Inspection Reports for Serenity Gardens at Mount Carmel
135 VERMONT DRIVE,, KULPMONT, PA, 17834
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
91% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
65% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Census: 55
Capacity: 85
Deficiencies: 1
Date: Apr 15, 2025
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for compliance.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. A deficiency was found related to the lack of a required cognitive preadmission screening for a resident admitted to the secured dementia care unit.
Deficiencies (1)
No cognitive preadmission screening completed for a resident prior to moving into the Secure Dementia Care Unit.
Report Facts
License Capacity: 85
Residents Served: 55
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 20
Current Hospice Residents: 1
Total Daily Staff: 85
Waking Staff: 64
Inspection Report
Renewal
Census: 46
Capacity: 85
Deficiencies: 15
Date: Dec 12, 2024
Visit Reason
The inspection was an unannounced renewal inspection conducted on 12/12/2024 to review the facility's compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post required regulations and emergency phone numbers, unsecured poisonous materials, obstructed emergency egress, combustible storage hazards, incomplete fire drill records, medication administration documentation errors, and incomplete resident assessments and support plans. All deficiencies had plans of correction accepted and were implemented or scheduled for ongoing compliance monitoring.
Deficiencies (15)
The 55 PA Code Chapter 2600 regulations were not posted in a public conspicuous area of the home.
An unattended cleaning cart with a bucket of blue liquid was found in the Secured Dementia Care Unit, accessible to residents not assessed to safely handle poisonous materials.
Resident #2 did not have the required emergency telephone numbers posted by the resident’s outgoing landline telephone in the resident’s bedroom.
Several small pieces of broken glass were found near the home’s dumpster.
A yellow and black cloth barrier was blocking egress to the emergency exit in the dining room, with confusing signage on the exit door.
Combustible and flammable materials were located near natural gas hot water heaters in the mechanical room.
Fire drill record did not indicate if the drill was conducted in the AM or PM.
Fire drills were routinely held between 5am and 6am, making them predictable.
Resident #3’s Documentation of Medical Evaluation did not include weight or type of evaluation.
Resident #2 had medications in their room but was not assessed to self-administer medications.
Medication administration records for Residents #4 and #5 were not documented at the time medications were administered on multiple occasions.
Resident #6 missed a required blood glucose reading and insulin dose; Resident #7 did not receive insulin as ordered based on blood glucose reading.
Resident #3's support plan did not document behavioral and cognitive care needs or how these needs will be met.
Resident #8 and/or their designated person were not involved in the development of the support plan.
Resident records were found accessible with the office door open and no staff present, risking unauthorized access.
Report Facts
License Capacity: 85
Residents Served: 46
Secured Dementia Care Unit Capacity: 22
Residents Served in SDCU: 16
Total Daily Staff: 68
Waking Staff: 51
Inspection Report
Census: 49
Capacity: 85
Deficiencies: 0
Date: Sep 4, 2024
Visit Reason
The inspection was a licensing inspection conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 09/04/2024.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 49
License Capacity: 85
Secured Dementia Care Unit Capacity: 22
Residents Served in Secured Dementia Care Unit: 17
Total Daily Staff: 76
Waking Staff: 57
Residents 60 Years or Older: 49
Residents with Mobility Need: 27
Inspection Report
Renewal
Census: 49
Capacity: 85
Deficiencies: 12
Date: Feb 8, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, including a full unannounced review and follow-up on plan of correction submissions.
Findings
The inspection found multiple deficiencies related to staff training, resident room lighting, hygiene supplies, food storage, egress routes, medication storage and administration, and support plan documentation. All deficiencies had plans of correction accepted and were reported as implemented or in progress with specified completion dates.
Deficiencies (12)
Direct care staff person did not complete and pass the Department-approved direct care training course and competency test before working unsupervised.
Residents in rooms 302 and 307 did not have an operable lamp or other source of lighting at bedside.
Room 302 bathroom had one bar of soap not labeled or in a labeled container.
Two dented cans were found in the kitchen can storage area.
Snow was not removed from behind the courtyard gate, blocking immediate egress.
Prescription medications and syringes were left unlocked and unattended in resident #1's room and on the medication cart.
Resident #1's medication container lacked proper pharmacy labeling and instructions did not match the medication administration record.
Medications for residents #1 and #2 were not available as ordered.
Narcotic medication count for resident #3 was inaccurate and not completed at shift change.
Resident #4 missed a prescribed dose of medication.
Resident #5's support plan did not indicate hospice services despite admission to hospice.
Resident #6 had a fall with injury; no addendum was completed to document safety measures.
Report Facts
License Capacity: 85
Residents Served: 49
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Current Hospice Residents: 2
Total Daily Staff: 76
Waking Staff: 57
Inspection Report
Original Licensing
Census: 54
Capacity: 85
Deficiencies: 3
Date: Jul 18, 2023
Visit Reason
The inspection was conducted due to a change in legal entity and initial licensing of the facility under new ownership.
Findings
The facility was found to be in substantial compliance with applicable regulations but the inspection was not fully completed due to the new legal entity status. Several citations were identified related to safety hazards such as a tripping hazard outside the secured dementia unit, an exit door that required excessive force to open, and incomplete evacuation documentation during a fire drill.
Deficiencies (3)
Tripping hazard due to a 12"x12" cut out in the cement filled with wood that had sunk by approximately 1 inch in the courtyard of the secured dementia unit.
Exit door outside the administrator's office would not open without excessive force, preventing immediate egress in an emergency.
Fire drill on 6/26/23 showed 56 residents present but only 52 evacuated; 3 residents were unaccounted for in evacuation documentation.
