Mount Carmel Care Center

F-F712

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42690

Residents Affected - Few Based on record review, and interviews, the facility failed to ensure one Resident (#56) out of a total sample of 15 residents, remained free from accidental hazards.

Specifically, for Resident #56, the facility failed to evaluate and analyze hazards and risks, implement interventions to reduce hazards and risks, monitor the effectiveness and modify interventions relative to falls.

Findsings include:

Review of the facility policy titled Fall Prevention Program, dated 2/13/25, indicated the following:

-Complete a fall risk assessment on admission, quarterly, and as indicated for significant condition changes and after each fall.

-Provide additional interventions as directed by the resident's assessment, including but not limited to:

i. Assistive devices

ii. Increased frequency of rounds

iii. Sitter if indicated

iv. Medication regimen review

v. Low bed

vi. Alternate call system access

vii. Scheduled ambulation or toileting assistance

viii. Family/family caregiver or resident education.

ix. Therapy services referral

-When any resident experiences a fall the home will:

a. Assess the resident

b. Complete a post fall assessment

c. Complete an incident report

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 d. Notify physician and family

Level of Harm - Minimal harm or e. Review the residence care plan and update as indicated potential for actual harm f. Document all assessments and actions Residents Affected - Few g. Obtain witness statements in the case of injury

h. Review with the IDT (Interdisciplinary Team) for appropriateness of interventions, additional interventions, as well as review of completed investigation.

Resident #56 was admitted to the facility in November 2024 with diagnoses including a wedge compression fracture of T11-T12 vertebra, cognitive communication deficit, muscle weakness, difficulty walking, lack of coordination, and adjustment disorder.

Review of Resident #56's Admission Fall Risk assessment dated [DATE REDACTED], indicated the following:

-in the last 90 days the Resident experienced 1-2 falls.

-Most recent fall - 11/26/24

-Ambulates with issues and with devices (unsteady, lurching, slow gait)

-Only able to stabilize with physical assistance, not steady

Review of the Fall Care Plan, initiated on 11/30/24 indicated the Resident had an increased fall risk, had a history of falls and had impaired mobility.

The following were identified as interventions:

-Resident required prompt responses to all requests for assistance.

-Follow facility fall protocol.

-Monitor for proper placement and functioning of tab alarm when in wheelchair every shift, initiated 12/23/24 and resolved (discontinued) 4/7/25.

-Offer to toilet Resident upon rising, before and after meals, and at bedtime, initiated 4/5/25.

Review of the medical record indicated Resident #56 experienced a fall on the following dates: 12/1/24, 2/9/25, 3/4/25, 3/13/25 (resulted in skin tears), 3/31/25 (resulted in a skin tear), 4/5/25 (unwitnessed fall, resulted in being sent to the emergency room for evaluation and a head laceration), 4/6/25, and 4/13/25.

Review of the medical record failed to indicate documented evidence that when Resident #56 experienced a fall, the Fall Care Plan had been reviewed and/or updated with new interventions on the following dates: 2/9/25, 3/4/25, 3/13/25, 3/31/25 and 4/13/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Review of the medical record failed to indicate documented evidence that when Resident #56 experienced a fall, a fall assessment had been completed on the following dates: 4/5/25 and 4/13/25. Level of Harm - Minimal harm or potential for actual harm Review of the medical record failed to indicate documented evidence that when Resident #56 experienced a fall, an incident report was completed on the following dates: 12/1/24, 2/9/25, 3/4/25, 3/13/25, 3/31/25, and Residents Affected - Few 4/6/25.

During an interview on 4/22/25 at 2:30 P.M., Nurse #1 said if a resident were to fall, we would assess the resident, get assistance to help get the resident up after determining they were okay to do so. Nurse #1 further said she would leave the resident with someone on the floor if they required urgent medical care. If

the resident did not require urgent medical care, after getting the resident to a safe space she would then notify the required people, complete a fall, skin and pain assessment, and update the care plan with a new appropriate intervention. Nurse #1 said she felt that Resident #56's falls were relative to his/her toileting habits and that Resident #56's newest intervention, updated on 4/5/25 was relative to his/her toileting habits and hoped that the new intervention would reduce his/her falls. Nurse #1 also said that they had attempted to put a chair alarm in place however the team felt that it posed more of a risk as he/she was distracted by the alarm and attempted to take it apart, turn it off or remove it.

During an interview on 4/22/25 at 4:17 P.M., the Director of Nursing (DON) said that when a resident falls

she expected the nursing staff to complete an incident report, notify the required people, write a progress note, complete a fall assessment and include any immediate or new interventions. The DON said that the facility had recently begun conducting interdisciplinary (IDT) team meetings that included daily meetings as well as weekly risk meetings to review cases like Resident #56, who had a high fall risk and had experienced frequent falls. The DON said that this was a new process, and that it was not in place at the time Resident #56 experienced most of his/her falls. The surveyor and the DON reviewed the Resident's Fall Care Plan and the DON said that the care plan had not been updated after a fall occurred on the following dates: 2/9/25, 3/4/25, 3/13/25, 3/31/25 and 4/13/25 to include a new intervention to try and reduce his/her risk of falling.

