ElderGrade

Inspection citations at Mount Carmel Senior Living Community

51 citations on record, 2 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 20 2
2024 22 0
2023 9 0
G December 3, 2025 Tag F0600 Complaint investigation

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Actual harm to a resident

D July 18, 2025 Tag F0914 Corrected Aug 2025

Environmental Deficiencies

Provide bedrooms that don't allow residents to see each other when privacy is needed.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0761 Corrected Aug 2025

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0744 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0689 Corrected Aug 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0685 Corrected Aug 2025

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0684 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0677 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0657 Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0641 Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0605 Corrected Aug 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0583 Corrected Aug 2025

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0947 Corrected Aug 2025

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0699 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0628 Corrected Aug 2025

Resident Rights Deficiencies

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

No actual harm, potential for more than minimal harm

F July 18, 2025 Tag F0812 Corrected Aug 2025

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

No actual harm, potential for more than minimal harm

D March 18, 2025 Tag F0880 Complaint investigation Corrected Apr 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E March 18, 2025 Tag F0584 Complaint investigation Corrected Apr 2025

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

No actual harm, potential for more than minimal harm

G March 18, 2025 Tag F0684 Complaint investigation Corrected Apr 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Actual harm to a resident

C January 2, 2025 Tag F0732 Complaint investigation

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

No actual harm, minimal potential

D November 25, 2024 Tag F0686 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D November 25, 2024 Tag F0677 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

E November 25, 2024 Tag F0684 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

E October 10, 2024 Tag F0804 Complaint investigation Corrected Nov 2024

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0759 Corrected Sep 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0755 Corrected Sep 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0695 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0684 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0641 Corrected Sep 2024

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0578 Corrected Sep 2024

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0561 Corrected Sep 2024

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

No actual harm, potential for more than minimal harm

D August 23, 2024 Tag F0558 Corrected Sep 2024

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E August 23, 2024 Tag F0887 Corrected Sep 2024

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

No actual harm, potential for more than minimal harm

E August 23, 2024 Tag F0880 Complaint investigation Corrected Sep 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E August 23, 2024 Tag F0848 Corrected Sep 2024

Administration Deficiencies

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

No actual harm, potential for more than minimal harm

E August 23, 2024 Tag F0730 Corrected Sep 2024

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

No actual harm, potential for more than minimal harm

E August 23, 2024 Tag F0700 Corrected Sep 2024

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

No actual harm, potential for more than minimal harm

E August 23, 2024 Tag F0689 Corrected Sep 2024

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

E August 23, 2024 Tag F0688 Corrected Sep 2024

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

D April 3, 2024 Tag F0580 Complaint investigation Corrected Apr 2024

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.