Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Carmel Senior Living Community during CMS and state inspections, most recent first.
Food items and kitchen equipment were found stored and maintained in unsanitary conditions in the main kitchen. Surveyors observed open prepared foods, undated items, food boxes stored on the floor, cracked and liquid-contaminated containers, debris behind equipment and in storage areas, grime on floors and shelves, dust on vents, and dirty serving ware and adaptive silverware; the DON and NHA reviewed the findings with staff.
Failure to Provide Written Transfer and Bed-Hold Notices: The facility did not provide written transfer notices or bed-hold policy notices to responsible parties for multiple residents sent to the hospital. Records showed several hospital transfers, including a resident who was found on the floor and later sent out again for chest pain, but only verbal communication was documented for the resident’s wife. The DON and NHA confirmed there was no evidence that the required written notices were provided, and one transfer form listed the LTC Ombudsman email address incorrectly.
Failure to Invite Residents to Care Plan Meetings: The facility did not document invitations for three residents to attend care plan meetings. One resident had a BIMS of 15 with no cognitive impairment, yet there was no evidence that the resident or representative was invited. Two other residents also reported no knowledge of care plan meetings, and the facility could not provide records showing that they or their family representatives were invited or attended.
A resident with a colostomy was observed wearing a hospital gown with a large dried brown stain over the colostomy area. The resident said colostomy care had been done overnight and the bag was to be changed, and the Kardex showed the last documented colostomy care at 4:12 AM. The issue was reviewed with the NHA and DON.
A resident had Nystatin topical powder at the bedside and said she used it for reddened areas to her groin and under her left breast, but could not apply it well because she could not reach under her left breast. Record review found no current MD order for Nystatin and no order or documentation that the resident was allowed or determined able to self-administer the medication.
A resident’s call bell was not kept within reach during observations. The resident was seated beside the bed with no visible call bell nearby, and later the adaptive call bell was clipped above the resident’s head on the opposite side of the bed. The resident stated she could not raise her left arm above her head due to ROM limits and could not reach the call bell, and an LPN and nurse aide confirmed it was out of reach.
A resident’s family told the facility she was not to have male caregivers, but male nurse aides later documented providing personal care, including dressing, toileting, incontinence care, and skin care. The resident’s Kardex stated no male nurse aides were to provide care, yet the chart showed multiple entries by two male aides attesting they reviewed and followed the Kardex. The NHA and DON said they believed a male staff member only made the bed, but the documentation reflected male staff providing care despite the stated preference.
A facility failed to maintain a clean, comfortable, homelike environment in a common area and in two resident rooms. The drinking water fountain between the nurse stations had a ripped plastic cover secured with duct tape, dried stains, and debris in the basin, including a plastic cup and used lollipop sticks. One resident's room had flies observed around the resident, and another resident's room had sugar granules on the windowsill plus a sticky floor with orange crumbs scattered around the bed and dresser.
A resident received Lorazepam for anxiety and Duloxetine for depression, but the facility did not show adequate support for continued psychotropic use. The care plan called for monitoring target behaviors and depressive symptoms, yet the MAR/TAR reflected only one behavior being tracked, and the consultant pharmacist’s request to consider GDR or discontinuation was answered only with “medically stable.” The DON and NHA confirmed there was no evidence of the required behavior monitoring or other rationale supporting the ongoing regimen.
PASRR screening was not completed or updated correctly for two residents. One resident’s PASRR was dated a year before admission and did not list MH diagnoses despite PTSD, anxiety, and major depression being present in the record, while another resident’s PASRR was not updated when depression was later added to the diagnosis list.
A facility failed to ensure dependent residents received needed ADL assistance, including feeding, hygiene, and bathing. One resident was documented as dependent for eating and hygiene, yet records showed repeated omissions for meals, oral hygiene, personal hygiene, and showers, and a family member reported the resident was not helped to eat lunch and appeared disheveled. Another resident, dependent for bathing and requiring two staff, reported missing showers, and records showed a shower was missed after a medical appointment return time.
The facility failed to provide ordered skin treatment for a resident with fungal rash and excoriated skin, with incomplete TAR documentation and no record of treatment to all affected areas. The facility also failed to document BP and HR checks before giving a resident’s daily metoprolol as ordered, despite active hold parameters in the MAR and clinical record.
A resident with a recent history of serious fall-related fractures and intracranial hemorrhage was found on the floor after sliding out of bed. The resident’s call light was not in reach, and the bed alarm in place did not activate; staff statements confirmed the call bell was not within reach and no alarm sounded.
A resident’s supplemental O2 was observed running below the ordered 2 L/min via NC, despite an active physician order for continuous oxygen every shift. The RN confirmed the incorrect setting and found the concentrator’s flow gauge was malfunctioning, preventing the machine from being set to the ordered rate.
A resident admitted with dementia had a care plan that listed only general interventions such as cueing, reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show an individualized person-centered care plan addressing the resident’s specific cognitive loss and dementia-related needs, and the findings were reviewed with the NHA and DON.
The facility failed to ensure consultant pharmacist recommendations were properly communicated, acted on, and documented for two residents. One resident had a pharmacist recommendation for GDR or discontinuation of psychoactive meds, but the physician’s response only stated the resident was medically stable, and a later lipid panel recommendation for Atorvastatin was not found in the chart. Another resident had a pharmacist recommendation for GDR of Tizanidine and Pregabalin, but no corresponding orders were written despite the physician’s agreement, and the Oxycodone recommendation was declined without the other medication changes being documented.
A resident with an active order for a liberalized renal diet was served a lunch meal that was described as dry, hard, mushy, and overcooked, and the menu in the room showed a regular diet instead of the ordered diet. The dietary manager stated that alternate diets were not printed, distributed, or displayed, and the resident reported this mismatch happened all the time.
Meals were not served at scheduled times on the Oak unit for multiple residents. Resident council minutes, grievances, and resident interviews described frequent late trays, including lunch being delayed by up to 40 minutes. Although the posted lunch time was 12:30 PM, trays were observed arriving at 1:16 PM, and the dietary manager said prep work due the prior day had not been completed by staff; the NHA confirmed ongoing issues with late meal trays.
Incomplete documentation was found for a resident with severe cognitive impairment who had a physician order for bilateral floor mats when in bed. The EHR task list required documentation every shift, but multiple day, evening, and night shift entries were left blank across several months, and the NHA and DON reported the missing entries were a documentation issue with staff.
Hospice documentation and the coordinated plan of care were incomplete for a resident receiving hospice services. The resident said hospice staff had been visiting regularly, but the facility had no provider documentation in the chart after hospice admission, and the plan of care at the nurses’ station was missing key items such as hospice dx, code status, diet, DME, medical supplies, funeral home info, and visit frequencies for social work and chaplain services. The DON and NHA confirmed the facility did not have hospice provider documentation until after the surveyor asked for it.
Improper Garbage Containment at Outside Dumpsters: The facility failed to properly contain and dispose of garbage at the outside dumpsters. Surveyors observed multiple open dumpster lids, birds on and inside the dumpsters, and discarded items around the dumpster area including a medical glove, food containers, paper products, a battery, and an energy shot bottle. The findings were reviewed with the NHA and DON.
The facility failed to post and retain daily nurse staffing information for the Marble unit. Surveyors found missing staffing postings for multiple dates during record review, and an observation of the unit showed no nurse staffing posting displayed; the scheduler confirmed the posting was absent and that the missing records could not be found.
A resident sustained a fracture to her lower leg after being transported in a wheelchair without leg rests by an agency LPN who was unaware of facility policy. The resident's legs were covered by a blanket and not properly supported, leading to her leg becoming stuck and subsequent injury. Ongoing pain and swelling were documented before a repeat x-ray confirmed the fracture.
Surveyors observed improper food storage and unsanitary conditions in the main kitchen and two pantries, including rusty shelving, unlabeled thawing meat, soiled equipment, undated snacks, missing refrigerator/freezer temperature logs, and significant ice buildup in cold storage units. These deficiencies were confirmed by the NHA and DON.
