Mt Carmel Home - Keens Memorial

In the surveyor’s words

From the most serious findings on record at Mt Carmel Home - Keens Memorial, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Nov 16, 2023

  Licensure Reference Number 175NAC 12-006.17D Licensure Reference Number 175NAC 12-006.18C1 Based on observations, record reviews, and interviews the facility failed to ensure that staff performed hand sanitization (hand washing using soap and water or an alcohol-based hand rub (ABHR) to remove germs for reducing the risk of transmitting infection among patients and health care personnel) to prevent the potential for cross contamination during laundry delivery for 13 residents (Residents 39, 40, 54, 47, 51, 14, 32, 11, 7, 22, 29, 50, and 2) of 13 residents observed; failed to ensure that staff performed hand sanitization to prevent the potential for cross contamination during delivery of room meals for 4 residents (Residents 29, 15, 26, and 31) of 4 residents observed; failed to ensure that… […]

• No harm, potential for more than minimal, patternF655May 11, 2021

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.09C1a Based on interview and record review, the facility staff failed to provide a written summary of the baseline care plan to the resident and/or PR (Personal Representative) which affected 3 of 8 sampled residents, Residents 35,46, and 39. The facility identified a census of 50 at the time of survey. Findings are: A. Review of Resident 35's Admission MDS (Minimum Data Set-a comprehensive assessment tool used to develop a resident's care plan) dated 3/16/2021 revealed an admitted [DATE]. Staff assessment for mental status indicated short term memory problems and modified independence with decision making. […]

• No harm, potential for more than minimal, patternF812May 11, 2021

  Licensure Reference Number 12-006.11C Based on observation, interview, and record review; the facility staff failed to ensure that meals were not served from reused food trays to prevent the potential for cross contamination in the main dining room which affected 36 of 36 residents who received food in the main dining room (Residents 13, 6, 2, 29, 20, 34, 40, 43, 19, 46, 41, 21, 17, 42, 48, 3, 1, 35, 32, 7, 9, 11, 39, 31, 33, 12, 45, 23, 28, 50, 5, 38, 52, 25, 51, and 10) and the facility failed to ensure that staff handled ready to eat foods in a manner to prevent hands from contacting the food to prevent the potential for cross contamination for 1 of 11 residents who ate their meal in the special care unit dining room (Resident 36). […]

• No harm, potential for more than minimal, patternF880May 11, 2021

  Licensure Reference Number 175NAC 12-006.17D Based on observation, interview, and record review the facility failed to ensure that staff followed the facility procedure for washing hands during food service and resident care to prevent the potential for cross contamination (the transfer of harmful microorganisms, usually bacteria and viruses from one person, object or place to another). This had the potential to affect 5 of 11 residents observed (Residents 44, 15, 22, 24, and 8). The facility census was 50. Findings are: Record review of the facility policy titled Hand Washing dated 12/19 revealed the policy that handwashing is regarded by the facility as the single-most important means of preventing the spread of infections and food borne illnesses. […]

• No harm, potential for more than minimal, patternF880Jan 7, 2021

  LICENSURE REFERENCE NUMBER 175 NAC 12-006.17B LICENSURE REFERENCE NUMBER 175 NAC 12-006.17D LICENSURE REFERENCE NUMBER 175 NAC 12-006.18C Based on observation, interview, and record review; the facility failed to prevent the potential spread of Covid-19 and other infectious diseases by failing to doff PPE (Personal Protective Equipment-gowns, gloves, face masks, shoe covers worn to protect the wearer from potential infection) at the point of contact (staff exited residents' rooms with gown and gloves and walked down the hall with them on) which had the potential to affect all of the residents who resided on units 1, 2 and 3 who had not tested positive for Covid-19 or had tested positive over 90 days ago and were at risk for re-infection: Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13,… […]