Carnegie Nursing Home, Inc.

In the surveyor’s words

From the most serious findings on record at Carnegie Nursing Home, Inc., in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Sep 5, 2025

  Based on observation, record review, and interview, the facility failed to develop and implement an infection control plan for enhanced barriers precautions for 2 (#3 and #4) of 2 sampled residents reviewed for enhanced barrier precautions.The ADON reported two residents on enhanced barrier precautions. Findings: 1. On 09/04/25 at 10:58 a.m., LPN #1 was observed to perform catheter care for Resident #3. LPN #1 washed their hands and applied gloves, then started the resident's catheter care. LPN #1 was not observed to wear a gown during the resident's catheter care. The resident's room was observed to have no PPE supplies near the room or enhanced barrier precaution signage. On 9/05/25 at 9:16 a.m., LPN #1 was observed to perform wound care for Resident #3. […]

• No harm, potential for more than minimal, patternF641Apr 18, 2024

  Based on record review and interview the facility failed to accurately code minimum data set (MDS)assessments for three (#13, 24, and #84) of 12 sampled resident reviewed for accurate MDS assessments. The facility administrator reported 31 residents resided in the facility. Findings: The facility's MDS policy, dated 10/08/20, read in part, To provide key information unique to the resident. 1. Resident #13 had diagnoses which included congestive heart failure. A physician's order, dated 02/15/24, documented the resident had been prescribed Lasix [a diuretic medication] one and one half tablets of Lasix 40 mg tablets was to be taken daily for congestive heart failure. […]

• No harm, potential for more than minimal, patternF689Apr 18, 2024

  Based on observation, record review, and interview the facility failed to ensure residents were free from accident hazards for two (#27 and #7) of four sampled residents. The ADON reported 31 residents resided in the facility. Findings: 1. Res #27 admitted to the facility with diagnoses of multiple sclerosis, diabetes mellitus, and pressure ulcer of the sacrum. On 04/15/24 at 10:50 a.m., the resident was observed resting in bed with bedrails observed on the resident's bed with a low loss air flow mattress in use. The resident's record did not contain a risk assessment for the use of bedrails with an air flow mattress. 2. Res #7 admitted to the facility with diagnoses of multiple sclerosis, congenital malformation, acquired absence of left leg, and acquired absence of right leg. […]

• No harm, potential for more than minimal, patternF730Apr 18, 2024

  Based on record review and interview, the facility failed to perform annual nurse aid performance reviews. The ADON reported 31 residents resided in the facility. Findings: An employee staff list documented five CNA's who had hire dates greater than one year. On 04/15/24 at 2:00 p.m. the annual nurse aid perform reviews were requested. On 04/17/24 at 1:55 p.m., the assistant administrator stated she could not find the performance reviews.

• No harm, potential for more than minimal, patternF641Mar 9, 2023

  Based on record review and interview, the facility failed to: a. ensure accurate coding of MDS assessments for medication use for two (#5 and #28) of 12 residents whose MDS assessments were reviewed, and; b. ensure accurate coding of MDS assessments for diagnoses for two (#5 and #28) of 12 residents whose MDS assessments were reviewed. The Resident Census and Conditions of Residents documented a facility census of 29 residents. Findings: 1. Resident #5 was admitted with diagnoses which included edema, dementia, and Schizoaffective disorder. Physician Orders for resident #5, dated March 2023, documented the resident was ordered a diuretic and an antianxiety medication for daily use. […]