Pennsylvania Department of Health
MOUNT CARMEL SENIOR LIVING COMMUNITY
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

MOUNT CARMEL SENIOR LIVING COMMUNITY
Inspection Results For:

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MOUNT CARMEL SENIOR LIVING COMMUNITY - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on an Abbreviated Survey in response to a Complaint, completed on May 3, 2024, it was determined that Mount Carmel Senior Living Community was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

§ 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based on a review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one nurse aide per 12 residents during the evening shifts for one of nine days reviewed; and failed to ensure a minimum of one nurse aide per 20 residents during the night shift for one of nine days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following nurse aides (NA) scheduled for the following resident census:

Evening:
April 25, 2024, 7.38 nurse aides for a census of 100; requires 8.33 nurse aides.

Night shift:
April 27, 2024, 5.00 nurse aides for a census of 102; requires 5.10 nurse aides.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 3, 2024, at 3:20 PM.

Plan of Correction - To be completed: 05/22/2024

1. The Facility is unable to correct past CNA staffing ratios.

2. The Facility continues recruitment for open CNA positions using online systems, fliers, and offsite recruiters. Agency staff continue to be used to fill open shifts Bonuses continue to be offered to Facility staff as necessary to fill open positions.

3. The Facility continues to conduct daily staffing meetings to ensure efforts were met to meet necessary CNA ratios.

4. DON/Designee will audit ratios weekly for 4 weeks, then monthly for two months to ensure CNA ratios are met. Results of audits will be reported to QA Committee for review and recommendations. These audits will be completed on a bi-monthly basis for one month and then follow monthly for 2 additional months.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing staffing hours and staff interview, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 40 residents during the night shift for two of nine days reviewed.

Findings include:

Review of nursing staff care hours provided by the facility revealed the following licensed practical nurse (LPN) scheduled for the following resident census:

Night shift:
April 24, 2024, 2.00 LPNs for a census of 99; requires 2.48 LPNs.
April 25, 2024, 2.00 LPNs for a census of 100; requires 2.50 LPNs.

The findings were reviewed with the Nursing Home Administrator and Director of Nursing on May 3, 2024, at 3:20 PM.

Plan of Correction - To be completed: 05/22/2024

1. The Facility is unable to correct past LPN staffing ratios.

2. The Facility continues recruitment for open LPN positions using online systems, fliers, and offsite recruiters. Agency staff continue to be used to fill open shifts Bonuses continue to be offered to Facility staff as necessary to fill open positions.

3. The Facility continues to conduct daily staffing meetings to ensure efforts were met to meet necessary LPN ratios.

4. DON/Designee will audit ratios weekly for 4 weeks, then monthly for two months to ensure LPN ratios are met. Results of audits will be reported to QA Committee for review and recommendations. These audits will be completed on a bi-monthly basis for one month and then follow monthly for 2 additional months.

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