The facility did not provide required written transfer notices or bed-hold policy information to several residents and/or their representatives during hospital transfers. In multiple cases, residents transferred for medical reasons did not receive documentation about the facility's bed-hold policy or complete transfer notices, as confirmed by staff interviews and record review.
Two residents with PTSD did not receive trauma-informed or culturally competent care, as the facility failed to identify trauma triggers, complete trauma assessments, or develop individualized care plans to address their needs. The DON confirmed awareness of the traumatic events affecting these residents.
A review of staff education records and interviews revealed that three nurse aides did not complete the required 12 hours of annual in-service training, with only six hours documented since the start of the year. The DON confirmed that in-service trainings for nurse aides had only recently started, resulting in insufficient training hours for these staff members.
A binder containing survey results, deficiency letters, and Statements of Deficiencies with resident names and identifiers was left accessible in a public area, resulting in a breach of confidentiality for multiple residents' personal health information.
A resident was prescribed an antipsychotic medication without documented evidence of a schizophrenia diagnosis or monitoring of target behaviors to justify its use. The resident's record only supported a history of depression, and staff confirmed the absence of documentation and appropriate behavior monitoring for the antipsychotic regimen.
Facility staff completed an MDS assessment indicating that a resident was discharged to a short-term general hospital, when in fact the resident had signed out against medical advice and was not discharged to a hospital. This inaccuracy was confirmed by the RNAC during staff interview.
A resident with a physician's order for supplemental oxygen was repeatedly observed without oxygen therapy, and both the resident and clinical staff confirmed that oxygen was not being used due to consistently high oxygen saturation levels. Despite this change, the care plan was not updated to reflect the resident's current needs and interventions.
A resident with physical limitations and vision loss was not consistently assisted out of bed for meals or provided with required feeding support, despite physician orders and care plan directives. Staff failed to follow care instructions, did not always document care, and were unaware of the resident's specific needs, resulting in the resident remaining in bed for all meals and experiencing significant weight loss.
Two residents did not receive care as ordered by their physicians: one was given Metoprolol despite a low apical pulse, with no documented reason for the deviation, and another did not have Geri-sleeves applied as ordered for skin protection, with observations showing sleeves were either missing or ill-fitting.
A resident with Alzheimer's dementia experienced ongoing hearing difficulties due to the facility's failure to ensure proper treatment and access to assistive hearing devices. Staff were aware of issues with the resident's hearing aid, including malfunction and missing parts, but did not coordinate with audiology services or accurately document the resident's needs in care plans and assessments. As a result, the resident did not receive appropriate support to maintain hearing ability.
A deficiency was found when a resident's room was observed to contain a block of large scissors and knives in plain view, while the resident reported frequently leaving the room and the door did not lock. This resulted in the environment not being free from accident hazards, as the items were accessible when the resident was not present.
A resident with severe cognitive impairment and a diagnosis of dementia was admitted and assessed, but the facility only provided general interventions in the care plan, lacking individualized, person-centered strategies to address the resident's dementia and cognitive loss.
An unlocked and unattended treatment cart containing multiple tubes of creams was found on a hallway outside a resident's room. The cart remained unsupervised for several minutes while two residents moved independently nearby. The DON confirmed the cart should have been locked.
A resident was observed in a state of undress during a brief change because the privacy curtain did not fully extend around the bed, preventing complete visual privacy. An LPN waited to pass by until the resident was no longer exposed, but the resident was still uncovered and wearing only a brief. The resident stated the curtain had not provided full coverage since admission, and the issue was confirmed by observation and discussed with the DON.
Mount Carmel Senior Living Community failed to correct infection control deficiencies, as observed during a revisit survey. Two residents under contact and droplet precautions were not adequately protected due to improper disposal systems for contaminated materials and staff not adhering to required PPE protocols. A nurse aide served lunch to a resident without wearing a gown and gloves, and a physical therapy assistant improperly handled used PPE. These actions indicate non-compliance with infection prevention standards.
The facility failed to administer bowel protocol medications and insulin as ordered, leading to prolonged constipation and hypoglycemia in residents. A resident with Type 2 diabetes was hospitalized due to early insulin administration relative to meal times. Other residents also experienced improper timing of blood sugar assessments and insulin administration, posing significant health risks.
The facility failed to provide a clean and homelike environment across four nursing units. Observations revealed rust, dirt, and black substances in the shower room, and cluttered and unclean conditions in residents' rooms. A resident's room had a brown substance on the floor that remained for hours despite staff presence. Housekeeping staff confirmed the oversight and addressed it only after being informed by the surveyor.
A facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by CMS guidelines. A nurse aide did not wear a gown while providing care, despite the presence of a sign indicating the need for such precautions. The deficiency was confirmed through staff interviews and was previously cited, indicating a recurring compliance issue.
Mount Carmel Senior Living Community failed to accurately post nurse staffing data, showing discrepancies in the number of nurse aides and hours worked during the dayshift. The posted data indicated 11 nurse aides and 88 hours, while only 10 aides and 70 hours were confirmed. This was verified by the DON.
The facility did not meet the required nurse aide-to-resident ratios from December 26, 2024, to January 2, 2025. The day shift was understaffed on six of eight days, the evening shift on five of eight days, and the night shift on four of eight days. This deficiency was confirmed through a review of staffing hours and an interview with the Nursing Home Administrator and DON.
The facility did not meet the required LPN-to-resident ratios, failing to provide adequate staffing on several occasions. On one day, the day shift was short of the required LPNs for 103 residents, and the overnight shift was understaffed on five days. Interviews with the Nursing Home Administrator and DON confirmed these deficiencies.
The facility did not meet the required minimum of 3.2 hours of direct resident care per patient day for four days during a review period. The nursing care hours fell short on specific days, with the lowest being 2.44 hours PPD. This was confirmed by reviewing staffing hours and through an interview with the Nursing Home Administrator and DON.
The facility failed to administer insulin according to professional standards, resulting in residents receiving insulin significantly earlier than their meals. Staff conducted blood glucose assessments and administered insulin before the end of their shift, leading to insulin being given more than an hour before breakfast. The facility lacked a policy to guide staff on proper timing for insulin administration relative to meals.
The facility failed to provide adequate bathing support for three residents requiring assistance. A resident did not receive a shower for 22 days despite her preference, while another received only two showers since admission. A third resident, dependent on staff for bathing, did not receive any showers or tub baths in the last 30 days. These issues were discussed with the Nursing Home Administrator and DON.
A resident at high risk for skin breakdown was not consistently assessed for pressure ulcers, with the last documented assessment on September 30, 2024. Despite a complaint of wound bleeding on October 2, 2024, no further assessments were documented until October 16, 2024, when the ulcers were noted as resolved. This lack of timely assessments led to a deficiency, as confirmed by a wound nurse.
The facility failed to serve meals at a palatable temperature and in a timely manner across four resident hallways. Meal carts were significantly delayed, with early trays arriving 45 minutes late and others over an hour late. A test tray revealed the shepherd's pie was lukewarm at 122.7°F. This issue was discussed with the Nursing Home Administrator and DON.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store food items in a safe and sanitary manner and failed to maintain kitchen equipment and food service areas in a sanitary condition in the main kitchen. During an initial tour with dietary staff, a walk-in cooler contained a bowl of pudding and two large flat trays of prepared food left open to the ambient air, a container of buttered noodles with no date, and six cardboard boxes of food items stored directly on the cooler floor. A second walk-in cooler contained a cracked juice pitcher marked prepared 6-10, a carton of thickener, and a container of plant-based milk alternative sitting in spilled liquid, along with two boxes of coffee items in liquid, milk and a butter packet on the floor, a shelf liner with red liquid spilled in multiple areas, and cartons of milk stored in a black container with excessive liquid in the bottom. The floor behind the ice machine had discarded straw wrappers, debris, and a plastic cup lid, and there was a significant accumulation of brown/tan debris on top of the dish machine. Additional observations showed debris in the food cart washroom drain and on the floor, significant grime on the floor, and a golf-ball sized hole in one wall. There was dried staining on a plastic cover over the mixer, grime and debris under the cook's food prep table, and a greasy buildup on the bottom shelf holding spices and olive oil. In the dry goods storage room, a box of straws and multiple food items were on the floor, several boxes were stored on the floor, and an open box of creamy French dressing packets had packets on the floor and on an adjacent box. The room leading to the walk-in freezer had dried leaves, cobwebs, dust buildup on two ceiling vents, and plastic lids and food debris on the freezer floor. In the main kitchen and dining room, serving ware and adaptive silverware had debris in the containers, and a small griddle covered with a red fabric cover had dried food debris on top.
