Carnegie Village Rehabilitation & Health Care Cent

In the surveyor’s words

From the most serious findings on record at Carnegie Village Rehabilitation & Health Care Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 19, 2024

  Based on interview and record review, the facility failed to contact Emergency Medical Services (EMS), check code status, initiate and provide cardiopulmonary resuscitation (CPR- an emergency procedure that is performed when a person's heartbeat or breathing has stopped) for one sampled resident (Resident #1) who was a full code status. On [DATE], Registered Nurse (RN) A and Agency Licensed Practical (LPN) A found the resident without spontaneous respirations and pulse. RN A and LPN A did not check the resident's code status, initiate CPR, or contact EMS. As a result the resident died . The facility census was 66. The Regional RN was notified on [DATE] at 12:03 P.M., of the Immediate Jeopardy (IJ) Past Non-Compliance which occurred on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jul 23, 2025

  Based on observation, interview and record review, the facility failed to store food appropriately in the kitchen. This practice has the potential to affect all residents, visitors, and employees who eat at the facility. The facility census was 68 residents.Review of the facility's undated policy titled Food Storage (Dry, refrigerated, and frozen) showed:-All food items must be labeled.-The labels must include the name of the food and the date by which it should be sold, consumed, or discarded.1. Observation on 7/17/25 at 9:14 A.M. […]

• No harm, potential for more than minimal, widespreadF880Sep 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure infection control to prevent cross contamination when staff failed to sanitize the access point of insulin pens prior to attaching the needle for two supplemental residents (Residents #26 and #38); to ensure infection control, including hand hygiene during wound dressing change for one sampled resident (Resident #46); to provide urinary catheter (a small tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infection and to ensure infection control practices were implemented to prevent cross contamination during perineal care on one sampled resident (Resident #32); to ensure hand hygiene during catheter care, colostomy (a surgically created opening for the large intestine,… […]

• No harm, potential for more than minimal, patternF584Jul 23, 2025

  Based on observation and interview, the facility failed to maintain commodes in the following resident rooms (rooms 107, 100, 167, 162, 140, 132, and 124) free of numerous indentations and scratches which rendered the commodes not easily cleanable. This practice potentially affected 7 residents who resided in those rooms. The facility census was 68 residents.1. Observation on 7/21/25 with the Maintenance Director showed:-At 1:51 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER].-At 1:59 P.M. there were numerous indentations on the commode seat in resident room [ROOM NUMBER].-At 2:29 P.M. there were numerous indentations on commode seat in resident room [ROOM NUMBER].-At 2:41 P.M. […]

• No harm, potential for more than minimal, patternF695Jul 23, 2025

  Based on observation, interview, and record review, the facility failed to ensure oxygen and respiratory equipment was kept in a sanitary condition when not in use for three sampled residents (Resident #7, #8, and #33) and failed to ensure one sampled resident's (Resident #33) oxygen was at the correct setting out of 17 sampled residents. The facility census was 68 residents.An oxygen policy was requested and not provided by the time of exit. 1. Review of Resident #7's face sheet showed he/she was admitted to the facility on [DATE] with a diagnosis of chronic respiratory failure with Hypoxia (when the lungs cannot properly exchange gases).Review of the resident's admission Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility for care planning) dated 6/20/25… […]