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 Complaint Investigations completed on January 19, 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:


483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on observation and staff interview, it was determined that the facility failed to provide a clean, comfortable, and homelike environment on one of four nursing units reviewed (Maple Nursing Unit, Resident 1).

Findings include:

Observation of Resident 1's room on the Maple Nursing Unit on January 19, 2024, at 11:10 AM and 12:19 PM revealed the following:

A significant accumulation of crumbs and debris under the bed especially near the foot of the bed.

The perimeter of the floor where it met the wall near the egress door to the room had an accumulation of crumbs and debris.

The floor mat next to the bed was covered with dirty footprints and had several white stains on it.

There was a plastic bag filled with rocks that was propped against the door to keep it open.

Resident 1's scoot chair had a significant accumulation of debris under the cushion of the chair.

The above information was reviewed in a meeting with the Director of Nursing and Assistant Director of Nursing on January 19, 2024, at 4:05 PM.

28 Pa. Code 201.18(b)(3)(e)(2.1) Management


 Plan of Correction - To be completed: 02/19/2024

F584
1. Resident 1's rooms has been cleaned, door has been adjusted, scoot-chair cleaned, and other noted items have been resolved.
2. Maple Nursing unit and resident rooms have been inspected and are routinely being cleaned and checked for repair needs.
3. Housekeeping and nursing staff have been re-educated to promote a clean and orderly environment. When areas of dirtiness are revealed, cleaning will be completed to eliminate the concern. Facility administration will complete routine environmental rounds to maintain a clean and orderly environment.
4. NHA/designee will audit nursing units and resident rooms to ensure a clean and orderly environment. 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.
5. Corrective Action Date: February 19, 2024.



483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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.
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to accurately document the nutritional status and ensure appropriate adaptive equipment was utilized for one of one resident reviewed for nutrition concerns (Resident 1).

Findings include:

A current diagnoses list for Resident 1 included a history of dysphagia oral phase (a type of swallowing disorder) and feeding difficulties.

A current physician's order for Resident 1 dated September 20, 2023, was to initiate "dependent for feeding" and other orders dated October 12, 2023, was to initiate a tall blue lidded cup with a straw at all meals and an early tray for all meals per family request.

Clinical record review for Resident 1 revealed a current care plan that noted nutritional concerns related to the resident's history, therapeutic diet, and varied intake. An intervention noted was to utilize adaptive equipment that included a tall cup with lid and straw.

Clinical documentation for Resident 1 revealed an MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) that indicated the resident had a BIMS (Brief Interview for Mental Status) score of 5 indicating a moderately impaired cognitive level.

A dietary note dated January 1, 2024, at 11:57 AM revealed the resident was a dependent feed and utilized a "tall blue cup with a straw to aid with meal acts."

Observation of Resident 1 on January 19, 2024, at 11:10 AM revealed the resident was in bed sleeping.

Review of the meal percentage documentation (the amount of meal eaten) for Resident 1 revealed that Employee 1, nurse aide, on January 19, 2024, at 12:28 PM documented the resident ate 26 percent to 50 percent of her lunch.

Observation of Resident 1 on January 19, 2024, at 12:38 PM revealed the resident was still in bed. The lunch meal tray was sitting untouched on a bedside table five feet from the resident with a floor mat between the bed and the bedside table. There were no staff present in the room. There was no adaptive cup with the food tray.

Observation of Resident 1 on January 19, 2024, at 1:18 PM revealed that Employee 2, nurse aide, had attempted to feed the resident her lunch after getting the resident out of bed.

Observation on January 19, 2024, at 1:22 PM revealed Employee 2 carrying Resident 1's meal tray from the room, which appeared to be uneaten. Employee 2 confirmed it was Resident 1's meal tray and advised the resident only ate "two bites." Employee 2 was also unsure about adaptive equipment for Resident 1 and stated that it would be listed on the meal ticket with the tray if anything is needed. Observation of the meal ticket for Resident 1 with the tray indicated a tall cup with lid and straw, which was not present on the tray.