Failure to Provide Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written notice of transfer and written notice of its bed-hold policy to residents’ responsible parties at the time of hospitalization for four of six residents reviewed for hospitalization concerns. Clinical record review showed that Resident 11 was sent to the hospital on April 10, April 13, and May 9, 2026, but there was no evidence that the resident representative was notified in writing of these transfers or that a bed-hold notice was provided. Resident 12 was sent to the hospital on March 4 and March 31, 2026, and the record did not show written notice to the resident representative for the March 31 transfer or any bed-hold notice for either hospitalization. Resident 113 was sent to the hospital on May 20, 2026, and there was no evidence of written transfer notice or a bed-hold notice. Resident 15 was hospitalized after staff found him on the floor on May 16, 2026, and his wife requested hospital evaluation; he returned to the facility on May 21, 2026. He was again sent out by 911 emergency personnel on May 28, 2026, after complaining of chest pain, and returned on May 31, 2026. The Notification of Transfer forms for these events documented verbal communication with his wife, but the resident’s medical record did not contain evidence of written notice to the resident or his representative that included the facility’s bed-hold policies. The forms also listed the Pennsylvania Long-Term Care Ombudsman email address incorrectly as [email protected] instead of [email protected]. The Nursing Home Administrator confirmed that no bed-hold transfer notices had been provided, and the NHA and DON confirmed there was no evidence that written notification was provided related to bed-hold policies and required transfer information.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite residents to their care plan meetings for three of three residents reviewed for care planning concerns. Resident 78 stated during interview that she had not received an invitation to care plan meetings. Her most recent comprehensive assessment showed a BIMS score of 15, indicating no cognitive impairment, yet the clinical record contained no evidence that she or her resident representative was invited to a care plan meeting. The Nursing Home Administrator and DON confirmed that no documentation could be provided to show that Resident 78 or her representative had been invited. Resident 36 stated that she had no knowledge of care plan meetings, and her clinical record identified her son as her resident representative. Her record included an annual MDS and quarterly MDS assessments, but the facility could not provide evidence that she or her family were invited to participate in care planning since the last standard survey. Resident 20 stated that he had never received an invitation to a care plan meeting and did not recall ever attending one. His clinical record contained no evidence that he was invited to or attended any care plan meetings, and the Nursing Home Administrator confirmed that the facility could not provide evidence of his invitation or attendance.
Failure to Maintain Resident Dignity During Colostomy Care
Penalty
Summary
The facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one resident with a colostomy. During an observation, the resident was seen wearing a hospital gown with a large dried brown stain, about eight inches and roughly round, on the right side of the abdomen over the colostomy site. The resident stated that colostomy care had been provided overnight and that the colostomy bag was to be changed. Review of the resident’s Kardex showed the last documented colostomy care was provided at 4:12 AM on June 15, 2026. These findings were reviewed with the NHA and DON during the survey.
Failure to Determine Ability to Self-Administer Medication
Penalty
Summary
The facility failed to ensure that it determined a resident's ability to self-administer medications for one of one resident reviewed. During observation, the resident was sitting in a reclining chair with a container of Nystatin topical powder on an adjacent bedside table. In interview, the resident stated she used the medication for reddened areas to her groin and under her left breast, but said she could not apply it because she could not reach under her left breast very well. Review of the clinical record showed there was no current physician's order for Nystatin and no physician's order allowing the resident to self-administer the medication or documenting that the facility had determined she was able to safely self-administer it.
Call Bell Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure call bell accessibility for one resident who was observed out of bed in a chair on the left side of the bed with no call bell device visible within reach, while an adaptive call bell was hanging from the top of the mattress on the right side of the bed. A licensed practical nurse confirmed the call bell was not within reach and moved it closer to the resident. On a later observation, the resident was in bed and the adaptive call bell was clipped above her head, above her pillow, on the right side of the bed. The resident stated she could not find her call bell and could not raise her left arm above her head due to range of motion limitations, making it impossible for her to reach high enough to feel for it. A nurse aide confirmed the call bell was out of the resident's reach and repositioned it to make it accessible.
Resident Choice Not Supported for Caregiver Preference
Penalty
Summary
The facility failed to support resident choice regarding providers of health care services for one resident whose family had stipulated that she was not to have any male caregivers. The resident’s daughter reported that she and her sisters had informed the facility that their mother was not to receive care from male staff, and she later learned during an investigation related to missing pillows that the resident had received care from a male caregiver. The daughter also stated that grievances had been submitted regarding her mother’s care, but the grievance forms provided by the facility did not reference male staff providing care to the resident. Clinical record review showed that the resident’s bedside Kardex, active since May 10, 2026, stated that no male nurse aides were to provide care. However, the resident’s Documentation Survey Report for May 2026 contained multiple entries by two male nurse aides documenting care such as upper and lower body dressing, personal hygiene, toilet transfers, toileting hygiene, incontinence care, and preventative skin care with barrier cream to the buttocks and sacrum. The report also showed that these male nurse aides documented care on additional June dates, including personal care, while attesting that the Kardex was reviewed and followed. The Nursing Home Administrator and DON stated that the facility was aware of the family’s report and believed a male staff member only made the resident’s bed, but the surveyor reviewed documentation showing male nurse aides recorded provision of personal care despite the resident’s preference for female nurse aides.
Unclean common area and resident rooms
Penalty
Summary
The facility failed to provide a clean, comfortable, homelike environment in the common area between the two nurse stations and in two resident rooms. The drinking water fountain in the common area had a plastic cover secured with duct tape, with the cover ripped in several areas and dried stains present. Paper debris was visible in the fountain basin, and on follow-up observation the basin also contained a plastic cup and what appeared to be used lollipop sticks. Resident 4's room had house flies observed flying around the resident, and a family member visiting the roommate stated that flies were always present in the room. On follow-up observation, a fly was seen on the ceiling, and the resident pointed to the ceiling and indicated that she did not like all the flies. Resident 12's room had two five-pound bags of sugar on the windowsill with sugar granules noted on the sill, and the floor felt very sticky with a large amount of orange crumbs scattered on the floor at the foot of the bed, beside the bed, and in front of the dresser.
Unnecessary Psychotropic Medication Use Not Supported by Monitoring
Penalty
Summary
The facility failed to ensure that one resident’s medication regimen was free from potentially unnecessary psychotropic medication. Resident 36 was receiving Lorazepam 0.5 mg daily for an anxiety disorder since July 8, 2024, and Duloxetine 20 mg daily since October 26, 2024. The facility’s policy required interdisciplinary review of psychotropic use, documentation of adequate indications, monitoring for efficacy and adverse consequences, and consideration of gradual dose reduction (GDR), including documentation of behavioral interventions or physician rationale when alternatives were clinically contraindicated. The resident’s care plans addressed monitoring for target behaviors related to the anti-anxiety medication and antidepressant use, including restlessness and signs and symptoms of depression, but the MAR/TAR showed only one target behavior, restlessness, had been identified for monitoring since May 2, 2025. The consultant pharmacist recommended that the physician consider a dose reduction or trial discontinuation of Duloxetine and/or Lorazepam, but the physician’s response only stated that the resident was medically stable. The DON and NHA confirmed there was no evidence of target behavior monitoring as outlined in the care plan and no additional information to support the physician’s response or to show a failed GDR or ongoing distressing behaviors.
