-a disorder in which a person has difficulty recovering after a traumatic experience), had a history of trauma and failed to identify any triggers which may cause re-traumatization.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure an accurate accounting of a controlled medication. Specifically the facility failed to account for the controlled medication (Ativan, generic name Lorazepam) in the controlled substance accountability record book, as required.

Inspectors wroteBased on record review and interview, the facility failed to monitor for side effects and adverse reactions to medications for one Resident (#45) out of a total sample of 17 residents. Specifically, for Resident #45, the facility staff failed to monitor for side effects and adverse reactions related to the use of an anticoagulant (medication used to thin the blood) medication.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that an as needed (PRN) psychotropic medication (medication that affect the mind, emotions and behavior) was limited to 14 days for one Resident (#60), of five applicable residents reviewed, out of a total sample of 17 residents. Specifically, the facility failed to ensure that PRN Valium (an anti-anxiety medication) was limited to 14 days and was reviewed by the Physician for continued use.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that Transmission Based Precautions (TBP: for patients who are known or suspected to be infected or colonized with infectious agents which require additional control measures to effectively prevent transmission) were in place and adhered to by staff in order to minimize the potential spread of infection for two Residents (#118 and #60), of three applicable residents reviewed, out of a total sample of 17 residents. Specifically, the facility failed to ensure that Enhanced Barrier Precautions (EBP: infection control intervention designed to reduce the transmission of multi-drug resistant organisms or MDROs) were implemented for Residents #118 and #60.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff maintained a clinical record that included documentation that residents were offered, received or declined the Pneumococcal immunization (a vaccine used to prevent possible life-threatening Pneumonia) for four Residents (#18, #24, #31, and #58), out of a total sample of five residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that its staff implemented the plan of care for one sampled Resident (#17), relative to interventions to address accidents such as falls, and for two sampled Residents (#17 and #58), relative to the administration of the prescribed flow rate of Oxygen therapy, out of a total sample of 17 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that its staff adhered to Isolation Precautions (measures put into place to reduce transmission of microorganisms) to minimize the risk of spread of infections for two sampled Residents (#6 and #51), out of 4 applicable residents, who were identified as having Coronavirus (COVID-19) infection. Specifically, facility staff failed to ensure: A) the required personal protective equipment (PPE) was utilized prior to entering and while within the Residents' room, and B) PPE was discarded/disinfected appropriately upon exiting the Isolation Precaution room.