During a follow-up interview on 4/23/25 at 8:30 A.M., the DON said that after she researched Resident #56's fall history she additionally found that no incident reports had been completed when the Resident experienced a fall on 12/1/24, 2/9/25, 3/4/25, 3/13/25, 3/31/25, and 4/6/25. The DON also said that no assessments had been completed when Resident #56 experienced a fall on 4/5/24 and 4/13/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or 42690 potential for actual harm Based on observation, interviews, and record review, the facility failed to ensure that acceptable parameters Residents Affected - Few of nutritional status were maintained for one Resident (#28), out of a total sample of 15 residents.

Specifically, the facility failed to:

-implement the Dietitian's recommendation for a nutritional supplement for Resident #28, who was identified as being at risk for inadequate intake of nutrition and hydration, and had experienced weight loss.

-assess Resident #28 when he/she continued to experience unplanned, undesired weight loss.

Findings include:

Review of the facility policy titled Weight Monitoring, dated 11/13/24, indicated the following in part:

-Based on the resident's comprehensive assessment, the home will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight and desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise.

-The home will utilize a systematic approach to optimize a resident's nutritional status. This process includes:

--- Evaluating slash analyzing the assessment information,

---Developing and consistently implementing pertinent approaches,

---Monitoring the effectiveness of interventions and revising them as necessary.

-Interventions will be identified, implemented, monitored and modified as appropriate consistent with the residents ' addressed needs, choices, preferences, goals and current professional standards to maintain acceptable parameters of nutritional status

-Weight analysis: A significant change in weight is defined as:

---5 percent (%) change in weight with one month (30 days)

--- 7.5% change in weight in three months (90 days)

---10% change in weight in six months (180 days)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 -The physician should be informed of a significant change in weight and may order nutritional interventions.

Level of Harm - Minimal harm or -The physician should be encouraged to document the diagnosis or clinical conditions that may be potential for actual harm contributing to the weight loss.

Residents Affected - Few Resident #28 was admitted to the facility in February 2025 with diagnoses including lymphedema, fracture of

the left femur (thigh bone), wedge compression fracture of T11-T12 vertebrae, wedge compression fracture of fifth lumbar vertebrae, wedge compression fracture of third lumbar vertebrae and protein calorie malnutrition (PCM).

Review of the Admission Baseline Care Plan, dated 2/18/25, indicated:

-Resident is at risk for inadequate intake of nutrition and/or hydration

---Report change in condition to the Primary Care Physician

Review of Resident #28's Nutrition Care Plan, initiated on 2/18/25, and revised on 3/9/25, indicated the Resident had a diagnosis of PCM with weight loss, loss of fat and muscle stores, was increased risk for continued decline in nutrition and hydration and included the following interventions:

--Supplements as prescribed -initiated on 2/18/25

--Report changes in condition to primary care physician -initiated on 2/18/25

Review of the Clinical Nutrition Note dated 3/9/25, indicated the following in part:

-Resident had a diagnosis of PCM as evidenced by recent 10-pound (lbs.) weight loss documented.

-Weight was 119 lbs. in September 2024, low Body Mass Index (BMI), and fat/muscle wasting was evident

on the hospital evaluation.

-Resident currently ate between 25-50% of meals.

-the Dietician made the following recommendation: house supplement four ounces (oz) twice a day (BID) with medication pass

Review of the facility's Communication Log, provided by the Dietician on 4/22/25 at 9:45 A.M., indicated the following recommendation was made by the Dietician on 3/9/25: 4 oz. house supplement BID with medication pass.

Review of the Physician Order Summary Report for active orders as of 4/22/25, failed to indicate an order was in place for a 4 oz. house supplement BID with medication pass.

Review of the Weights and Vital Summary indicated the following weights and dates:

-2/19/25: 99.0 lbs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 -2/20/25: 98.9 lbs.

Level of Harm - Minimal harm or -2/21/25: 99.8 lbs. potential for actual harm -2/22/25: 102.4 lbs. Residents Affected - Few -3/4/25: 96.8 lbs.

-3/5/25: 99.6 lbs.

-3/11/25: 96.7 lbs.

-3/18/25: 90.6 lbs.

-3/19/25: 99.4 lbs.

-3/26/25: 91.8 lbs.

-3/27/25: 92.0 lbs.

-4/2/25: 90.2 lbs. -6.8 % weight loss since 3/4/25 (greater than 5 % change in weight within one month) and

an 8.9 % weight loss since 3/4/25 (greater than 7.5 % change in weight in three months [90 days]) indicated

a significant weight loss.