PASRR Screening Not Completed or Updated Correctly
Penalty
Summary
The facility failed to ensure that residents were appropriately screened through the PASRR process prior to and during admission for two residents reviewed for PASRR concerns. One resident was admitted on April 29, 2026, but the PASRR Level I form available in the record was documented as completed on April 29, 2025, a year before admission. That form listed no mental health diagnoses in Section III-A, question one, even though the resident’s admission diagnoses dated April 27, 2026 included PTSD, anxiety disorder, and major depressive disorder, recurrent. The admission MDS dated May 9, 2026 also included anxiety disorder, depression, and PTSD, and the medication regimen included mirtazapine and sertraline for major depressive disorder, recurrent. For another resident, the PASRR completed on admission dated June 14, 2024 identified dementia and no other diagnosis. Later, depression was added to the resident’s diagnosis list on October 25, 2024, but there was no evidence the PASRR was updated to reflect that additional diagnosis. When the issue was reviewed with the NHA and DON, the facility provided an updated PASRR that added unspecified psychosis not due to a substance or known physiological condition and depression, with social services documenting the change after the surveyor brought the issue to the facility’s attention.
Failure to Provide ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living, including feeding, oral hygiene, personal hygiene, bathing, and transfers. For one resident, the clinical record showed dependence on staff for eating, oral hygiene, showering/bathing, dressing, personal hygiene, toileting, bed mobility, and transfers, yet the documentation survey report contained multiple omissions for meals, oral hygiene, personal hygiene, and scheduled showers across May and June 2026. The resident’s daughter reported that on Mother’s Day she found the resident had not been assisted to eat lunch and appeared disheveled and undignified during a group activity. An observation later showed the resident in a wheelchair in the hallway with hair that did not appear combed, and the June documentation also lacked staff initials for oral and personal hygiene care that day. For another resident, the interview and record review showed the resident was dependent for showering/bathing and required two staff for care. The resident stated they often did not get showers because of this need and reported missing a shower on June 9, 2026. The Kardex indicated the resident was not available for a shower that day because they returned from a medical appointment at 6:10 PM, and the facility leadership confirmed that showers were still being conducted after the resident’s appointment return time. The cited deficiency referenced failure to provide ADL care for dependent residents under 483.24(a)(2) and 28 Pa. Code 211.12(d)(1)(5).
Failure to follow skin treatment orders and medication monitoring parameters
Penalty
Summary
The facility failed to provide the highest practicable care related to altered skin integrity for one resident. Resident 16 reported broken skin under the stomach and breasts that was red and stated staff did not apply treatment every day. Observation showed reddened skin under both breasts and in the bilateral inguinal areas with a white substance present, and the resident stated not all staff had her lie down to best apply the treatment to the groin areas. The clinical record showed a prior fungal rash with excoriation and foul odor in the right abdominal fold, with an order for Nystatin powder twice daily for seven days, but the record did not contain an order to treat the reddened areas under the bilateral breasts or left groin at that time. Treatment records for Resident 16 did not document completion of ordered treatment to the right abdominal fold on two dates, and some entries used a code directing staff to refer to nursing documentation even though no nursing documentation addressed those treatments. The record also showed no documentation of treatment to the bilateral breast areas or left groin despite the observed white substance and resident report. In a separate deficiency, Resident 78 had a current order for Metoprolol Succinate 50 mg daily with instructions to hold for systolic blood pressure less than 100 or heart rate less than 60, but the June 2026 MAR and blood pressure/pulse records did not show that staff measured blood pressure and heart rate before each administration as ordered. The DON stated the parameters had been discontinued previously, but no physician documentation supported that change and the order remained active in the record.
Failure to Maintain Fall Prevention Measures
Penalty
Summary
The facility failed to implement a fall prevention intervention for one resident who had been admitted after a serious fall that caused left frontal and parietal bone fractures, multicompartmental intracranial hemorrhage, and left inferior and superior pubic rami fractures. On admission, the resident’s plan of care identified fall risk interventions that included keeping the call light within reach and encouraging its use for assistance, with a prompt response to requests for help. Nursing documentation later noted the resident was falling/crawling out of bed during a shift, and a bed alarm was placed under the resident. On a later date, staff observed the resident on the floor and the call light was not activated. The resident stated he had been trying to sit on the side of the bed and slid out, and he was incontinent of urine at the time of the fall. The bed alarm in place did not activate, and the resident’s call light was not in reach. Staff obtained a physician’s order for emergency room evaluation, and the facility’s investigation confirmed that two staff statements indicated the call bell was not in reach and no alarm activated.
Supplemental Oxygen Not Set Per Physician Order
Penalty
Summary
The facility failed to ensure that supplemental oxygen was applied according to the physician’s order for one resident reviewed for oxygen concerns. On June 15, 2026, the resident was observed using supplemental oxygen via a room concentrator set at less than one liter per minute, even though the active physician’s order required oxygen at two liters per minute via nasal cannula continuously every shift. The same issue was observed again on June 16, 2026, when the oxygen was set at approximately one liter per minute. During interview, the RN confirmed the active order for two liters per minute and observed the setting at approximately one liter per minute. The RN then attempted to adjust the concentrator but found that the machine’s liter flow gauge was malfunctioning and would not allow the correct setting to be entered.
Failure to Individualize Dementia Care Plan
Penalty
Summary
Failure to provide appropriate treatment and services for dementia was identified for Resident 11, who was admitted on April 3, 2026 with a diagnosis including dementia, described as loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life. Review of the resident’s current care plan for impaired cognitive function/dementia or impaired thought processes related to dementia showed only general interventions such as cueing and reorienting, reporting changes to the physician, and providing activities that accommodate needs. The record did not show that the facility had implemented an individualized person-centered care plan to address the resident’s specific dementia and cognitive loss needs. The findings were reviewed with the NHA and DON on June 17, 2026 at 12:10 PM.
Pharmacy Recommendations Not Properly Addressed or Documented
Penalty
Summary
The facility failed to ensure that consultant pharmacist recommendations were appropriately addressed and documented for two residents. The facility policies stated that the consultant pharmacist performs a monthly medication regimen review, reports findings to the DON, attending physician, medical director, and administrator as appropriate, and that recommendations should be communicated and responded to in a timely fashion. The policies also stated that physician responses should either accept and act on the suggestion or reject it with an explanation for disagreement. For one resident, the consultant pharmacist recommended consideration of a gradual dose reduction or trial discontinuation of Duloxetine and/or Lorazepam, with documentation of the clinical rationale if the reduction was contraindicated. The physician responded only that the resident was "medically stable," without supporting rationale such as progress toward goals of therapy, ongoing distressing target behaviors, or a failed gradual dose reduction. The record also showed that on a later consultant pharmacist review, a recommendation was made for a periodic lipid panel to monitor Atorvastatin, but the facility did not have the recommendation on a Note to Attending Physician/Prescriber, and no Clinical Pharmacy Report was found in the record for that review. For another resident, the consultant pharmacist recommended a gradual dose reduction or documented rationale for declining Tizanidine, Pregabalin, and Oxycodone. The physician agreed to stop or decrease Tizanidine and Pregabalin and declined the recommendation to stop Oxycodone, stating it should continue for pain management. However, the record contained no evidence that any order was written to decrease or stop the Tizanidine or Pregabalin as the physician indicated. Facility leadership confirmed that no further documentation was available.
Menu and Meal Service Did Not Match Ordered Diet
Penalty
Summary
The facility failed to provide palatable food items and menu items as indicated for one resident who had an active physician’s order for a liberalized renal diet. During lunch observation, the resident was served breaded chicken, noodles, and mixed vegetables and stated that the chicken and noodles were “gross,” with the chicken described as dry and hard. The chicken was observed to be difficult to cut, with damp breading but very dry meat, and the noodles were mushy and overcooked. The resident reported that the meal did not match the menu in the room because the menu reflected a regular diet rather than the resident’s ordered renal diet, and that this happened all the time. Review of the facility menu confirmed that the items served were for a regular diet. The dietary manager stated that menus are delivered to residents by her or the resident council president, but alternate diets are not printed, distributed, or displayed anywhere, and the resident was not aware of the foods to be received because the menu only reflected a regular diet.
