Deficiency Records for Mount Carmel Senior Living Community
Updated as of March 01, 2024
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? |
|---|---|---|---|---|
| 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 |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-24 | 2021-11-08 | N |
| 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 | 2021-09-24 | 2021-11-08 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-24 | 2021-11-08 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-24 | 2021-11-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-24 | 2021-11-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-24 | 2021-11-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-24 | 2021-11-08 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2021-09-24 | 2021-11-08 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-09-24 | 2021-11-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-24 | 2021-11-08 | N |
| Provide or obtain dental services for each resident. | Health | 2021-09-24 | 2021-11-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-09-28 | 2021-11-08 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-09-28 | 2021-11-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-09-28 | 2021-11-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-28 | 2021-11-08 | N |
