Health inspection·December 3, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few Based on observation, clinical record review, review of facility documents, and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm related to a fracture of her left lower leg for one of five residents reviewed for abuse/neglect (Resident 1). This deficiency is cited as past noncompliance Findings include: Observation of Resident 1 on December 3, 2025, at 1:00 PM revealed she was in bed and she appeared to be sleeping. Clinical record review for Resident 1 revealed a progress note dated October 24, 2025, at 11:27 AM that indicated Resident 1 was being transported in her wheelchair to an outside activity. Resident 1 was holding her legs up, but she put them down. Her legs were not on leg rests, and she started to complain of pain in her left leg. Further clinical record review revealed that Resident 1 had her initial x-ray of her left lower leg on October 24, 2025. The results were received the same day at 3:17 PM and were negative for a fracture. On October 26, 2025, at 10:39 PM nursing documentation indicated that Resident 1 was resting in bed with her call bell in reach. Resident 1 continued to complain of left ankle discomfort. Her ankle remained edematous (swollen) and ice and Tylenol were administered per physician orders. Resident 1's feet were propped up on pillow. she yells out with any movement of her foot. Nursing will continue to observe. On October 28, 2025, at 11:31 AM the PA-C reviewed the left knee ankle x-rays and had no new orders. A physician's progress note dated October 30, 2025, at 11:38 AM revealed that Resident 1 was examined, and she was still complaining of pain in her left ankle. The physician ordered for her left lower leg to be x-rayed again. A progress note dated October 30, 2025, at 1:26 PM indicated that the x-ray results were received and showed an acute fracture of the distal left tibia (large bone in the lower leg between the knee and ankle) and fibula (thin bone in the lower leg that runs parallel to the tibia on the outer side of the leg). A progress note dated October 30, 2025, at 1:26 PM revealed that Resident 1's physician was made aware of her left lower leg x-ray results and ordered an orthopedic consult, pain medications, a splint to the left lower leg, and for her to be non- weight bearing on her left leg. A progress note dated October 30, 2025, at 2:32 PM indicated that the Certified Physician Assistant ordered the facility to send Resident 1 to the emergency room because orthopedics was unable to see her. Resident 1 was transferred to the emergency room at 2:49 PM. She returned to the facility on October 31, 2025, at 8:15 AM. A CT scan completed in the emergency room confirmed Resident 1 had a fracture of her left tibia and fibula. A progress note dated November 6, 2025, at 2:55 PM revealed that resident returned from an orthopedic appointment with a cast on her left lower extremity. Review of the facility's investigation into Resident 1's incident that caused the fracture, dated October 24, 2025, at 10:00 AM revealed a witness statement by Employee 1, Licensed Practical Nurse (LPN) that indicated she was pushing Resident 1 back in the door from an outside activity when Resident 1 yelled that her leg got stuck. Employee 1 indicated that she did not see Resident 1's legs because they were covered with a blanket. Her statement (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395589 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395589 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/03/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mount Carmel Senior Living Community 2616 Locust Gap Highway MT Carmel, PA 17851 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)