Late Meal Service on Oak Nursing Unit
Penalty
Summary
Meals were not served at regularly scheduled times in accordance with resident needs on the Oak Nursing Unit, affecting Residents 6, 30, and 78. The facility’s Resident Council meeting minutes documented resident concerns about meal trays arriving late, and grievances were filed for Resident 30 related to late meals. Resident 78 stated that meals were frequently late and could be up to 40 minutes late on some days, and Resident 6 expressed concern about lunch being served late. The facility’s posted meal service times and a facility document both listed Oak Nursing Unit lunch at 12:30 PM. However, observation on the unit showed lunch trays arriving at 1:16 PM, with staff then beginning to pass the trays. The dietary manager stated that the late lunch on the observed date occurred because food preparation that was supposed to be completed the day before had not been finished by staff. The Nursing Home Administrator confirmed there had been ongoing issues with late meal trays.
Incomplete Documentation for Safety Device Task
Penalty
Summary
The facility failed to ensure complete and accurate clinical documentation for 1 of 24 residents reviewed, Resident 30. The resident had a current physician order dated August 18, 2025, for bilateral floor mats when in bed, and a quarterly MDS dated May 26, 2026, showed a BIMS score of 00, indicating severe cognitive impairment. The electronic task list also included a safety device task for bilateral floor mats when in bed every shift, but review of task documentation for April, May, and June 2026 showed multiple blank entries where staff did not document that the floor mats had been addressed on several day, evening, and night shifts. The issue was reviewed with the NHA and DON on June 16, 2026, and June 17, 2026, and the facility reported the missing documentation was a documentation issue with staff.
Hospice Documentation and Plan of Care Were Incomplete
Penalty
Summary
The facility failed to ensure that contracted hospice services met professional standards of practice and timeliness of services for one resident receiving hospice care. The resident reported that hospice staff had been coming almost daily and that he had received hospice services for a couple of weeks. Nursing documentation showed that a physician’s order for referral to the contracted hospice provider was obtained, and the resident’s hospice admission became effective shortly thereafter. However, the resident’s clinical record contained no documentation related to the hospice provider’s visit on the day hospice services began, and the facility did not have provider documentation available in the record at that time. Review of the Hospice and Facility Coordinated Plan of Care in a binder at the nurses’ station showed that required information was missing, including the date, hospice diagnosis, funeral home information, diet, durable medical equipment used, medical supplies, code status, and the frequency of social worker or chaplain visits. The plan of care listed only that a nurse and hospice aide would visit twice a week. When the surveyor requested hospice documentation, the facility produced an email from the hospice provider containing the admission note only after the surveyor’s questioning. The DON and NHA later confirmed that the facility had no documentation from the contracted hospice provider since the resident’s admission more than a week earlier, and the facility stated that the hospice provider had told them documentation would be supplied monthly.
Improper Garbage Containment at Outside Dumpsters
Penalty
Summary
The facility failed to properly contain and dispose of garbage at the outside dumpsters. Observation of the main dumpsters on facility property found four dumpsters with at least one hinged lid open on each dumpster. One dumpster had multiple birds sitting on the top rail, and birds were observed on the garbage bags inside the dumpster and flew away when approached. The ground around the dumpsters contained discarded items including a plastic energy shot bottle, a medical glove, sugar packets, a discarded milk pint container, a plastic two-section tray, a plastic white single-serve pudding container, small paper products, and a battery. These observations were reviewed with the Nursing Home Administrator and DON.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post and retain daily nurse staffing information for one of four nursing units, Marble, over the past 18 months. Review of nurse staff postings for May 1, 2026 through June 14, 2026 showed no evidence of a staffing posting for May 19, 2026. Further review with the scheduler of October 2025 postings identified no evidence of daily staff postings for October 2, 10, 12, 15, 16, 17, 23, and 26, 2025. During observation of the Marble unit, surveyors found no evidence of nurse staff postings on the unit, and the scheduler confirmed there was no posting on the Marble unit and no evidence of the missing postings for the noted dates.
Failure to Prevent Neglect During Wheelchair Transport Resulting in Fracture
Penalty
Summary
A resident was being transported in a wheelchair by an agency LPN after attending an outside activity. During the transport, the resident's legs were not placed on leg rests and were covered by a blanket, which prevented the LPN from seeing their position. The resident complained of pain in her left leg after stating that her leg got stuck. Initial x-rays taken the same day were negative for fracture, but the resident continued to experience pain, swelling, and discomfort in her left ankle over the following days. Despite ongoing complaints and visible symptoms, it was not until a repeat x-ray several days later that an acute fracture of the distal left tibia and fibula was identified. The facility's investigation revealed that the LPN was unaware of the policy requiring the use of leg rests for residents unable to self-propel during wheelchair transport. The lack of adherence to this policy resulted in the resident's legs not being properly supported, leading to the incident and subsequent injury. The deficiency was identified as a failure to protect the resident from neglect by not providing necessary services to prevent physical harm.
Deficient Food Storage and Sanitation in Kitchen and Pantries
Penalty
Summary
The facility failed to store food and maintain food service equipment in accordance with professional standards for food safety in the main kitchen and two nursing unit pantries. In the main kitchen, open wire rack shelving in the walk-in cooler was found to be rusty with the exterior finish worn off, and food products were stored on lower shelves without barriers to protect from mop water splash or floor debris. A black plastic tub containing multiple clear plastic bags of chicken thighs was observed thawing in water without any labeling to indicate the product, date placed, or use-by date. Additional issues included a plate warmer with dust and dried food debris, bulk flour and sugar bins with soiled exteriors, and a buildup of dirt and debris on the floor under and around kitchen equipment. In the Oak/[NAME] pantry, a bin of individually packaged cookies was stored without any date to indicate when they were placed or needed to be used by, and refrigerator/freezer temperature logs had not been recorded for several days. In the Marble/Maple pantry, soiled meal trays, a package of graham crackers, and used plastic lids were stored in a cabinet with a large dried brown liquid spill and soiled door rims. The refrigerator and freezer in this pantry also had no recent temperature logs, and both units had significant ice and frost buildup. These findings were confirmed during an interview with the Nursing Home Administrator and DON.
Failure to Provide Required Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to provide required written notifications to residents and/or their representatives regarding transfers and the facility's bed-hold policy during hospitalizations. Specifically, for one resident who requested transfer to the hospital due to rectal pain, there was no documented evidence that either the resident or her responsible party received written notice of transfer or information about the facility's bed-hold policy. Interviews with facility staff confirmed that these notifications were not provided. Additionally, for two other residents who were transferred to the hospital for medical reasons, there was no documentation that they or their representatives received written notice of the facility's bed-hold policy at the time of transfer. Further review revealed that another resident was transferred to the hospital on two separate occasions for hypotension, and in both instances, there was no evidence that the resident received written information regarding the facility's bed-hold policy or a transfer notice containing all required information, such as contact details for the State Long-Term Care Ombudsman. Staff interviews confirmed the absence of these required notifications and documentation for all affected residents.
Failure to Provide Trauma-Informed and Culturally Competent Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents diagnosed with Post-Traumatic Stress Disorder (PTSD). For one resident, who had a diagnosis of PTSD since admission, the care plan did not identify any triggers or interventions to address individualized needs, and there was no documentation of a trauma assessment. For the second resident, who was diagnosed with PTSD following the murder of her two daughters, the facility did not identify her trauma, complete a trauma assessment, or develop a care plan to address triggers or interventions. These deficiencies were confirmed through clinical record review and staff interview, with the DON acknowledging awareness of the traumatic events affecting the residents.
