Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Carmel Care Center during CMS and state inspections, most recent first.
The facility failed to provide timely assistance with bedpan use for a resident at risk for pressure ulcers, leading to the development of a new ulcer. Additionally, the facility did not complete weekly skin assessments for another resident, resulting in a Stage 2 pressure ulcer that worsened over time. Staffing issues and delayed response times contributed to these deficiencies.
The facility failed to ensure sufficient nursing staff, resulting in delayed responses to call lights and inadequate assistance with toileting and personal care. Residents reported long wait times, especially on weekends and night shifts, leading to episodes of incontinence and unmet needs. Staff interviews confirmed the challenges posed by insufficient staffing levels.
The facility failed to ensure that six nurses had the necessary competencies and certification to provide appropriate CVAD care for a resident receiving IV antibiotics for a left hip infection. The facility lacked a system to verify the competencies of nurses, leading to a significant lapse in resident care.
The facility failed to ensure a resident's privacy and dignity during personal care by not providing appropriate clothing or covering while transporting the resident to and from the shower. The resident's private areas were exposed, and staff confirmed that a blanket or towel should have been used.
A resident on anticoagulant therapy was found bleeding from the left index finger, but the facility failed to notify the physician and resident representative as required by policy. The incident was not investigated or documented properly, and the Director of Nurses was unaware until informed by the surveyor.
The facility failed to accurately code a resident's pressure injury in the MDS Assessment. The resident, admitted with Dementia and Diabetes, developed a Stage 2 pressure injury that was not resolved for over a year. The MDS Nurse confirmed the coding error during an interview.
The facility failed to provide treatment and care in accordance with professional standards for two residents. One resident did not receive proper weekly skin assessments or monitoring of their CVAD catheter site, while another resident did not have weekly skin assessments or a Nurse Practitioner's recommendation for edema management implemented. These deficiencies were confirmed through record reviews, observations, and staff interviews.
The facility failed to investigate and implement interventions for accident/hazard incidents for two residents. One resident with severe cognitive impairment had a new skin area on their left index finger that was not properly investigated or treated. Another resident, who was cognitively intact, developed a pressure injury on their right sacrum after being on a bedpan for too long, but no investigation or changes to their care plan were made.
The facility failed to perform a trauma assessment on admission and develop a care plan for a resident with PTSD. Despite the resident being cognitively intact and having a PTSD diagnosis, no trauma assessment was completed, and no care plan was in place to address potential triggers for re-traumatization, as required by the facility's policy.
The facility failed to ensure an accurate accounting of Lorazepam (Ativan) in the controlled substance accountability record book. An opened syringe with 15cc remaining was found in an unlocked controlled substances lock box and was not recorded as required. The DON confirmed that all controlled substances should be counted and recorded by two nurses at the beginning and end of each shift.
The facility failed to monitor for side effects and adverse reactions to anticoagulant medication for a resident with Pulmonary Embolism and Atrial Fibrillation. The required monitoring was not documented in the resident's clinical record or Medication Administration Records (MARs). A nurse confirmed that the monitoring was not done as required.
The facility failed to ensure that a PRN psychotropic medication, Valium, was limited to 14 days and reviewed by the Physician for continued use for a resident with Alzheimer's disease. The medication was administered multiple times without documented evidence of reassessment by the Physician.