Report Facts
License Capacity: 85
Residents Served: 54
Capacity of Secure Dementia Care Unit: 22
Residents Served in Secure Dementia Care Unit: 15
Staffing Hours: 80
Waking Staff: 60
Fire Drill Residents Present: 56
Fire Drill Residents Evacuated: 52
Inspection Report
Follow-Up
Census: 57
Capacity: 57
Deficiencies: 7
Date: Oct 12, 2022
Visit Reason
The inspection was a follow-up review conducted on 10/12/2022 to verify that the submitted plan of correction was fully implemented at Serenity Gardens at Mount Carmel.
Findings
The facility was found to have fully implemented the plan of correction for previous deficiencies, including proper labeling of poisonous materials, hot water temperature adjustments, correction of emergency telephone numbers, monthly fire drills, fire drill record keeping, designated meeting place evacuation procedures, and smoking area safety.
Deficiencies (7)
Poisonous materials were stored in spray bottles without original manufacturers' labels.
Hot water temperature in resident-accessible areas exceeded 120°F, measuring 129°F and 131°F in two bathrooms.
Wrong number for the personal care home complaint hotline was posted with emergency telephone numbers.
No fire drill was conducted in December 2021.
Fire drill logs from 1/22-9/22 lacked documentation of exit routes used and residents evacuated.
Resident #1 was not evacuated during fire drills contrary to policy and physician/legal guardian instructions.
Four nylon fabric chairs were located in the designated smoking area, posing a fire hazard.
Report Facts
Residents served: 57
Secured Dementia Care Unit capacity: 22
Secured Dementia Care Unit residents served: 13
Hospice residents: 3
Residents with mobility need: 20
Residents aged 60 or older: 57
Residents diagnosed with intellectual disability: 1
Hot water temperature: 129
Hot water temperature: 131
Resident Support Staff: 20
Total Daily Staff: 97
Waking Staff: 73
Inspection Report
Follow-Up
Census: 58
Capacity: 85
Deficiencies: 1
Date: Dec 22, 2021
Visit Reason
The inspection visit on 12/22/2021 was a partial, unannounced follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The submitted plan of correction was determined to be fully implemented, with staff retraining on resident rights completed and ongoing compliance to be maintained by the administrator.
Deficiencies (1)
Resident #1 was found tied to a wheelchair with a bedsheet to prevent falling, which is a prohibited manual restraint.
Report Facts
License Capacity: 85
Residents Served: 58
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 4
Total Daily Staff: 73
Waking Staff: 55
Inspection Report
Renewal
Census: 54
Capacity: 85
Deficiencies: 15
Date: Sep 28, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation of the facility Serenity Gardens at Mount Carmel on 09/28/2021 and 09/29/2021.
Complaint Details
The inspection included a complaint investigation as part of the renewal process. The report does not explicitly state the substantiation status of the complaint.
Findings
The inspection found multiple deficiencies including failure to post the current license inspection summary, lack of documentation for periodic Quality Management meetings, incomplete criminal background checks, missing emergency telephone numbers, incomplete or outdated resident medical evaluations and assessments, inaccuracies in medication documentation, and issues with support plans and preadmission screenings. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (15)
The most current LIS dated 8-20-2019, was not posted in a conspicuous location.
There was no documentation of a periodic Quality Management meeting having been held within the last 12 months.
Staff member A had their Criminal Background check completed on 1/30/2017 but results were under review and no documentation of receiving results within 90 days.
The landline phone located in the room of resident 1 did not have emergency numbers posted near the phone.
Resident 2 and Resident 3 had incomplete or missing annual medical evaluations.
Meal menus were only posted up until 10/02/2021 instead of a full week in advance.
Resident 4’s glucometer reading was documented incorrectly in the MAR log.
Pre-admission screening forms for Resident 5 and Resident 6 did not indicate that the resident’s needs can be met by the home.
Resident 6 did not have a completed assessment plan within 15 days of admission.
Resident 7 and Resident 2 had outdated or missing additional assessments and support plans.
Resident 3’s diet change was not reflected in their current support plan.
Resident 7 was transferred to the secured dementia unit without a current DME and missing cognitive preadmission screening and non-objection statement.
Resident 7 was not assessed annually for continuing need in the secured dementia care unit.
Instructions to open the locked gate from the secured dementia unit outside patio were faded and unreadable.
Resident 7 did not have a new support plan completed within 1 year of admission to the secured dementia unit.
Report Facts
License Capacity: 85
Residents Served: 54
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 16
Hospice Residents: 3
Residents with Mobility Need: 21
Total Daily Staff: 75
Waking Staff: 56
Notice
Capacity: 85
Deficiencies: 0
Date: Aug 31, 2021
Visit Reason
The document serves as a renewal notification and license issuance for the Personal Care Home 'Serenity Gardens at Mount Carmel' following receipt of the renewal application dated July 29, 2021.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 85
Secure Dementia Care Unit capacity: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
Inspection Report
Plan of Correction
Census: 43
Capacity: 85
Deficiencies: 0
Date: Jun 10, 2021
Visit Reason
The inspection was conducted as a follow-up review to verify that the submitted plan of correction was fully implemented at the facility.
Findings
The Pennsylvania Department of Human Services determined that the submitted plan of correction was fully implemented and that continued compliance must be maintained.
Report Facts
License Capacity: 85
Residents Served: 43
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 2
Resident Support Staff Hours: 0
Total Daily Staff: 59
Waking Staff: 44
Residents Age 60 or Older: 43
Residents with Mobility Need: 16
Residents Receiving Supplemental Security Income: 2
Inspection Report
Routine
Deficiencies: 0
Date: Jan 15, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 01/15/2021.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
The inspection visits on 10/14/2020, 10/19/2020, 10/23/2020, and 10/30/2020 were conducted as licensing inspections by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of these inspections.
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