Pennsylvania Department of Health
CARNEGIE PARK POST ACUTE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

CARNEGIE PARK POST ACUTE
Inspection Results For:

There are 190 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


CARNEGIE PARK POST ACUTE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to seven complaints, completed on May 29, 2025, it was determined that Carnegie Park Post Acute, was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.

Observations:
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for one of three residents (Resident R1).

Review of facility policy "Medication Monitoring" dated 3/14/25, indicated staff monitor and document events including medication error.

Review of the clinical record indicated Resident R1 was admitted to the facility on 1/2/25.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/12/25, included diagnoses of peritoneal abscess (abscess near the large bowel), colitis (inflammation in the colon), and high blood pressure.

Review of the provider orders reveal the residents Total Parenteral Nutrition (TPN) is to run a cycle for twelve hours from 9 p.m. to 9 a.m. daily.

Review of the clinical record on 5/9/25 revealed Resident R1 received the incorrect TPN. This was reportedly discovered and hour later when Resident R4 was to have TPN prepared and administered. The infusion was stopped, the provider was notified.

During an interview with the Resident R1 on 5/29/25 at 11:30 a.m., she reported no ill effects or concerns with her daily TPN infusions.

During an interview on 5/29/21 at 2:20 p.m., Licensed Practical Nurse (LPN) Employee E1 confirmed the wrong TPN was administered to the resident.

During an interview with LPN Employee E1 on 5/29/25 at approximately 2:20 p.m., stated the TPN was administered by the shift supervisor, Registered Nurse (RN) Employee E2 on 5/10/25. The TPN is to run a cycle for twelve hours from 9 p.m. to 9 a.m. At approximately 5:00 a.m. the infusion pump read complete, and the pump stopped the infusion with medication remaining. The pump was reported to be set at the incorrect rate.

Review of employee statement 5/29/25 at 2:46 p.m. RN Employee E 3 confirmed she mixed the incorrect TPN.

Review of the TPN storage on 5/29/25 at 3:30 p.m. revealed the TPN products are packaged, labeled, sealed, and in a dedicated bin for the individual residents on TPN.

Review of the facility record on date 5/11/25 revealed Resident R1 did not receive the complete dose of TPN.

During an interview on 5/29/25 at approximately 2:50 p.m., with the Assistant Director of Nursing the investigation concluded that the pump was set at the incorrect rate.

During an interview on 5/29/25, at approximately 4:30 p.m. the Nursing Home Administrator and the Assistant Director of Nursing confirmed the facility failed to make certain that residents are free of significant medication errors for two of three residents.

Plan of Correction - To be completed: 06/24/2025

There were no negative outcomes that occurred due to the medication error identified on the abbreviated survey completed on May 29th, 2025 at Carnegie Park Post Acute.

The facility currently resides two residents who are prescribed TPN, an audit was conducted for the past 30 days to ensure no further medication errors occurred.

The Director of nursing and/or designee will educate the nursing staff on the 5 rights of medication administration.

An audit of residents receiving TPN will be conducted 5 times a week for 4 weeks, weekly for 4 weeks then as determined in QAPI thereafter to ensure the proper administration of TPN as it pertains to the 5 rights of medication administration and including the proper settings on the IV pump.

LICENSURE Charge nurse:

Charge nurse-A person designated by the facility who is experienced in nursing service administration and supervision and in areas such as rehabilitative or geriatric nursing or who acquires the preparation through formal staff development programs and who is licensed by the Commonwealth as one of the following:
(i) An RN.
(ii) An RN licensed by another state as an RN and who has applied for endorsement from the State Board of Nursing and has received written notice that the application has been received by the State Board of Nursing. This subparagraph applies for 1 year, or until Commonwealth licensure is completed, whichever period is shorter.
(iii) [Reserved].
(iv) An LPN designated by the facility as a charge nurse on the night tour of duty in a facility with a census of 59 or less in accordance with § 211.12 (relating to nursing services).

Observations:
Based on review of facility provided documents and staff interview, it was determined that the facility utilized Licensed Practical Nurses (LPNs) as charge nurses.

Findings include:

Review of the Pennsylvania Department of Health, Long Term Care Facility Regulations, effective 10/31/23, indicated the following definition for a Charge nurse:
-A person designated by the facility who is experienced in nursing service administration and supervision and in areas such as rehabilitative or geriatric nursing or who acquires the preparation through formal staff development programs and who is licensed by the
Commonwealth as one of the following:
(i) An RN (registered nurse).
(ii) An RN licensed by another state as an RN and who has applied for endorsement from the State Board of Nursing and has received written notice that the application has been received by the State Board of Nursing. This subparagraph applies for 1 year, or until Commonwealth licensure is completed, whichever period is shorter.
(iii) An LPN (licensed practical nurse) designated by the facility as a charge nurse on the night tour of duty in a facility with a census of 59 or less in accordance with section 211.12.

Review of facility census data from 4/27/25, through 5/17/25, did not reveal a census below 100 residents.

Document review of three weeks of facility deployment sheets from 4/27/25 through 5/17/25 revealed, Employee E1 LPN was assigned the position of charge nurse on the following dates and shifts,

4/27/25 11p-7a
4/30/25 3p-11p
5/1/25 11p-7a
5/4/25 11p-7a
5/9/25 7p-7a
5/10/25 7p-7a
5/11/25 11p-7a
5/16/25 3p-11p
5/16/25 11p-7a
5/17/25 3p-11p
5/17/25 11p-7a

During an interview on 5/29/25, at approximately 4:35 p.m. the Nursing Home Administrator and the Assistant Director of Nursing confirmed the facility facility utilized Licensed Practical Nurses (LPNs) as charge nurses.

Plan of Correction - To be completed: 06/24/2025

There were no negative outcomes that occurred due to the facility utilizing a Licensed practice Nurse (LPN) as a charge nurse on the abbreviated survey completed on May 29th, 2025 at Carnegie Park Post Acute.

The regional director of nursing will educate the administrator, director of nursing and staff scheduler on not utilizing LPN's as charge nurses.

An audit will be conducted weekly x 4 weeks to ensure a registered nurse is present in the building 24 hours a day and designated as the charge nurse.

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