Mount Carmel Senior Living Community

In the surveyor’s words

From the most serious findings on record at Mount Carmel Senior Living Community, in the surveyor’s own words.

• Actual harm, isolatedF600Dec 3, 2025

  Based on observation, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm related to a fracture of her left lower leg for one of five residents reviewed for abuse/neglect (Resident 1). This deficiency is cited as past noncompliance Findings include: Observation of Resident 1 on December 3, 2025, at 1:00 PM revealed she was in bed and she appeared to be sleeping. Clinical record review for Resident 1 revealed a progress note dated October 24, 2025, at 11:27 AM that indicated Resident 1 was being transported in her wheelchair to an outside activity. […]

• Actual harm, isolatedF684Mar 18, 2025

  Based on a review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding bowel protocol medication administration for three of seven residents reviewed (Residents 1, 2, and 4); and physician ordered blood sugar assessments and insulin administration for five of nine residents reviewed (Marble hallway: Residents 3, 7, and 8; Maple hallway: Resident 5; and [NAME] Hallway: Resident 4) resulting in hypoglycemia and hospitalization for one of nine residents reviewed (Maple hallway: Resident 1). […]

• No harm, potential for more than minimal, widespreadF812Jun 17, 2026

  Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner and maintain equipment in a sanitary condition, in the main kitchen of the facility.Findings include: Initial tour of the facility's main kitchen with Employee 1, dietary staff, on June 14, 2026, at 9:20 AM revealed the following: A walk-in cooler contained the following: a bowl of pudding and two large, flat trays of a prepared food item open to the ambient air with no protection from the contamination, a container of buttered noodles with no dates on it, six cardboard boxes of food items (some of the boxes contained yogurt, a box with pork printed on the side, and cucumbers) that were stored directly on the floor of the cooler. […]

• No harm, potential for more than minimal, widespreadF812Jul 18, 2025

  Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in accordance with professional standards for food service safety in the facility's main kitchen, and two of two nursing unit pantries (Oak/[NAME] and Marble/Maple). Findings include: An observation in the facility's main kitchen on July 15, 2025, at 9:22 AM revealed the following: Open wire rack shelving was observed in the walk-in cooler near the beverage station. Multiple wire shelves were observed rusty with the exterior finish worn off. The lower shelves located six to eight inches from the floor with food products stored on them contained no barrier from the potential for mop water splash or sweeping debris from the floor. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2023

  Based on observation and staff interview, it was determined that the facility failed to store and prepare food in a safe and sanitary environment in the facility's main kitchen. Findings include: An observation of the facility's main kitchen on September 19, 2023, at 9:37 AM revealed the following: The ice machine was leaking water from the back right corner base of the machine directly on to the flooring, a large puddle of water was observed on the floor, no water was observed entering the floor drain from the machine. The flooring in the dry storage room contained a buildup of dust, debris, condiments, lids, and papers under the shelving units, along the walls, and corners of the room. Some condiment packets were observed discolored and stuck to the floor along the wall. […]