Carnegie Nursing Home, Inc.

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. LPN #1 and CNA #1 performed hand hygiene and applied gloves to perform wound care to the resident's left buttock. LPN #1 and CNA #1 were not observed to wear a gown while they performed the wound care. On 09/05/25 at 9:29 a.m., CNA #1 was observed to put on gloves and empty Resident #3's catheter bag into a urinal. CNA #1 emptied…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. An administration record, dated 03/01/24 through 03/31/24, documented the resident was administered Lasix tablets each day on 03/01/24 through 03/28/24. A quarterly MDS assessment, dated 04/01/24, did not document in section N that the resident had been administered a diuretic medication during the seven day look-back period. 2. Resident #24 had diagnoses which include major depressive disorder. A physician's order,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. The resident's record did not contain a risk assessment for the use of bedrails with an air flow mattress. On 04/15/24 at 8:30 a.m., Res #7 was observed in bed. The bed was observed with full bedrails raised on both sides. An air flow mattress was observed on the bed. A motor for an air flow mattress was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.

Based on observation, interview, and record review, the facility failed to develpo/implement a care plan for one (27) of 16 residents review for care plans. The ADON reported 31 residents resided inthe facility. Findings: A care plan, dated 04/01/24, contained no documentation of bedrails. On 04/15/24 at 10:50 a.m., the resident was observed resting in bed with bedrails observed to be in use for both sides of the resident's bed. On 04/16/24 at 1:39 p.m., the ADON reported the bed rails should have been care planned.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to conducted interdisciplinary team [IDT] meetings following quarterly assessments for the purpose of review and revision of the comprehensive care plan for two (#21 and #22) of 12 sampled residents reviewed for care plans. The administrator reported 31 residents resided at the facility. Findings: 1. Resident #21's admission summary documented the resident was admitted to the facility on [DATE]. A review of the resident's medical record did not locate documentation of care plan meetings having occurred for Resident #21 for the period of 04/15/23 through 04/15/24. 2. Resident #22's admission summary documented the resident was admitted to the facility on [DATE]. A review of the resident's medical record did not located documentation of care plan meetings having occurred for Resident #22 for the period of 04/15/23 through 04/15/24. On 04/15/24 at 10:19 a.m., Resident # 22 stated they were not aware what care plan meetings were or if they had attended. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed prevent the use of bed rails until: a. alternatives to the use of bed rails had been attempted, and b. informed consent had been obtained and documented, and c. an assessment of the resident's ability to safely use a bed rail was conducted for one (#84) of three sampled residents reviewed for accident hazards. The ADON stated seven residents had side rails attached to their beds and in use. Findings: A facility Restraint policy and procedure, dated 06/01/2017, documented resident were to be assessed for their ability to reposition themselves using bed rails and the bed rails were to be checked monthly for safety. The policy and procedure did not document the requirements for using alternative methods to using bed rails prior to their use, assessing the residents for safety prior to the use of bed rails, or obtaining informed consent prior to the use of bed rails. A review of Resident #84's records contained no documentation of the attempted use of alternatives to the use of bed rails, a safety assessment related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure a medication/storage closet was locked when left unsupervised. The ADON reported 31 residents resided in the facility. Findings: On 04/15/24 at 8:45 a.m., a medication/storage closet on the north hall was observed to be unlocked and unsupervised. The closet was observed to contain over-the-counter medications and medical supplies. On 04/15/24 at 8:51 a.m., CMA #1 was asked if the medication/storage closet door is supposed to be locked. CMA #1 reported yes.

Based on record review and interview, the facility failed to create a water management plan to prevent water borne pathogens. The facility administrator reported 31 residents resided in the facility. Findings: Facility policy and procedures were reviewed. No water management plan to prevent waterborne pathogens was located. On 04/18/24 at 9:59 a.m., the assistant administrator stated they had not heard of the water management plan to prevent waterborne pathogens. At 10:07 a.m., the assistant administrator stated the facility had not created a water management plan as of that time.

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. A Quarterly Assessment for resident #5, dated 03/04/23, had no documentation to show the resident received a diuretic and antianxiety medication for seven out of the seven days look back period. 2. Resident #28 was admitted with diagnoses which included cerebral infarction and chronic obstructive pulmonary disease. A Quarterly Assessment for resident #28, dated 03/04/23, documented the resident received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure kitchen sanitation was performed for: ~ sanitary ice machine was maintained ~ clean and free of residue coffee maker ~ clean and free of dust on portable fans ~ clean and free of grease residue on vent hood was maintained The Resident Census and Condition of Residents form documented 28 residents received nourishment from the kitchen. Findings: The facility policy, Dietary Policy and Procedure for Cleaning and Infection Control, read in parts .monitor the cleaning .signed by employee .if soap or chemical cleaners are used be sure they are completely rinsed away .wipe interior and all surface areas . On 03/07/23 at 9:30 a.m., an initial tour of the kitchen was conducted. The dietary manager provided documentation of the cleaning schedule for the ice machine which documented it had been cleaned March 2023. The ice machine was observed to have brown spots of residue on the inside ice guard. The dietary manager was shown the area of brown residue that was easily removed with a paper towel. The coffee maker…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to refer a resident to the appropriate state-designated authority for PASARR, who was later identified with a newly related condition, for one (#4) of one resident who was reviewed for PASARR. The Resident Census and Condition of Residents documented the facility had eight residents with behavioral healthcare needs. Findings: Resident #4 was admitted on [DATE]. A level one PASARR, dated 08/26/15, read in parts, .Level one PASRR screen . 2. 0 yes 0 no Diagnosis of a serious mental illness (for example, schizophrenic, paranoid, panic, mood or other severe anxiety or depressive disorder .0. No had been checked. Physician Orders for resident #4, dated March 2023, documented the resident received a diagnosis of major depressive disorder on 12/12/19 and a diagnosis of Schizoaffective disorder on 08/31/20. The clinical record contained no documentation to show resident #4, who was later identified with a possible serious mental disorder or related condition, was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation, and interview, the facility failed to ensure a resident received care in accordance with professional standards of practice, by using two-person assist when transferring a resident with a Hoyer lift, for one (#18) of one resident sampled who required a Hoyer lift. The Administrator identified 9 residents who required Hoyer lifts for transfers. Findings: A facility policy titled Policy and Procedure for Hoyer Mechanical Lift, revision date 10/08/20, read in parts, .the purpose for using a mechanical lift is to keep residents free of falls and injuries and to protect skin from bruising and tearing .one-person position resident in center of Hoyer lift and guide resident while second person pushes lift . Resident #18 was admitted with diagnoses which included cerebral infarction, anxiety disorder, and hemiplegia. A Quarterly MDS Assessment, dated 02/13/23, documented the resident was severly cognitively impaired and required total assistance with transfers. A Care Plan, dated 08/01/22, documented resident #18 was a high fall risk and required a Hoyer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.