-4/16/25: 89.2 lbs. (continued weight loss).

On 4/17/25 at 11:45 A.M., Resident #28 was observed to be sleeping in bed and to be thin and frail in appearance. During an interview at the time with Resident #28's family member who was also in the room,

the family member said Resident #28 had lost about ten pounds since his/her admission to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 During an interview on 4/22/25 at 9:31 A.M., the Dietician said the Activity Director (AD) reported to her that morning that Resident #28 had been in his/her room, was not eating, had not been very alert and appeared Level of Harm - Minimal harm or to have lost weight. The Dietician said she had not been notified prior to today about the Resident's decline potential for actual harm The Dietician said that she reviewed resident weights monthly. The Dietician said when she reviewed Resident #28's weights, she noted the weights seemed to vary for the month of March. The Dietician said Residents Affected - Few she had not yet evaluated the Resident this month, and had not received notification that the Resident had any significant weight loss noted. The Dietician said had she received any information relative to significant weight loss for Resident #28, she would have reassessed him/her. The surveyor and the Dietician reviewed

the Clinical Nutrition Note dated 3/9/25, the facility's Communication log, the current Physician Orders and

the Resident's weights, and the Dietician said she made the recommendation to add the 4 oz. house supplement twice daily for Resident #28 in the facility's communication dashboard which was utilized by the facility staff to communicate between departments on 3/9/25. The Dietician also said she was unable to find evidence that the recommendation for the 4 oz. house supplement recommended was implemented. The Dietician said she would have expected the staff to notify her regarding the Resident's significant weight loss noted on 4/2/25 and again on 4/16/25. The Dietician said prior to today, when the AD reported her

observation of the Resident's decline, no one had communicated with the Dietician that the Resident was not receiving the supplement or that he/she had a significant weight loss.

During an interview on 4/22/25 at 9:56 A.M., the Physician said that he expected to be notified when a resident experienced significant weight loss. The Physician said he had not been notified of Resident #28's significant weight loss and should have been. The surveyor and the Physician reviewed the Physicians Progress Notes and were unable to find any documented evidence that Resident #28 had been seen by the Physician since his/her admission in February 2025. The Physician further said he found it hard to believe that he had not seen Resident #28 at this point but could not recall when he last saw him/her.

During an interview on 4/22/25 at 10:05 A.M., Nurse #1 said that the Communication Log utilized through the electronic medical record (EMR) was a new process, but the expectation was that the Communation Log was reviewed daily, and recommendations made were followed up on. Nurse #1 said there was a communication breakdown and that the recommendation for the 4 oz. house supplement twice daily (BID) for Resident #28, should have been followed up on and implemented as the Resident was at risk for weight loss. Nurse #1 said relative to the Resident's weight loss, she used a five-pound range rule, meaning that if there was a difference from the previous weight of five pounds or greater, she requested a re-weight for the following day. Nurse #1 said that if the weight was still a five-pounce difference from the previous weight, she would notify the Physician and the Dietician. Nurse #1 further said that she did not believe that the Physician or the Dietician had been notified of Resident #28's weight changes.

During a follow-up interview on 4/22/25 at 10:45 A.M., Nurse #1 reviewed Resident #28's weights and said

the Resident's weights had been a little all over the place starting with 3/11/25 (96.7 lbs.), 3/18/25 (90.6), 3/19/25 (99.4), 3/26/25 (91.8) and 3/27/25 (92.0) and if the weights did not seem right, she would request the Resident be re-weighed on the following day. Nurse #1 said she did not notice Resident #28 had a significant weight loss therefore did not notify the Physician or Dietician.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0712 Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Level of Harm - Minimal harm or 42690 potential for actual harm Based on record review and interview, the facility failed to ensure timely Physician visits for one Resident Residents Affected - Few (#28) out of total sample of 15 residents.

Specifically, the facility failed to ensure that Resident #28 was seen by a Physician as required after his/her admission to the facility in February 2025.

Findings include:

Review of the facility policy titled, Physician Services: Supervision, Visits and Frequency of Visits, dated 3/31/23, indicated the following:

-Ensure that all residents remain under the care of a physician.

-The Medicare A skilled resident is seen by a physician at least once every 30 days. For a resident in a Part

A Medicare stay the, NPP (non-physician practitioner) must follow the requirements for physician services in

a skilled nursing facility. This includes, at the option of a physician, required physician visits alternated between personal visits by the physician and visits by the NPP after the physician makes the initial comprehensive visit.

-A physician visit is considered timely if it occurs not later than 10 days after the date the visit was required.

