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Deficiency Records for Mount Carmel Senior Living Community
A list of the most recent deficiencies for Mount Carmel Senior Living Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Mount Carmel Senior Living Community. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-23 | 2024-09-27 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-08-23 | 2024-09-27 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2024-08-23 | 2024-09-27 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-23 | 2024-09-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-23 | 2024-09-27 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-08-23 | 2024-09-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-23 | 2024-09-27 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-23 | 2024-09-27 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2024-08-23 | 2024-09-27 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-08-23 | 2024-09-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-23 | 2024-09-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-23 | 2024-09-27 | Y |
| Provide a neutral and fair arbitration process and agree to arbitrator and venue. | Health | 2024-08-23 | 2024-09-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-23 | 2024-09-27 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-08-23 | 2024-09-27 | Y |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2024-08-06 | 2024-09-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-08-06 | 2024-09-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-06 | 2024-09-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-06 | 2024-09-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-03 | 2024-04-23 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-19 | 2024-02-19 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-01-19 | 2024-02-19 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-09-22 | 2023-10-27 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-22 | 2023-10-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-22 | 2023-10-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-09-22 | 2023-10-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-22 | 2023-10-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-22 | 2023-10-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-22 | 2023-10-27 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-09-22 | 2023-10-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-22 | 2023-10-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-30 | 2023-09-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-30 | 2023-09-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-30 | 2023-09-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-30 | 2023-09-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-23 | 2023-03-16 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-09-20 | 2022-10-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-20 | 2022-10-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-20 | 2022-10-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-20 | 2022-10-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-02 | 2022-09-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-02 | 2022-09-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-02 | 2022-09-28 | N |
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