Above average — CMS composite of the measures below.
The next survey window likely opens around August 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carnegie Nursing Home, Inc. during CMS and state inspections, most recent first.
Surveyors found that two residents with indwelling catheters and buttock wounds did not receive care under enhanced barrier precautions. An LPN and a CNA performed catheter care, wound care, and catheter bag emptying using hand hygiene and gloves but did not wear gowns, and there were no PPE supplies or enhanced barrier precaution signs near the rooms. Care plans for both residents lacked enhanced barrier precaution interventions despite physician orders for ongoing wound and catheter care and assessments noting moisture-associated skin damage. Staff, including an LPN and the ADON, reported no knowledge of or policy for enhanced barrier precautions, and the ADON acknowledged that enhanced barrier precautions had not been implemented for these residents.
The facility failed to accurately code MDS assessments for three residents, leading to deficiencies in documenting medication administration. The ADON admitted to oversight, and there was no process in place to verify the accuracy of the MDS assessments.
The facility failed to ensure residents were free from accident hazards by not completing risk assessments for the use of bedrails with air flow mattresses for two residents. The ADON and DON confirmed that assessments and informed consent were not properly conducted, leading to the noted deficiency.
The facility failed to perform annual nurse aide performance reviews for five CNAs who had hire dates greater than one year. When the reviews were requested, the assistant administrator could not find them. The ADON reported that 31 residents resided in the facility.
The facility failed to develop and implement a care plan for a resident, as a care plan dated 04/01/24 did not document the use of bedrails. The resident was observed with bedrails in use, and the ADON confirmed that the bedrails should have been included in the care plan.
The facility failed to conduct quarterly interdisciplinary team (IDT) meetings for care plan review and revision for two residents. The ADON confirmed that no quarterly IDT meetings had occurred following MDS assessments in the past year, and the DON was unaware of who planned and conducted these meetings.
The facility failed to prevent the use of bed rails until alternatives had been attempted, informed consent had been obtained, and a safety assessment had been conducted. A resident expressed a preference against the bed rails and was unsure if alternatives had been tried or if they had signed a consent form. Staff confirmed that no alternatives had been attempted, no safety assessment had been conducted, and no informed consent had been obtained.
The facility failed to ensure a medication/storage closet was locked when left unsupervised. A medication/storage closet on the north hall was observed to be unlocked and unsupervised, containing over-the-counter medications and medical supplies. A CMA confirmed that the door is supposed to be locked.
The facility failed to create a water management plan to prevent waterborne pathogens. The assistant administrator confirmed the absence of such a plan, affecting 31 residents.
Failure to Implement Enhanced Barrier Precautions for Residents With Wounds and Indwelling Catheters
Penalty
Summary
Surveyors identified a failure to develop and implement an infection control plan for enhanced barrier precautions for two residents who required such measures. Observations showed that an LPN performed catheter care and wound care for one resident without wearing a gown, using only hand hygiene and gloves. The resident’s room lacked PPE supplies and enhanced barrier precaution signage. The same resident’s care plan did not include any interventions for enhanced barrier precautions, despite physician orders for ongoing wound care to the left buttock and thigh and catheter care every shift, and an assessment documenting an indwelling catheter and moisture-associated skin damage. A CNA who emptied this resident’s catheter bag also did not wear a gown and reported no knowledge of enhanced barrier precautions or a requirement to wear a gown for this task. For the second resident, surveyors observed an indwelling urinary catheter draining to gravity with a dignity bag in place, but again noted no PPE supplies or enhanced barrier precaution signage near the room. An LPN performed wound care to the right buttock using hand hygiene and gloves but did not wear a gown. Physician orders documented regular wound care and catheter care every shift, and an assessment showed severely impaired cognition, an indwelling catheter, and moisture-associated skin damage. The resident’s care plan included urinary catheter care and wound care but did not include enhanced barrier precaution interventions. During interviews, the LPN reported no knowledge of enhanced barrier precautions, and the ADON stated there was no policy for enhanced barrier precautions available and that the facility had not implemented enhanced barrier precautions, even though two residents were identified as needing them.
Inaccurate MDS Assessments for Medications
Penalty
Summary
The facility failed to accurately code Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in documenting medication administration. Resident #13, diagnosed with congestive heart failure, was prescribed Lasix, a diuretic medication, which was administered daily from 03/01/24 to 03/28/24. However, the quarterly MDS assessment dated 04/01/24 did not document the administration of this medication during the seven-day look-back period. Similarly, Resident #24, diagnosed with major depressive disorder, was prescribed Remeron, an antidepressant, and received it daily from 03/26/24 to 03/31/24. The quarterly MDS assessment dated 04/01/24 failed to document the administration of this medication as well. Resident #84, who had pain and was prescribed Hydrocodone, an opioid pain medication, received it on 03/28/24, 03/29/24, and 03/31/24. The admission MDS assessment dated 04/03/24 did not document the administration of this medication during the five-day look-back period. The Assistant Director of Nursing (ADON) admitted to not documenting section N correctly in the MDS assessments of the three residents, attributing the errors to oversight. Despite having a process where an LPN and the Director of Nursing (DON) were supposed to check the ADON's work, LPN #1 stated that they did not double-check the ADON's work, and the DON confirmed the absence of a process to verify the ADON's MDS assessments. The DON acknowledged the importance of completing MDS assessments correctly but admitted that there was no current process to ensure the accuracy of the ADON's work.
