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

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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 four Complaints, completed on April 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.


 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in 483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in 483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in 483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in 483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under 483.15(c)(9).
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to notify the responsible party of a resident's change in condition requiring interventions for one of five residents reviewed (Resident CR1).

Findings include:

Closed clinical record review for Resident CR1 revealed a progress note dated November 28, 2023, at 8:47 AM that indicated she was coughing with her meal, pocketing food, and a speech therapy consult was initiated.

Review of the speech therapy screen completed on November 28, 2023, and signed by the speech therapist on November 29, 2023, at 11:30 AM, revealed that Resident CR1 was pocketing food, but she was not medically appropriate for skilled treatment due to increased lethargy (unusual decrease in consciousness/alertness). The speech therapist indicated to downgrade Resident CR1's diet to puree (smooth with no lumps) texture with nectar thick (easily to pour and are comparable to heavy syrup found in canned fruit) liquids.

Further clinical record review revealed a nursing progress note dated November 29, 2024, at 5:26 AM that indicated the nurse could not safely administer Resident CR1's medications due to lethargy and her being slow to arouse. The note also indicated that Resident CR1 was pale and that her temperature was 101.7 degrees Fahrenheit, so she administered Tylenol (a fever-reducing medication).

A physician's order dated December 1, 2023, at 9:54 AM revealed that the physician ordered for Resident CR1 to have the following labs STAT (immediately): Complete Blood Count (CBC, a measure of the number of red blood cells, white blood cells, and platelets in the blood in order to look at overall health), Basic Metabolic Panel (BMP, a test that measures important information regarding the body's chemical balance), and a Urinalysis with Culture and Sensitivity (UA C&S, a lab test to check for bacteria or other germs in the urine).

A nursing progress note dated December 1, 2023, at 10:00 AM indicated that Resident CR1's daughter was called and updated on her increased lethargy, tremors, difficulty taking medications, having a fever, and new orders.

The facility did not update Resident CR1's daughter about her change of condition that began on November 28, 2024, that required new interventions, until December 1, 2023.

The surveyor confirmed the above findings during an interview with the Director of Nursing and Nursing Home Administrator on April 3, 2024, at 11:15 AM.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services


 Plan of Correction - To be completed: 04/23/2024

1. Facility cannot retroactively correct closed record one.

2. Administration has completed in-service education with all staff related to 483.10(g)(14) Notification of Changes.

3. Facility implemented system of daily review of nurses' notes addressing resident condition changes and medication/treatment changes. Corresponding notes are reviewed for confirmation of the notification. Professional nursing staff have been educated on this process.

4. DON/Designee will audit ratios weekly for 4 weeks, then monthly for two months to ensure proper notification. 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)(2) LICENSURE Nursing services. :State only Deficiency.
(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 day shift for three of the 22 days reviewed; one nurse aide per 12 residents during the evening shift for three of 22 days reviewed; and one nurse aide per 20 residents during the night shift for one of the 22 days reviewed.

Findings include:

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

Day shift:

February 29, 2024, 8.32 NAs for a census of 101; requires 8.42
March 2, 2024, 7.47 NAs for a census of 100; requires 8.33
March 10, 2024, 8.00 NAs for a census of 97, requires 8.08

Evening shift:

March 2, 2024, 7.03 NAs for a census of 100; requires 8.33
March 22, 2024, 6.50 NAs for a census of 95; requires 7.92
April 1, 2024, 8.00 NAs for a census of 101; requires 8.42

Night shift:

April 1, 2024, 4.00 NAs for a census of 101; requires 5.05

The above findings were confirmed with the Nursing Home Administrator and Director of Nursing on April 3, 2024, at 11:30 AM.


 Plan of Correction - To be completed: 04/23/2024

1. Facility cannot retroactively correct past Nursing ratios.

2. The facility continues recruitment for open Nursing positions, through online systems, fliers, and offsite recruiters. Sign-on bonuses continue to be offered to prospective employees for open positions.

3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet necessary NA ratios. Nursing Scheduler educated with this process.

4. DON/Designee will audit ratios weekly for 4 weeks, then monthly for two months to ensure NA 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. :State only Deficiency.
(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 a 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 25 residents during the day shift on 2 of 22 days reviewed and one licensed practical nurse per 40 residents during the night shift.

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:

Day shift:

March 16, 2023, 3.00 LPNs for a census of 96; requires 3.84
March 17, 2023, 3.00 LPNs for a census of 96; requires 3.84

Night shift:

March 2, 2024, 2.09 LPNs for a census of 100; requires 2.50
March 14, 2024, 2.00 LPNs for a census of 98; requires 2.45
March 19, 2024, 2.00 LPNs for a census of 96; requires 2.40
March 22, 2024, 2.00 LPNs for a census of 95; requires 2.38
April 1, 2024, 2.00 LPNs for a census of 101; requires 2.53

The above findings were reviewed with the Nursing Home Administrator and the Director of Nursing via telephone on April 3, 2024, at 11:30 AM.


 Plan of Correction - To be completed: 04/23/2024

1. Facility cannot retroactively correct past Nursing ratios.

2. The facility continues recruitment for open Nursing positions, through online systems, fliers, and offsite recruiters. Sign-on bonuses continue to be offered to prospective employees for open positions.

3. Facility implemented system of daily staffing meetings to ensure efforts were met to meet necessary LPN ratios. Nursing Scheduler educated with this process.

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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