Inspection Reports for Mt Carmel Home – Keens Memorial

The complaint alleged failure to ensure transportation to medical appointments and failure to answer call lights timely. Transportation was found compliant, but call light response was substantiated as deficient with documented delays and resident/family concerns.

The facility was found compliant with transportation requirements but failed to answer call lights in a timely manner for dependent residents, with multiple documented delays up to 90 minutes. Additionally, the facility failed to provide an RN for at least eight consecutive hours on one day during the review period.

The complaint allegations included failure to use fall interventions to prevent injuries, failure to immediately report allegations of abuse, failure to ensure residents do not have access to hazardous items, and failure to protect residents from abuse. The investigation found the facility in compliance with all related regulatory requirements for these allegations.

The complaint allegations regarding failure to use fall interventions, failure to immediately report abuse, failure to protect residents from abuse, and failure to ensure residents do not have access to hazardous items were investigated during the annual survey. The facility was found to be in compliance with related regulatory requirements for all allegations. Several deficiencies were cited related to criminal background checks, resident belongings inventory, resident dignity, accuracy of assessments, unnecessary drug use, food safety, sprinkler system maintenance, corridor door latching, electrical system maintenance, and oxygen cylinder storage.

The complaint alleged the facility failed to protect residents from residents with adverse behaviors. The complaint was investigated and substantiated with findings of physical altercations and lack of care plan revisions.

The investigation found that the facility failed to review and revise care plans for six sampled residents following physical altercations between residents, resulting in violations of federal and state regulations.

The complaint investigation included allegations of failure to reevaluate interventions for adverse behaviors, failure to provide medications as ordered, failure to ensure residents were free from misappropriation, failure to put interventions in place to prevent injuries, and failure to ensure clean clothing and/or groomed hair. All allegations were found to be in compliance after investigation.

The complaint allegations regarding failure to reevaluate interventions for adverse behaviors, medication administration, misappropriation prevention, injury prevention interventions, and ensuring clean clothing and grooming were all found to be in compliance. However, multiple deficiencies were identified including residents' fear of reprisal when voicing grievances, failure to deliver mail on Saturdays, unsecured hazardous chemicals accessible to residents, failure to follow menu portions, unsanitary kitchen conditions, outdated nursing supplies, improper suprapubic catheter care, missing 'No Exit' signage on courtyard doors, obstructed exit doors, delayed egress door issues, lack of hard path to public way from exit, lack of preventative maintenance for fire doors, smoke barriers with unsealed penetrations, missing fire alarm notification in courtyard, missing smoke detector sensitivity tests, sprinkler system issues, incomplete fire watch policy, improper smoking area ashtray disposal, missing remote manual stop for emergency generator, and electrical hazards.

The complaint investigation addressed allegations that the facility failed to maintain safe temperatures, provide wound care according to physician orders, maintain sufficient staffing, promptly respond to calls for assistance, and provide medications as ordered. The facility was found compliant except for the failure to promptly respond to calls for assistance, which was substantiated.

The facility was found to be in compliance with regulatory requirements for maintaining safe temperatures, providing wound care according to physician orders, maintaining sufficient staffing, and providing medications as ordered. However, the facility failed to promptly respond to calls for assistance, resulting in violations of Federal tag F312 and State Licensure tag 175 NAC 12-006.09D1c, affecting Residents 10, 16, 44, and 46.

The complaint alleged the facility failed to protect residents from abuse and from residents with behaviors. The investigation found no evidence of abuse and that the facility had measures in place to protect residents from abuse and from other residents' behaviors. The facility was found to be in compliance with related regulatory requirements.

The facility was found to be in compliance with related regulatory requirements regarding protection of residents from abuse and from residents with behaviors. Deficiencies were found related to notice of rights, rules, services, charges, grievance process, housekeeping and maintenance, and life safety code violations including fire safety and electrical safety.

The complaint investigation found the facility was in compliance with regulatory requirements for allegations related to pests, abuse, medical record falsification, restraints, and aggressive behaviors. However, the facility was found deficient in providing bathing preferences for 3 residents and in housekeeping and maintenance services, affecting 22 residents.

The complaint alleged the facility failed to implement new interventions after a resident was noted at risk for falls. The investigation included review of incident reports, medical records, observations, and staff interviews. The facility was found compliant with fall prevention but had other deficiencies as noted.