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were properly implemented and adhered to by staff for two residents, leading to potential infection control issues. Staff members did not consistently wear gowns and gloves during high-contact care activities, despite the requirements outlined in the facility's EBP policy.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide timely assistance with bedpan use for Resident #57, who was at increased risk for pressure ulcers. Despite being cognitively intact and able to request assistance, the resident reported waiting for up to an hour for staff to respond to call lights, especially during night shifts when staffing was low. This delay in assistance led to the development of a new pressure ulcer on the resident's sacrum, which was identified on 1/18/24. The wound consultant suspected the ulcer was caused by prolonged pressure from the bedpan, and the facility did not conduct an investigation or incident report when the ulcer was identified. For Resident #15, the facility failed to complete weekly skin assessments as ordered by the physician. The resident, who had a history of dementia, diabetes, hypertension, and obesity, was at risk for pressure ulcers and had a Stage 2 pressure ulcer that was not identified in a timely manner. The facility missed several weekly skin assessments, including one on 11/20/23, which could have potentially identified the pressure ulcer at an earlier stage. The resident's pressure ulcer worsened over time, indicating a lack of consistent monitoring and timely intervention. The facility's policy on wound and skin care emphasized the importance of regular skin assessments and timely interventions to prevent and manage pressure ulcers. However, the facility did not adhere to these protocols, resulting in the development and worsening of pressure ulcers for the two residents. Interviews with staff and residents highlighted issues with staffing levels and response times, which contributed to the deficiencies in care.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and inadequate assistance with toileting, bedpan use, and other personal care needs. Observations and interviews revealed that call lights were often left unanswered for extended periods, particularly on weekends and night shifts. For instance, Resident #16's call light was not answered for 7 minutes and then again for 9 minutes, causing the resident to wait for assistance with toileting. Similarly, Resident #57 reported waiting up to an hour for assistance with a bedpan, leading to episodes of incontinence due to the lack of timely help. Residents consistently expressed concerns about the long wait times for staff assistance, especially during the night and weekend shifts. Resident #62 mentioned having to wait up to an hour for bathroom assistance during meal times, while Resident #32 reported frequent accidents due to delayed responses to call lights. The Resident Council Meeting highlighted that 9 out of 10 residents experienced long wait times for call light responses, particularly on the night shift and weekends. Staff interviews corroborated these findings, with CNAs and nurses acknowledging the challenges posed by insufficient staffing levels, especially during weekends when call-outs and no-shows were common. The facility's staffing plan indicated a minimum staff-to-resident ratio that was not consistently met, leading to significant delays in providing necessary care. For example, on one observed day, only two CNAs were available for 30 residents, resulting in prolonged wait times for assistance. The lack of administrative staff presence on weekends further exacerbated the issue, as CNAs struggled to manage the workload. This deficiency in staffing directly impacted the residents' ability to attain and maintain their highest practicable physical, mental, and psycho-social well-being, as evidenced by the numerous instances of delayed care and unmet needs.
Failure to Ensure Nursing Competencies for IV Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to ensure the safety and well-being of a resident receiving intravenous (IV) antibiotics. Specifically, six nurses lacked the necessary competencies and certification to provide appropriate Central Venous Access Device (CVAD) care and services for a resident with a left hip infection. The facility's policy required documented education and competency in the management of vascular access devices, but this was not adhered to for the nurses involved in the resident's care. The resident, who had severe cognitive impairment and a recent hip replacement surgery, was admitted with diagnoses including Alzheimer's disease and a bacterial infection. Physician's orders included specific instructions for the care and maintenance of a Peripherally Inserted Central Catheter (PICC) line, which was used to administer IV antibiotics. Despite these orders, the facility did not ensure that the nurses providing care had the required competencies, as evidenced by the lack of documentation for their IV certification and competency. Interviews with the Administrator and Director of Nurses (DON) revealed that the facility had been without a Staff Development Coordinator (SDC) since February, and there was no system in place to verify the competencies of the nurses providing IV care. The Administrator acknowledged the oversight and the inability to provide evidence of the required training and competencies for the nurses involved. This deficiency was identified through observation, interviews, and a review of records and policies, highlighting a significant lapse in ensuring the safety and well-being of the resident receiving IV antibiotics.
Failure to Provide Privacy and Dignity During Personal Care
Penalty
Summary
The facility failed to ensure that Resident #25 was provided privacy and dignity during personal care. Specifically, the staff did not provide appropriate clothing or covering for the resident's private areas while being transported to and from the shower. The resident, who has diagnoses including cognitive communication deficit and mood disorder, was observed being assisted by a CNA while seated on a shower chair and dressed in a hospital gown. The resident's legs, bare bottom, and private parts were exposed as they were moved down the hallway to the shower room. This observation was confirmed by another CNA who noted that a blanket or towel should have been used to cover the resident's lower extremities to maintain privacy and dignity. Further observations revealed that when the resident was being transported back to their room, their bare bottom remained visible while seated on the shower chair. Multiple staff members were present in the hallway during this time, witnessing the resident's exposure. Interviews with the involved staff confirmed that the resident should have been covered to prevent exposure. The facility's policy on promoting and maintaining resident dignity was not followed, leading to this deficiency.
Failure to Notify Physician and Resident Representative of Change in Skin Condition
Penalty
Summary
The facility failed to notify the physician and the resident representative of a change in skin condition for a resident who was found bleeding from the left index finger while on anticoagulant therapy. The facility's policy required immediate notification of the physician and resident representative in such cases, but this was not done. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was observed with an undated bandage on the left index finger on multiple occasions. The nurse's note indicated the bleeding was treated, but there was no documentation of physician or resident representative notification or new treatment orders. Interviews with the Unit Manager and Director of Nurses revealed that no investigation or incident report was completed for the bleeding incident, which should have been done according to facility policy. The Director of Nurses was unaware of the incident until informed by the surveyor and confirmed that the required notifications were not made. The nurse who documented the incident admitted that the physician and resident representative were not notified as required.