An interview with Employee 1 on January 19, 2024, at 1:32 PM regarding the meal percent being documented as 26 percent to 50 percent of Resident 1's lunch being eaten revealed that she had documented "putting a cereal left over from breakfast" under the lunch meal percentage. However, Employee 1 could not verbalize the time this was given to the resident and further noted she could have documented it under an "as needed" meal instead.

The facility failed to accurately document a lunch intake for Resident 1 and provide the appropriate adaptive equipment as noted in the care plan and physician's order.

The above information was review with the Director of Nursing, Assistant Director of Nursing, and
Dietitian on January 19, 2024, at 4:05 PM.

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


 Plan of Correction - To be completed: 02/19/2024

F692
1. Resident 1 has been reviewed by therapy; appropriate adaptive equipment is being used based on the recommendations from the therapy department. Documentation is being recorded accurately.
2. Current residents utilizing adaptive equipment have been reviewed and are utilizing the equipment according to physician order and documentation is accurately being recorded.
3. Nursing staff have been re-educated on the facility on ensuring appropriate adaptive equipment is in place and the need for accurate documentation.
4. Nursing/Dietary staff will audit resident records to ensure accurate documentation is completed and appropriate adaptive equipment is being provided. 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.
5. Corrective Action Date: February 19, 2024.

§ 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 21 days reviewed; one nurse aide per 12 residents during the evening shift for one of 21 days reviewed; and one nurse aide per 20 residents for eight of the 21 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:

December 31, 2023, 7.50 NAs for a census of 98; requires 8.17 NAs
January 2, 2024, 7.94 NAs for a census of 99; requires 8.25 NAs
January 14, 2024, 8.50 NAs for a census of 104; requires 8.67 NAs

Evening shift:

January 6, 2024, 8.25 NAs for a census of 101; requires 8.42 NAs

Night shift:

December 31, 2023, 4.13 NAs for a census of 98; requires 4.90 NAs
January 1, 2024, 4 NAs for a census of 99; requires 4.95 NAs
January 2, 2024, 4.13 NAs for a census of 99; requires 4.95 NAs
January 3, 2024, 4 NAs for a census of 99; requires 4.95 NAs
January 6, 2024, 4 NAs for a census of 101; requires 5.50 NAs
January 7, 2024, 4 NAs for a census of 101; requires 5.05 NAs
January 9, 2024, 4 NAs for a census of 100; requires 5 NAs
January 10, 2024, 4.5 NAs for a census of 100; requires 5 NAs

The above findings were confirmed via phone with the Director of Nursing on January 22, 2024, at 1:53 PM.


 Plan of Correction - To be completed: 02/19/2024

P5510

Staffing

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.

5. Corrective Action Date: February 19, 2024

§ 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 30 residents during the evening shift for one of the 21 days reviewed; and one licensed practical nurse per 40 residents during the night shift for nine of 21 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:

Evening shift:

January 6, 2024, 3.31 LPNs for a census of 101; requires 3.37 LPNs

Night shift:

December 29, 2023, 2.13 LPNs for a census of 98; requires 2.45 LPNs
December 31, 2023, 2.13 LPNs for a census of 98; requires 2.45 LPNs
January 2, 2024, 2.13 LPNs for a census of 99; requires 2.48 LPNs
January 6, 2024, 2.13 LPNs for a census of 101; requires 2.53 LPNs
January 9, 2024, 2 LPNs for a census of 100; requires 2.5 LPNs
January 13, 2024, 2 LPNs for a census of 106; requires 2.65 LPNs
January 14, 2024, 2 LPNs for a census of 104; requires 2.6 LPNs
January 15, 2024, 2 LPNs for a census of 104; requires 2.6 LPNs
Janaury 16, 2024, 2 LPNs for a census of 103; requires 2.58 LPNs

The above findings were reviewed via phone with the Director of Nursing on Janaury 22, 2024, at 1:53 PM.


 Plan of Correction - To be completed: 02/19/2024

P5530


Staffing

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.

5. Corrective Action Date: February 19, 2024


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