Carnegie Park Post Acute

In the surveyor’s words

From the most serious findings on record at Carnegie Park Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Oct 11, 2024

  Based on review of the American Heart Association (AHA) Guidelines, clinical records, facility policies, and staff interviews it was determined that the facility failed to ensure consistent care by initiating Cardio Pulmonary Resuscitation (CPR) to an unresponsive resident for one of eighty-seven residents (Resident R1), resulting in immediate jeopardy. Findings include: The Pennsylvania Code Title 49, Professional and Vocational Standards through the Department of State indicates under Responsibilities of the Registered Nurse 21.11 General functions (a) The registered nurse assesses human responses and plans, implements, and evaluates nursing care for individuals or families for whom the nurse is responsible. […]

• Immediate jeopardy, isolatedF689Apr 28, 2023

  Based on facility policy review, clinical and facility record review, facility provided documents, and staff interviews, it was determined that the facility failed to provide adequate supervision for a resident resulting in elopement (resident leaves the premises or a safe area without the facility's knowledge). This failure created an immediate jeopardy situation for one of 12 residents (Resident R340). Findings include: A review of the facility policy Elopement of Resident reviewed 2/7/23, stated that the facility will identify patient's elopement risk upon admission, re-admission, quarterly, or with a significant change in condition. It is indicated for patients identified as a risk; an interdisciplinary elopement prevention patient-centered care plan will be developed. […]

• No harm, potential for more than minimal, widespreadF730Apr 18, 2025

  Based on review of personnel records and staff interview it was determined that the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides (Employees E11, E12, E13, E14, and E15). Findings include: Review of employee personnel files indicated no nursing staff annual performance evaluations. During an interview on 4/16/25, at approximately 1:00 p.m. the Nursing Home Administrator confirmed the facility failed to provide nursing staff annual performance evaluations based on the date of hire for five of five nurse aides. 28 Pa Code: 201.20 (a)(b)(c)(d) Staff development. 28 Pa Code: 201.14 (a) Responsibility of licensee.

• No harm, potential for more than minimal, widespreadF921Jul 9, 2024

  Based on observation and staff interviews, it was determined that the facility failed to ensure a clean, sanitary, functional environment in the main laundry room. Findings include: During observation of the main laundry room on 7/9/24 at 2:00 p.m., revealed that there are three professional commercial sized washing machines and three commercial sized dryers. Only one of the three washing machines was functional, and two of the three dryers were functional. The soiled linen holding area had approximately eight bags of soiled linen laying in the laundry chute, and over 15 bags of soiled linen, and a large bin of overflowing soiled linen waiting to be laundered. […]

• No harm, potential for more than minimal, widespreadF812Mar 22, 2024

  Based on review of dish machine temperature/sanitation logs, observations, and staff interviews, it was determined that the facility failed to follow proper sanitation and temperature procedures for the dish machine operation allowing for the potential for cross contamination in the main kitchen for seven of nine months (July 2023, August 2023, October 2023, November 2023, January 2024, February 2024 and March 2024). Findings include: During a observation of the staff use of the low temperature dish machine, the Assistant Dietary Manager Employee E4 stated that she did not know what the temperatures of the dish machine wash should be or the sanitation level that is required to make certain the dishes and items being washed were sanitized and clean for resident use. […]