Mount Carmel Care Center

In the surveyor’s words

From the most serious findings on record at Mount Carmel Care Center, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 10, 2024

  Based on observation, interview, record and policy review, the facility failed to ensure that care and services to prevent and/or treat pressure ulcers were provided for two Residents (#57 and #15), out of three applicable residents reviewed, out of a total sample of 17 residents. Specifically, the facility failed to: 1. For Resident #57, ensure timely assistance with bedpan use to prevent the development of a pressure ulcer to his/her sacrum (triangular bone in the lower back) for the Resident who was at increased risk for pressure ulcers. 2. […]

• Actual harm, isolatedF580Aug 31, 2021

  Based on policy review, record review, observation and interviews, the facility failed to notify the Resident and their Physician of a significant change in the Resident's physical status in relation to his/her weight, for one sampled Resident (#56), out of a total sample of 15 residents. Findings include: Review of the facility policy titled, Nursing Service: Notification of Changes, dated 9/15/17, indicated: -the facility shall promptly notify the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative(s) when there are changes in the resident's condition or status, in order to obtain orders for appropriate treatment and monitoring, and promote the resident's right to make choices about treatment and care… […]

• Actual harm, isolatedF692Aug 31, 2021

  Based on record review, interview and observations, the facility failed to ensure care and services were provided relative to therapeutic nutritional interventions for one sampled Resident (#56) identified as at nutritional risk, out of a total sample of 15 residents. Findings include: For Resident #56, the facility failed to ensure weekly weights were monitored and failed to ensure nutritional interventions were provided as recommended by the dietitian. The Resident experienced significant weight loss (5 percent (%) of weight decline over one month, or 10% weight decline over six months) since admission. Resident #56 was admitted to the facility in April 2021. […]

• No harm, potential for more than minimal, widespreadF725Apr 10, 2024

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

• No harm, potential for more than minimal, widespreadF726Apr 10, 2024

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