Inaccurate MDS Assessment for Pressure Injury
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) Assessment was accurate for one resident out of a total sample of 17 residents. Specifically, the facility did not accurately code that a resident had a pressure injury. The resident, who was admitted in October 2020 with diagnoses including Dementia and Diabetes, developed a Stage 2 pressure injury in November 2022 that was not resolved until March 2024. However, the MDS assessment did not indicate the presence of this pressure injury. During an interview, the MDS Nurse confirmed that the assessment was coded incorrectly and required modification.
Failure to Monitor and Assess Skin Conditions and CVAD Catheter Site
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards relative to monitoring and assessing the skin condition for two residents. For one resident, the facility did not perform weekly skin assessments, notify and obtain orders from the physician when a new skin area of concern was identified, and failed to monitor a Central Venous Access Device (CVAD) access site relative to measuring and documenting the external catheter length according to standards of practice. Specifically, the resident was found with blood on their hands, and the source of the bleeding was not properly documented or treated according to protocol. Additionally, the resident's CVAD catheter site was not properly monitored, and there was no documented evidence of the external catheter length being measured upon re-admission or during subsequent assessments, as required by the facility's policy and physician's orders. The Director of Nursing (DON) and Unit Manager (UM) acknowledged these deficiencies during interviews with the surveyor, noting that incident reports, physician notifications, and treatment orders were not completed as required. For another resident, the facility failed to perform weekly skin assessments per facility policy and physician's order, and did not implement a Nurse Practitioner (NP) recommendation relative to edema. The resident had severe cognitive impairment and was usually understood by others. Despite having a physician's order for weekly skin assessments and a recommendation to keep their legs elevated to manage edema, there was no evidence that these assessments were completed or that the recommendation was integrated into the resident's care plan. Observations by the surveyor revealed that the resident's legs were reddened and edematous, and the resident reported not being aware of any treatments in place to alleviate their condition. Interviews with nursing staff and the UM confirmed that the required skin assessments and care plan updates were not performed. The facility's policies for CVAD catheter dressing changes and skin assessments were not followed, leading to inadequate monitoring and care for the residents. The deficiencies were identified through a combination of record reviews, observations, and staff interviews, highlighting a failure to adhere to professional standards and facility protocols. The DON and UM acknowledged the lapses in care and documentation, indicating a need for improved compliance with established procedures to ensure resident safety and well-being.
Failure to Investigate and Implement Interventions for Skin Issues
Penalty
Summary
The facility failed to investigate and implement interventions for accident/hazard incidents for two residents. For Resident #60, who had severe cognitive impairment and required assistance with activities of daily living, the facility did not thoroughly investigate or add interventions when a new skin area was identified on the resident's left index finger. Despite the resident being found with blood on their hands and a subsequent bandage being observed on multiple occasions, no incident report was completed, and the physician and resident representative were not notified. The Director of Nurses was unaware of the issue until it was brought to her attention by the surveyor. For Resident #57, who was cognitively intact and at risk for pressure injuries, the facility did not thoroughly investigate or add interventions when a new pressure injury was identified on the resident's right sacrum. The injury was reported to have occurred after the resident was on a bedpan for longer than usual. Despite the wound being documented and treated, no changes were made to the resident's plan of care, and no incident report or investigation was completed. The Unit Manager and Director of Nurses acknowledged that an investigation should have been initiated but was not. The facility's policy on wound and skin care required a full body skin assessment and documentation upon the identification of any new pressure injury. However, this policy was not followed for either resident, leading to a lack of proper investigation, notification, and intervention for the identified skin issues.
Failure to Perform Trauma Assessment and Develop Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to perform a trauma assessment on admission and develop a trauma care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted in February 2023, was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Despite the resident's PTSD diagnosis, the medical record did not indicate that a trauma assessment was ever completed, nor was there a care plan developed to address the resident's PTSD and potential triggers for re-traumatization. During an interview, the social worker confirmed that the facility did not utilize a trauma assessment and that information about a resident's trauma history usually emerged during the initial social service assessment or a visit with the psychiatric nurse practitioner. The social worker acknowledged that a care plan should have been developed to identify the resident's triggers for re-traumatization. However, upon review, it was found that no trauma assessment was completed, and no PTSD care plan was in place for the resident, as required by the facility's policy on trauma-informed care.