Resident #28 was admitted to the facility in February 2025 with diagnoses including lymphedema, fracture of

the left femur (thigh bone), wedge compression fracture of T11-T12 vertebrae, wedge compression fracture of fifth lumbar vertebrae, wedge compression fracture of third lumbar vertebrae and protein calorie malnutrition (PCM).

Review of the medical record failed to indicate any documented evidence that Resident #28 had been seen by the Physician since being admitted to the facility.

During an interview on 4/22/25 at 9:56 A.M., the surveyor and the Physician reviewed the Physician's Progress Notes both in the electronic medical record (EMR) and in the paper chart, and were unable to find any documented evidence that Resident #28 had been seen by the Physician since his/her admission in February 2025. The Physician further said he found it hard to believe that he had not seen Resident #28 at

this point but could not recall when he last saw him/her.

During an interview on 4/22/25 at 12:02 P.M., the Director of Nursing (DON) said that she researched Resident #28's medical record and did not find any evidence that Resident #28 had been seen by the Physician as required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 50563 potential for actual harm Based on record review, observation, and interview, the facility failed to adhere to infection control standards Residents Affected - Few of practice for one Resident (#29) out of a total sample of 15 residents, and on one unit (St. Luke's) out of a total of two units.

Specifically,

1) For Resident #29, the facility failed to ensure that staff wore the required Personal Protective Equipment (PPE: items such as gown and gloves worn by the staff member to decrease the spread of infection) while in

the Resident's room when he/she was on Contact Precautions (interventions including use of PPE to prevent

the spread of a communicable diseases).

2) For St. Luke's Unit, the facility failed to ensure that staff performed hand hygiene after removing gloves creating a risk for cross contamination.

Findings include:

1) Review of the facility policy titled Determining Precaution Type Policy, dated 3/3/23, indicated the following:

-Contact Precautions: In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with the environmental surfaces or resident-care items in the resident's environment.

>Gloves and Handwashing: in addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile) when entering the room.

>Gown: wear a disposable gown upon entering the Contact Precautions room or cubicle.

Resident #29 was admitted to the facility in February 2023, with diagnoses including Parkinsonism.

Review of the Contact Precautions sign posted outside Resident #29's room indicated the following:

-Providers and staff must also:

>put on gloves before room entry

>put on gown before room entry

Review of Resident #29's Care Plan, last revised 4/16/25, for his/her colostomy (surgical procedure where a surgeon creates an opening, or stoma, in the abdomen and connects it to the colon, allowing stool to be collected in a pouch instead of exiting through the rectum) indicated the following:

-Contact Precautions were in place.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 -Ensure proper personal protective equipment is in place.

Level of Harm - Minimal harm or On 4/17/25 at 9:05 A.M., the surveyor observed the Admissions Registered Nurse (RN) enter Resident #29's potential for actual harm room where the Contact Precautions Sign was posted without first donning (putting on) a gown and gloves and pick up the Resident's breakfast tray. Residents Affected - Few

During an interview on 4/22/25 at 1:14 P.M., the surveyor and the Infection Preventionist (IP) reviewed the Contact Precautions sign and the observation of the Admissions RN entering Resident #29's room. The IP said that the Admissions RN should have put on a gown and gloves when entering the room as the Contact Precautions sign indicated this should be done.

2) Review of the facility policy titled Infection Control: Handwashing Policy, dated 3/13/23, indicated the following:

-Hand hygiene is always the final step after removing and disposing of personal protective equipment.

Review of the facility educational module titled Hand Hygiene Basics indicated the following:

-Hand hygiene is the single most important infection control measure to prevent the spread of germs.

On 4/22/25 at 10:13 A.M., the surveyor observed the relative to Certified Nurses Aide (CNA) #1 on the St Luke's Unit:

-CNA #1 entered a resident room to assist the Nurse and doffed (removed) a pair of gloves as he entered

the room and proceeded to discard the gloves in the trash.

-CNA #1 obtained a new pair of gloves and donned them without first performing hand hygiene.

-CNA #1 assisted the Nurse to position the resident in bed.

-CNA #1 doffed the gloves and discarded them in the trash.

-CNA #1 obtained a new pair of gloves and donned them without performing hand hygiene.

-CNA #1 assisted another CNA with transferring another resident, who resided in the same room, out of bed.

-CNA #1 doffed the gloves, discarded them in the trash, and performed hand hygiene before exiting the room.

During an interview on 4/22/25 at 8:38 A.M., CNA #1 said that after doffing his gloves he should have performed hand hygiene before donning a new pair of gloves as a part of infection control, but he did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 225581 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 225581 B. Wing 04/23/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Mount Carmel Care Center 320 Pittsfield Road Lenox, MA 01240

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 4/22/25 at 1:14 P.M., the surveyor and the IP reviewed the observation of CNA #1.

The IP said CNA #1 should have performed hand hygiene after doffing his gloves to prevent the potential for Level of Harm - Minimal harm or cross contamination. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 225581