Failure to Provide Required Annual In-Service Training for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides received the required 12 hours of annual in-service training, as evidenced by a review of employee education records and staff interviews. Specifically, three nurse aides, all hired prior to the current year, had only completed six hours of in-service training since January 2025, with no documentation showing completion of the full annual requirement. The Director of Nursing confirmed that in-service trainings for nurse aides had only recently begun in January 2025, resulting in insufficient training hours for the reviewed staff. This deficiency was identified through review of personnel files and confirmed in an interview with the Director of Nursing.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal health information by placing a binder in the main lobby that contained full health survey letters, complaint deficiency letters, and Statements of Deficiencies (Form CMS-2567) from previous surveys. These documents included specific resident identifiers and associated resident names for cited deficiencies, making personal and medical information accessible to anyone in the lobby. The binder was observed to contain deficiency letters and survey results from four previous surveys, each listing multiple residents by name and identifier. This breach of confidentiality was confirmed during an interview with the Nursing Home Administrator.
Failure to Ensure Psychotropic Medication Use Was Clinically Justified
Penalty
Summary
A resident was prescribed the antipsychotic medication Loxapine Succinate for a diagnosis of unspecified schizophrenia, according to her medication regimen and care plan. However, clinical record review and interviews revealed that there was no supporting documentation in the resident's medical record to confirm a diagnosis of schizophrenia. The facility's consulting psychiatric provider's progress notes only referenced a history of depression and did not mention schizophrenia or provide justification for the use of an antipsychotic. The care plan addressing psychotropic medication use did not include any target behaviors to support the indication for antipsychotic use, and behavior monitoring was limited to tracking if the resident was withdrawn. The resident herself reported a history of depression following her mother's death and denied ever experiencing symptoms such as delusions, hallucinations, or disorganized thinking. Interviews with facility staff confirmed the absence of documentation supporting a schizophrenia diagnosis and the lack of monitoring for specific target behaviors related to antipsychotic use. As a result, the facility failed to ensure the resident's medication regimen was free from potentially unnecessary psychotropic medication, as required by regulation.
Inaccurate MDS Discharge Assessment
Penalty
Summary
Facility staff failed to ensure that the assessment for one resident accurately reflected the resident's discharge status. Clinical record review showed that the Minimum Data Set (MDS) assessment documented the resident as being discharged to a short-term general hospital. However, further review revealed that the resident had actually signed out of the facility against medical advice and was not discharged to a hospital on the date in question. This discrepancy was confirmed during an interview with the Registered Nurse Assessment Coordinator (RNAC), who acknowledged that the MDS did not accurately represent the resident's actual discharge status.
Failure to Revise Care Plan Following Change in Oxygen Therapy Needs
Penalty
Summary
A deficiency was identified when the facility failed to revise the comprehensive care plan for a resident following a significant change in their condition. Clinical record review showed that the resident had a recent MDS assessment indicating the use of oxygen therapy, with a physician's order for supplemental oxygen at two liters per minute via nasal cannula every shift, and instructions to monitor oxygen saturation to keep it above 90 percent. The care plan included interventions for continuous oxygen use and medication administration as ordered, with monitoring for side effects and effectiveness. However, during observations on two separate occasions, the resident was found in bed without supplemental oxygen being administered. The resident confirmed in an interview that they were not utilizing the supplemental oxygen. Further interviews with the DON and Regional Director of Clinical Services revealed that the oxygen order was based on oxygen saturation, which had consistently been above 95 percent. Despite these changes in the resident's needs and interventions, the care plan was not updated to reflect the current status, resulting in a failure to revise the comprehensive care plan as required.
Failure to Provide Required Transfer and Eating Assistance to Dependent Resident
Penalty
Summary
A deficiency was identified when a resident, who was dependent for activities of daily living following right leg surgery and had significant vision loss, was not provided with the required assistance for transfers and eating. Despite an active physician's order and care plan interventions specifying that the resident should be out of bed for all meals and required two staff for transfers and repositioning, staff consistently failed to get the resident out of bed for meals. Observations and interviews confirmed that the resident remained in bed for all meals and was not routinely asked if she wanted to get out of bed, contrary to her care plan and physician's orders. Additionally, the resident, who was dependent for feeding, reported that not all staff stayed to assist her with meals, and staff interviews revealed a lack of awareness regarding her need for feeding assistance and transfer out of bed for meals. Documentation was inconsistent or missing for care provided, and staff were unclear about the resident's care requirements. The resident experienced significant weight loss since admission, and dietary documentation noted the need for meal assistance to ensure adequacy. The failure to provide necessary services for eating and transfer assistance constituted a deficiency in care for a dependent resident.
Failure to Follow Physician Orders for Medication Administration and Skin Protection
Penalty
Summary
The facility failed to provide care and treatment in accordance with physician orders for two residents. For one resident with a history of atrial fibrillation and hypertension, Metoprolol Succinate ER was administered on multiple occasions despite the resident's apical pulse being below the physician-ordered threshold of 60 beats per minute. There was no documentation explaining why the medication was given outside of the specified parameters, and staff interviews confirmed there was no reason for this deviation from the order. Another resident, who was prone to easy bruising and had a physician's order for Geri-sleeves to be applied to both arms every shift for skin protection, was repeatedly observed without the sleeves in place. The resident reported not having the sleeves applied for several days and denied refusing them. When sleeves were eventually applied, they were ill-fitting and slid down to the wrists, failing to provide the intended protection. These findings were confirmed through observations and interviews with the resident and facility staff.
Failure to Ensure Resident Access to Hearing Services and Devices
Penalty
Summary
The facility failed to ensure that a resident with Alzheimer's dementia received proper treatment and assistive devices to maintain hearing abilities. The resident reported difficulty hearing and was observed using a headphone amplifier, which he removed to answer his mobile phone, further decreasing his ability to hear. Documentation showed that staff were aware of issues with the resident's hearing aid, including a non-working device, an occluded filter, and battery corrosion. The resident's daughter was informed of these issues and questioned whether the facility could handle the service, but was told the facility could not and was encouraged to contact the hearing aid provider. Subsequent documentation indicated ongoing problems, such as the need for batteries, a missing hearing aid, and confusion about the device's whereabouts. The resident was described as a poor historian, and there was no evidence in the clinical record that staff contacted the audiology provider to arrange necessary services or confirm the status of the hearing aid. The resident's care plan and assessments did not accurately reflect the use of a hearing aid or include interventions for the hearing deficit, despite documentation of hearing difficulties. The Minimum Data Set (MDS) assessments failed to indicate the use of a hearing aid, and the care plan lacked individualized interventions addressing the resident's hearing needs. Additionally, after a VA appointment, there was no documentation regarding the repair or possession of the hearing aid, nor any follow-up communication with the audiology provider. These actions and omissions resulted in the facility's failure to accurately complete assessments, develop an individualized plan of care, and coordinate professional audiology services to assist the resident in maintaining hearing ability.
Unsecured Knives and Scissors Found in Resident's Unlocked Room
Penalty
Summary
A deficiency was identified when a resident's room was observed to contain a countertop wooden block with large scissors and seven knives visible near the television. The resident confirmed that he frequently leaves his room during the day to go outside or on leaves of absence, and that his room door does not lock. This situation resulted in the resident's environment not being free from accident hazards, as the unsecured knives and scissors were accessible in an unlocked room while the resident was often absent. The deficiency was confirmed through observation, resident interview, and review of the clinical record.
Failure to Develop Individualized Dementia Care Plan
Penalty
Summary
Facility staff failed to develop and implement an individualized, person-centered care plan for a resident diagnosed with unspecified dementia and severe cognitive impairment. Clinical record review showed that the resident was admitted with dementia and had a BIMS score of three, indicating severe cognitive impairment. The resident's care plan only included general interventions such as cueing, reorienting, therapy staff as needed, and lab work as needed, without any evidence of individualized interventions tailored to address the resident's specific dementia-related needs. This deficiency was identified through clinical record review and staff interview, and was confirmed during a review with the Director of Nursing.
Unattended, Unlocked Treatment Cart with Medications on Hallway
Penalty
Summary
A deficiency was identified when an unlocked treatment cart was observed on the Maple Hallway, positioned against a wall outside a resident's room. Upon inspection, multiple tubes of creams were found inside the cart's drawers. The cart remained unattended for five minutes, during which time two residents were seen moving independently in the hallway. No staff member was present to supervise the cart during this period. In an interview, the Director of Nursing confirmed that the cart should have been locked, as required by facility policy and regulations.