Failure to Account for Controlled Medication
Penalty
Summary
The facility failed to ensure an accurate accounting of a controlled medication, specifically Lorazepam (Ativan), in the controlled substance accountability record book. During an observation, the surveyor noted that one of the controlled substances lock boxes in the medication storage room was unlocked. Nurse #5 found an opened 20cc Lorazepam syringe with 15cc remaining, labeled for a resident who had expired in February 2024. This medication was not part of the controlled substance count and was not recorded in the corresponding controlled substance accountability record book, as required by the facility's policy and federal and state regulations. Nurse #5 confirmed that the Lorazepam should have been counted and recorded in the controlled substance accountability log book for the St. Luke's Unit front medication cart. The Director of Nurses (DON) stated that all controlled substances, including those in the medication room refrigerator, should be counted, recorded, and reconciled by two nurses at the beginning and end of each shift. The failure to account for the Lorazepam indicates a lapse in adherence to the facility's policy on the handling, storage, and record-keeping of controlled substances.
Failure to Monitor for Side Effects and Adverse Reactions to Anticoagulant Medication
Penalty
Summary
The facility failed to monitor for side effects and adverse reactions to medications for one resident out of a total sample of 17 residents. Specifically, the facility staff did not monitor for side effects and adverse reactions related to the use of an anticoagulant medication for a resident who was admitted with diagnoses of Pulmonary Embolism and Atrial Fibrillation. The resident had an order to monitor for specific symptoms such as discolored urine, black tarry stools, sudden severe headache, numbness and tingling, diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs, shortness of breath, and nose bleeds. The monitoring was to be documented on the Medication Administration Records (MARs) with a 'Y' if no symptoms were observed and an 'N' if any symptoms were observed, along with a progress note if necessary. However, the review of the resident's clinical record and MARs for March and April 2024 indicated no documented evidence that any monitoring for side effects and/or adverse reactions from anticoagulant therapy was being done as required. During an interview, a nurse confirmed that residents prescribed anticoagulant medications should be monitored for signs and symptoms such as nose bleeds, bruising, and tarry stools, and that this monitoring should be documented on the MAR. The nurse reviewed the resident's medical record and confirmed that the required monitoring was not documented. The nurse acknowledged that residents receiving anticoagulants should be monitored per shift and that it should be documented whether they were monitored with no symptoms or with symptoms. The lack of documentation indicated that the resident was not being monitored for signs and symptoms of anticoagulant medication use as required.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication, Valium, was limited to 14 days and reviewed by the Physician for continued use for one resident. The resident, who was admitted with Alzheimer's disease, had a PRN order for Valium 5 mg to be given every 8 hours as needed for spasms. The medication was administered 9 times in March and 5 times in early April. However, there was no documented evidence that the PRN Valium had been assessed by the Physician and a duration given for its use beyond 14 days. During an interview, the Unit Manager confirmed that PRN Valium should be ordered for 14 days and then reassessed by the Physician or Practitioner. The Unit Manager stated that upon assessment, the Physician can continue the medication for PRN use and indicate a duration for re-evaluation, schedule the PRN medication, or discontinue it. This failure to reassess and document the continued use of PRN Valium beyond 14 days led to the deficiency noted in the report.
Failure to Implement and Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) were properly implemented and adhered to by staff for two residents, leading to potential infection control issues. Resident #118, who was admitted with a left hip fracture and had an open wound, was observed being assisted by a CNA into the bathroom without the CNA wearing a gown, despite the requirement for gown and gloves during high-contact care activities. The CNA admitted to only wearing gloves during toileting assistance, contrary to the facility's EBP policy. Resident #60, admitted with a bacterial infection and a vascular access site, was also not properly managed under EBP. The resident required assistance with various personal care activities and had a PICC line for IV antibiotics. Observations revealed that CNAs and a nurse did not consistently wear gowns while providing care, including during the administration of IV antibiotics and transferring the resident using a hoyer lift. The staff members either wore only gloves or a surgical mask, failing to comply with the EBP requirements. Interviews with the staff, including CNAs and a nurse, indicated a lack of awareness or understanding of the EBP requirements. One CNA was unaware of the precautions for Resident #60, and another admitted to not wearing a gown during a high-contact activity. The Unit Manager confirmed that staff should don gowns and gloves for direct care under EBP, highlighting a gap in adherence to infection control protocols for residents with specific medical conditions requiring enhanced precautions.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Lenox
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kimball Farms Nursing Care Center | 2.7 mi | ★★★★★ | 3 | 0 |
| Berkshire Place | 3.2 mi | ★★★★★ | 2 | 0 |
| Springside Rehabilitation And Skilled Care Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Hillcrest Commons Nursing & Rehabilitation Center | 4.3 mi | ★★★★★ | 0 | 0 |
| Lee Healthcare | 4.9 mi | ★★★★★ | 17 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.