Mount Carmel Care Center

Review of Resident #56's Admission Fall Risk assessment dated [DATE], 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.

225581

Form Approved OMB

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