Failure to Ensure Full Visual Privacy During Personal Care
Penalty
Summary
A deficiency was identified when a resident was observed in their room during a brief change, and the privacy curtain did not fully extend around the bottom of the bed, resulting in a lack of full visual privacy. During a medication pass for the resident's roommate, a staff member waited until the resident was no longer exposed before proceeding, but the resident was still observed in bed, uncovered, and in a state of undress. Further observation confirmed that the curtain was not large enough to provide complete privacy, and the resident reported that the curtain had not extended around the bed since their admission. These findings were discussed with the Director of Nursing.
Infection Control Deficiencies at Mount Carmel Senior Living
Penalty
Summary
Mount Carmel Senior Living Community failed to correct previously identified deficiencies related to infection prevention and control, as observed during a revisit survey. The facility did not ensure an environment free from the potential spread of infection for two residents. Resident 15, who was under contact precautions for suspected C. diff infection, had inadequate disposal systems for contaminated materials. The cardboard receptacle used for disposing of gowns and gloves was porous and could not be properly disinfected, posing a risk of harboring bacteria. Additionally, a nurse aide was observed serving lunch to Resident 15 without wearing the required gown and gloves, contrary to the contact precautions in place. Resident 14, who had recently returned from a hospital stay for human metapneumovirus pneumonia, was under droplet precautions. However, the facility failed to provide appropriate disposal bins for personal protective equipment (PPE) within the resident's room. A physical therapy assistant was observed improperly handling used PPE, including carrying a contaminated glove under his arm due to the lack of disposal bins. Furthermore, a nurse aide entered Resident 14's room without wearing a gown, gloves, or mask, despite the droplet precautions, while delivering meal trays to both Resident 14 and their roommate. These observations indicate that the facility did not adhere to the required infection control protocols, as evidenced by the improper handling and disposal of PPE and the failure of staff to follow precautionary measures. The deficiencies were reviewed with the Nursing Home Administrator, highlighting ongoing non-compliance with infection prevention and control standards.
Plan Of Correction
Unable to correct the issue identified regarding Resident 15 related to a staff member not wearing proper PPE. Unable to correct the issue identified regarding Resident 14 related to a staff member not wearing Proper PPE. Isolation bins were put in Resident 14's room at the time of survey. New isolation bins with foot pedals have been ordered. A Facility sweep will be conducted to identify residents on any type of precautions to ensure proper protocols are in place (signage, isolation bins, etc.). Staff will be educated on the PPE requirements for the different types of isolation/precautions (ex. Contact, Droplet, Enhanced Barrier Precautions). Audits will be conducted by the IP/Designee weekly x 4 weeks, then monthly x 2 months for compliance with the applicable isolation protocols. Results of the audits will be reviewed at the monthly QAPI meetings.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to administer bowel protocol medications as ordered for three residents, leading to prolonged periods without bowel movements. Resident 1 did not receive the prescribed Bisacodyl tablet after three days without a bowel movement, as documented in the Medication Administration Record (MAR). Similarly, Resident 2 did not receive any Dulcolax medications or enemas despite not having a bowel movement for several days, as per the physician's orders. Resident 4 was also not administered the Bisacodyl suppository after the oral Dulcolax was ineffective, contrary to the physician's orders. The facility also failed to adhere to physician orders for blood sugar assessments and insulin administration for five residents, resulting in hypoglycemia and hospitalization for one resident. Resident 1, who has Type 2 diabetes mellitus, received insulin significantly earlier than her breakfast meal, leading to a dangerously low blood sugar level and subsequent hospitalization. The MAR indicated that insulin was administered well before the anticipated meal delivery, which is against the recommended timing for insulin administration relative to meals. Additionally, other residents, including Residents 3, 4, 5, 7, and 8, experienced similar issues with the timing of blood sugar assessments and insulin administration. Insulin was administered too early, relative to meal times, which could potentially lead to hypoglycemic events. The facility's failure to follow proper medication administration protocols and timing resulted in significant health risks for the residents involved.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment across four nursing units, as observed on March 18, 2024. In the [NAME] nursing unit shower room, there was rust around the doors, a warped and splintered door, and a brown substance with loose dirt particles on the floor. The shower stalls had black substances on the floors and walls, dirty shower chairs, rusted grab bars, and a clogged drain with hair buildup. The sink area was dirty, with a candy wrapper and hair in the sink, and the linen bins and trash bin were also dirty. The toilet area was unclean, with a bucket containing a brown substance nearby. Resident 6's room had a dirty overbed table, black areas on the floor, and a dirty privacy curtain. Resident 3's room was cluttered with personal items, including a box of instant coffee on the floor, baskets, a box, and slipper socks under the bed, and a disorganized tabletop with papers, food items, and hygiene products, hindering effective housekeeping. Resident 1's room had a brown substance smeared on the floor, which remained for several hours despite staff presence. Housekeeping staff confirmed the oversight and addressed it only after being informed by the surveyor. These environmental concerns were acknowledged by the Nursing Home Administrator and Assistant Director of Nursing during a meeting on the same day.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions for a resident with an indwelling urinary catheter, as required by the Centers for Medicare and Medicaid Services (CMS) guidelines. The guidelines specify that enhanced barrier precautions, including the use of gowns and gloves, should be used during high-contact resident care activities for residents with chronic wounds or indwelling medical devices. During an observation, it was noted that a nurse aide, identified as Employee 6, did not wear a gown while emptying urine from the resident's catheter collection bag, although gloves were used. The deficiency was confirmed through an interview with Employee 6, who acknowledged not wearing a gown and had no extenuating circumstances preventing her from doing so. The issue was further discussed with the Nursing Home Administrator and the Assistant Director of Nursing, highlighting the facility's failure to adhere to the required infection prevention and control measures. This deficiency was previously cited in August 2024, indicating a recurring issue with compliance in this area.
Inaccurate Nurse Staffing Data Posting
Penalty
Summary
Mount Carmel Senior Living Community was found to be non-compliant with the requirements for posting nurse staffing information as per 42 CFR Part 483, Subpart B. During an observation on January 2, 2024, it was noted that the facility's posted nurse staffing data inaccurately reflected the number of nurse aides working the dayshift. The posted information indicated that 11 nurse aides were on duty, while only 10 were actually present. Additionally, the posted nurse aide hours for the dayshift were listed as 88 hours, but the facility's schedule showed only 70 actual hours worked. The discrepancy in the posted nurse staffing data was confirmed through an interview with the Director of Nursing on the same day. This failure to accurately post nurse staffing information is a violation of the federal regulation that requires facilities to maintain and display accurate daily nurse staffing data. The facility's inability to ensure the accuracy of this information was a key factor leading to the deficiency cited in the survey report.
Plan Of Correction
The error in the Staff Posting was corrected at the time of Survey. The daily Staff Posting will be reviewed for accuracy by the DON/Designee. Staff responsible for completing the Staff Posting will be educated regarding its completion and the importance of its accuracy. Random audits of the Staff Posting will be conducted by the DON/Designee weekly for 4 weeks and monthly for 2 months. Results of the audits will be reviewed at the monthly QAPI meeting.
Facility Fails to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident ratios as mandated by regulations effective July 1, 2024. During the review period from December 26, 2024, to January 2, 2025, the facility did not maintain the minimum staffing levels for nurse aides across various shifts. Specifically, the day shift required one nurse aide per 10 residents, but the facility fell short on six out of eight days. Similarly, the evening shift required one nurse aide per 11 residents, but the facility did not meet this requirement on five out of eight days. The night shift, which required one nurse aide per 15 residents, was also understaffed on four out of eight days. The deficiency was confirmed through a review of nursing staff care hours and an interview with the Nursing Home Administrator and Director of Nursing. The review highlighted specific days where the number of nurse aides scheduled was insufficient for the resident census. For instance, on December 31, 2024, during the day shift, only 5.56 nurse aides were scheduled for a census of 104 residents, whereas 10.40 nurse aides were required. This pattern of understaffing was consistent across the reviewed period, indicating a systemic issue in maintaining the mandated staffing levels.