The facility was found to be in compliance with relevant regulatory requirements regarding fall interventions. However, deficiencies were found related to medication errors, nurse staffing posting, hand hygiene during ice water pass, medication error documentation, mechanical lift sanitation, and life safety code violations regarding electrical panel clearance.

The facility was found deficient in multiple areas including failure to notify physicians of significant resident changes, inadequate investigation and reporting of abuse allegations, poor housekeeping and maintenance leading to unsafe conditions, failure to properly assess and monitor residents' skin conditions, inadequate interventions to prevent accidents related to assistive devices, improper timing of insulin administration, expired medications and supplies, poor infection control practices including hand hygiene and equipment sanitization, and multiple life safety code violations including unsealed stairwell penetrations, lack of smoke resistant partitions, corroded sprinkler heads, non-flame retardant window coverings, and unsafe electrical wiring and equipment.

The complaint investigation focused on the facility's failure to ensure safety for residents identified as at risk for elopement, specifically Residents 45 and 01, among others.

The facility failed to ensure a safe environment for residents at risk of elopement, including malfunctioning wander guard bracelets and unlocked doors that allowed residents to exit without staff knowledge. Documentation of safety checks was incomplete, and the facility did not consistently check all alarmed doors or bracelets as required.

The complaint investigation sample included 6 residents, and the failure affected Resident 01. The physician notification was tardy, occurring 43 hours after the open area was first documented.

The facility failed to notify the physician in a timely manner about Resident 01's open abdominal wound, resulting in delayed treatment. The physician was notified 43 hours after the wound was first documented.

The complaint investigation involved a sample of 3 residents, with 2 residents affected by allegations of abuse or neglect that were not reported or investigated properly. Resident 1 alleged abuse by a nurse aide on 10/19/2012. Resident 2 fell on 10/17/2012 and sustained facial fractures and a subdural hematoma. The facility delayed reporting these incidents to the State Agency until 10/23/2012 and had not completed investigations at the time of the survey.

The facility failed to report and investigate allegations of staff to resident abuse for two residents. Resident 1 alleged a nurse aide hit them, and Resident 2 had a fall resulting in serious injury. The facility did not report these incidents timely to the State Agency and had not completed investigations at the time of survey.

The facility was found deficient in multiple areas including failure to inform residents of Medicare appeal rights, failure to notify physicians of changes in resident condition, environmental hazards such as beds placed against heat registers, duplicate medication therapies, failure to prevent animals in dining areas, medication administration errors, inadequate ventilation in resident bathrooms, quality assurance committee deficiencies, fire safety code violations including door latch failures, locked exit door issues, incomplete fire drills, fire alarm system maintenance, use of non-flame retardant decorations, and improper electrical wiring.

The complaint investigation involved allegations of mistreatment, neglect, and misappropriation of resident property. The complaint survey sample size was 3 residents.

The facility failed to prevent neglect by ensuring staff implemented established interventions specified on the comprehensive care plan and failed to intervene during a witnessed potential abusive/neglect incident for one sampled resident (Resident 46). The facility also failed to report and thoroughly investigate incidents of alleged neglect, injury of unknown origin, and potential verbal abuse within required timeframes.

Complaint investigation revealed failures related to Resident 105's change in condition notification, bed-hold policy notice for multiple residents, care and assessments for changes in condition and falls, supervision of facility pets causing injuries, and hydration maintenance. Resident 105 was hospitalized and later expired due to complications including dehydration and renal failure.

The facility failed to notify the physician of a significant change in condition for Resident 105, resulting in hospitalization and death. The facility failed to provide bed-hold policy notice to residents and/or family for three residents. The facility failed to provide timely assessments and care for residents with changes in condition and after falls. The facility failed to supervise pets to prevent bites and scratches for Resident 68. The facility failed to provide sufficient fluid intake to prevent dehydration for Resident 105.

The complaint investigation focused on Resident 14, who had multiple falls and deteriorating condition. The facility failed to notify the physician and DPOA timely, failed to assess and monitor the resident's condition adequately, and failed to provide appropriate emergency care and follow physician orders. The resident was eventually hospitalized with a vertebral fracture.

The facility failed to notify the physician and DPOA of Resident 14's significant changes in condition following falls and deteriorating health status. Resident 14 experienced two falls within 36 hours, had low oxygen saturation, confusion, and other symptoms, but the physician was not promptly notified. The resident was eventually transferred to the hospital where a non-displaced vertebral fracture was diagnosed. The facility also failed to assess and monitor Resident 14 adequately to identify and respond to changes in condition.