Failure to Ensure Residents Were Free from Accident Hazards
Penalty
Summary
The facility failed to ensure residents were free from accident hazards, specifically regarding the use of bedrails with air flow mattresses. Resident #27, who was admitted with multiple sclerosis, diabetes mellitus, and a pressure ulcer of the sacrum, was observed with bedrails on a low loss air flow mattress. However, the resident's record did not contain a risk assessment for the use of bedrails with this type of mattress. Similarly, Resident #7, admitted with multiple sclerosis, congenital malformation, and the acquired absence of both legs, was observed multiple times with full bedrails raised on both sides of an air flow mattress. The resident's record also lacked a risk assessment for the use of bedrails with the air flow mattress. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that no risk assessments had been completed for the use of bedrails with air flow mattresses for these residents. The ADON reported that Resident #7 had been using the low loss air flow mattress for two years and had bedrails for positioning since July 2023. The DON stated that assessments and informed consent should precede the use of bedrails, but acknowledged that the charge nurses were responsible for these assessments and may not have understood the process. This lack of proper assessment and documentation led to the deficiency noted in the report.
Failure to Perform Annual Nurse Aide Performance Reviews
Penalty
Summary
The facility failed to perform annual nurse aide performance reviews. An employee staff list documented five CNAs who had hire dates greater than one year. On 04/15/24 at 2:00 p.m., the annual nurse aide performance reviews were requested. On 04/17/24 at 1:55 p.m., the assistant administrator stated she could not find the performance reviews. The ADON reported that 31 residents resided in the facility.
Failure to Document Bedrails in Care Plan
Penalty
Summary
The facility failed to develop and implement a care plan for one of the 16 residents reviewed for care plans. Specifically, a care plan dated 04/01/24 did not document the use of bedrails. On 04/15/24, the resident was observed resting in bed with bedrails in use on both sides of the bed. The ADON confirmed on 04/16/24 that the bedrails should have been included in the care plan.
Failure to Conduct Quarterly IDT Meetings for Care Plan Review
Penalty
Summary
The facility failed to conduct interdisciplinary team (IDT) meetings following quarterly assessments for the purpose of reviewing and revising the comprehensive care plan for two residents out of a sample of 12. Resident #21's medical record showed no documentation of care plan meetings from 04/15/23 through 04/15/24. Similarly, Resident #22's medical record lacked documentation of care plan meetings for the same period. Resident #22 was unaware of what care plan meetings were or if they had attended any. The Assistant Director of Nursing (ADON) confirmed that no quarterly IDT meetings had occurred following MDS assessments in the past year, attributing this to the departure of the staff member responsible for these meetings. The Director of Nursing (DON) was also unaware of who planned and conducted the care plan meetings and stated that the facility did not have a policy and procedure for such meetings.
Failure to Follow Bed Rail Safety Procedures
Penalty
Summary
The facility failed to prevent the use of bed rails until alternatives had been attempted, informed consent had been obtained, and a safety assessment had been conducted. Specifically, for one resident, there was no documentation of attempted alternatives to bed rails, a safety assessment, or informed consent. The resident expressed a preference against the bed rails and was unsure if alternatives had been tried or if they had signed a consent form. Staff members, including a CMA and the ADON, confirmed that no alternatives had been attempted, no safety assessment had been conducted, and no informed consent had been obtained. The facility's Restraint policy and procedure did not include requirements for using alternative methods, assessing residents for safety, or obtaining informed consent prior to the use of bed rails. The DON acknowledged that a bed rail safety assessment had not been performed for the resident and that the charge nurses were likely unaware of the required procedures. The facility recognized the need to implement a procedure for the use of bed rails and to provide education to the staff.
Unsupervised Unlocked Medication/Storage Closet
Penalty
Summary
The facility failed to ensure a medication/storage closet was locked when left unsupervised. 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 contained over-the-counter medications and medical supplies. At 8:51 a.m., a Certified Medication Aide (CMA) confirmed that the medication/storage closet door is supposed to be locked.
Lack of Water Management Plan for Pathogen Prevention
Penalty
Summary
The facility failed to create a water management plan to prevent waterborne pathogens. During a record review and interview, it was found that the facility's policy and procedures did not include a water management plan. The assistant administrator confirmed that they were unaware of such a plan and that the facility had not created one. This deficiency was identified while 31 residents resided in the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carnegie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Anadarko Nursing & Rehab | 20.3 mi | ★★★★★ | 9 | 0 |
| Binger Nursing And Rehabilitation | 20.5 mi | ★★★★★ | 0 | 0 |
| Corn Heritage Village And Rehab | 21.1 mi | ★★★★★ | 4 | 2 |
| Cordell Nursing And Rehabilitation | 25.6 mi | ★★★★★ | 18 | 0 |
| Hobart Nursing & Rehabilitation | 28.4 mi | ★★★★★ | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Carnegie Nursing Home, Inc..
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.