Plan Of Correction
The Facility is unable to correct past CNA ratios. The Facility is currently in the process of trying to partner with an outside provider to offer CNA classes at the Facility with the hope of increasing the Facility staff when the participants become CNAs. Facility ancillary Nursing staff assist in filling open shifts. Nursing staff will be educated on the Facility Attendance Policy. The Facility continues to actively recruit for open CNA positions using online systems, fliers, and outside recruiters. The Facility continues to use Agency staff to fill open shifts. Agency CNA rates were recently increased as an attempt to aid with staffing. Shift bonuses continue to be offered to Facility staff as necessary to aid in filling open positions. The Facility continues to conduct daily staffing meetings to ensure all available efforts are being made to meet necessary CNA ratios. The DON/Designee will audit CNA ratios weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reported at the monthly QAPI meeting for review and recommendations.
LPN Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to meet the required LPN-to-resident ratios as per the regulation effective July 1, 2023. During the review of nursing staffing hours from December 26, 2024, to January 2, 2025, it was found that the facility did not maintain the minimum staffing levels on several occasions. Specifically, on December 29, 2024, the day shift had 4.00 LPNs for a census of 103 residents, falling short of the required 4.12 LPNs. Additionally, the overnight shift was understaffed on five of the eight days reviewed, with the number of LPNs consistently below the required ratio for the resident census. Interviews with the Nursing Home Administrator and Director of Nursing confirmed these staffing deficiencies.
Plan Of Correction
The Facility is unable to correct past LPN ratios. Nursing staff will be educated on the Facility Attendance Policy. Facility ancillary Nursing staff assist in filling open shifts. The Facility continues to actively recruit for open LPN positions using online systems, fliers, and outside recruiters. The Facility also uses Agency staff to fill open shifts. Agency LPN rates were recently adjusted in an attempt to aid with staffing. Shift bonuses continue to be offered to Facility staff as necessary to aid in filling open shifts. The Facility continues to conduct daily staffing meetings to ensure all available efforts are being made to meet necessary LPN ratios. The DON/Designee will audit LPN ratios weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reported at the monthly QAPI meeting for review and recommendations.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per patient day (PPD) for four out of eight days reviewed. Specifically, on December 26, 2024, the facility provided 2.97 hours PPD; on December 29, 2024, 2.65 hours PPD; on December 31, 2024, 2.44 hours PPD; and on January 2, 2025, 3.13 hours PPD. This deficiency was confirmed through a review of nursing staffing hours and an interview with the Nursing Home Administrator and Director of Nursing on January 2, 2025, at 1:17 PM.
Plan Of Correction
The Facility is unable to correct the past issue of not meeting the 3.2 daily Nursing PPD requirement. The Facility is currently in the process of trying to partner with an outside provider to offer CNA classes at the Facility with the hope of increasing the Facility staff when the participants become CNAs. Facility ancillary Nursing staff assist in filling open shifts. Nursing staff will be educated on the Facility Attendance Policy. The Facility continues to recruit for open RN, LPN, and CNA positions using online sites, fliers, and outside recruiters. The Facility continues to use Agency staff to fill open shifts. Agency CNA rates were recently increased to try to assist with staffing. Shift bonuses are also offered as necessary to Facility staff to fill open shifts. The Facility continues to conduct daily staffing meetings to ensure efforts were made to meet the daily PPD requirement. The DON/Designee will audit the daily PPD weekly for 4 weeks, then monthly for 2 months for compliance. Results of the audits will be reviewed at the monthly QAPI meeting.
Deficiency in Insulin Administration Timing
Penalty
Summary
The facility failed to provide the highest practicable care regarding physician-ordered blood sugar assessments and insulin administration for five of nine residents reviewed. The facility's policy on insulin administration, last reviewed without changes, did not include instructions for administering insulin per professional standards of practice, such as administering fast-acting insulin with a meal. This led to residents receiving insulin significantly earlier than their meals, which is not in line with the recommended practice of administering fast-acting insulin within five to ten minutes before a meal. Interviews with staff revealed that third-shift employees were conducting blood glucose assessments and administering insulin before the end of their shift, which was well before the residents' breakfast meals were served. For instance, Resident 1 received her insulin more than an hour before her breakfast, despite physician orders indicating insulin should be administered based on a sliding scale before meals. Similar issues were observed with Residents 2, 3, 8, and 9, where blood glucose assessments and insulin administrations were conducted significantly earlier than meal times, contrary to the recommended practice. The Director of Nursing confirmed that the scheduling of blood glucose assessments and meal delivery predisposed residents to receive insulin more than an hour before their meals. The facility lacked a policy or standard of practice to guide licensed staff on implementing physician orders that included parameters for completion before a meal. This deficiency was previously cited, indicating a recurring issue with the facility's management of insulin administration and blood glucose monitoring in relation to meal times.
Failure to Provide Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing support for three residents who required staff assistance with activities of daily living. Resident 6, who was assessed as needing supervision and touching assistance for bathing, did not receive a shower for 22 days despite her preference for showers on specific days. The nursing staff documented that Resident 6 refused showers, but during an interview, she stated that she did not refuse them. Resident 5, admitted on November 11, 2024, required partial moderate assistance for bathing and preferred showers on specific days. However, since admission, he only received two showers, and he expressed confusion about receiving bed baths instead of showers. Resident 7, who was dependent on staff for bathing, did not receive any showers or tub baths in the last 30 days, contrary to her care plan. She expressed a desire for showers but was unable to walk, and she became emotional during the interview. These deficiencies were discussed with the Nursing Home Administrator and Director of Nursing.
Failure to Promote Healing of Pressure Ulcers
Penalty
Summary
The facility failed to promote the healing of pressure ulcers for a resident identified as high risk for skin breakdown. Upon admission, the resident was assessed with a Braden score of 12, indicating a high risk for skin breakdown, and was noted to have redness and an open area on the left buttock. Despite the facility's policy requiring ongoing weekly evaluations of resident skin, the last documented assessment was on September 30, 2024, which noted unstageable slough and/or eschar on the resident's left gluteal fold and sacrum. No further assessments were documented after this date. On October 2, 2024, the resident complained of wound bleeding, prompting new orders for the sacral and left gluteal fold injuries. However, the next documentation regarding the resident's pressure ulcers was not until October 16, 2024, when it was noted that the ulcers had resolved. The lack of consistent and timely assessments and documentation of the resident's pressure ulcers led to the deficiency, as confirmed by a licensed practical nurse and wound nurse during an interview.
Failure to Serve Meals Timely and at Proper Temperature
Penalty
Summary
The facility failed to serve food at a palatable temperature and in a timely manner across four resident hallways: Maple, Marble, Oak, and [NAME] hallways. Observations revealed discrepancies between the posted meal serving times and the actual delivery times of meal carts. Specifically, early trays were scheduled for 11:45 AM but arrived at 12:30 PM, Marble Hall trays were scheduled for 12:00 PM but arrived at 1:20 PM, [NAME] Hall trays were scheduled for 12:18 PM but arrived at 1:00 PM, Oak Hall trays were scheduled for 12:10 PM but arrived at 1:35 PM, and Maple Hall trays were scheduled for 12:35 PM but arrived at 1:42 PM. During the meal service on Maple Hall, the shepherd's pie was found to be lukewarm at 122.7 degrees Fahrenheit when tested by the surveyor. This information was reviewed with the Nursing Home Administrator and Director of Nursing.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 258 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mt Carmel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Rehabilitation And Senior Living Ctr | 6.2 mi | ★★★★★ | 30 | 0 |
| Tremont Health & Rehabilitation Center | 11 mi | ★★★★★ | 8 | 0 |
| Broad Mountain Health And Rehabilitation Center | 11.1 mi | ★★★★★ | 16 | 1 |
| Ridgeview Healthcare & Rehab Center | 12.9 mi | ★★★★★ | 26 | 0 |
| Shenandoah Senior Living Community | 13.2 mi | ★★★★★ | 16 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.