Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
58% better than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
79% occupied
Based on a July 2024 inspection.
Occupancy rate over time
Inspection Report
Plan of Correction
Census: 67
Deficiencies: 5
Date: Jul 31, 2024
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with fire safety regulations and hazardous area requirements at Carnegie Village Senior Living Community.
Findings
The facility failed to meet several fire safety regulations including certification of the range hood extinguishing system, illumination of exit signs, maintenance of smoke partitions, installation of sprinkler systems, and use of approved wastebaskets. These deficiencies affected all sixty-seven residents present during the inspection.
Deficiencies (5)
19 CSR 30-86.022(4)(C) Range Hood Certification. The facility failed to certify the range hood extinguishing system in accordance with NFPA 96. The kitchen hood suppression system was not inspected or tagged as required twice annually.
19 CSR 30-86.022(8)(C) Exit Sign-Illumination. The facility failed to ensure all exit signs were illuminated under normal and emergency conditions. Several exit signs were unapproved and not illuminated.
19 CSR 30-86.022(10)(A) Hazardous Area Requirements. The facility failed to maintain smoke partitions separating the kitchen area from the dining area. An air vent provided no fire/smoke protection and the kitchen fire/smoke door was propped open.
19 CSR 30-86.022(11)(E) Sprinkler System, Res. Impaired, Multilevel. The facility failed to install a complete sprinkler system in accordance with NFPA 13. No sprinkler heads were installed in certain bathrooms.
19 CSR 30-86.022(15)(A) Wastebaskets, Metal/UL/FM-Requirements. The facility failed to ensure only metal or UL/FM-fire-resistant wastebaskets were used. Unapproved wastebaskets were found throughout the facility.
Report Facts
Facility census: 67
Inspection Report
Plan of Correction
Census: 57
Deficiencies: 2
Date: Sep 14, 2023
Visit Reason
The inspection was conducted to investigate and document deficiencies related to safeguarding residents and following physician orders at Carnegie Village Senior Living Community.
Findings
The facility failed to safeguard one resident from verbal abuse by a Certified Nurse's Aide and failed to ensure physician orders were followed regarding wound care for the same resident. The facility census was 57 residents at the time of inspection.
Deficiencies (2)
19 CSR 30-86.047(28)(J) Plan to Safeguard Residents. The facility failed to protect the rights and safety of one resident when a CNA used a loud tone of voice during interaction.
19 CSR 30-86.047(47)(A) Physicians Orders Followed. The facility failed to ensure physician orders were followed for wound care for one resident out of three sampled.
Report Facts
Facility census: 57
Sampled residents: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse's Aide | Named in verbal abuse finding and plan of correction |
| Administrator | Administrator | Responsible for oversight and plan of correction |
| Administrator in Training (AIT) | Administrator in Training | Involved in investigation of abuse allegation |
| Director of Nursing | Director of Nursing | Oversight of abuse prevention program and wound care |
| Certified Medication Technician (CMT) B | Certified Medication Technician | Interviewed regarding medication and resident interaction |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding wound care |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding wound care and treatment |
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: May 1, 2023
Visit Reason
The inspection was conducted due to allegations of misappropriation and abuse involving residents at Carnegie Village Assisted Living Facility.
Complaint Details
The complaint investigation substantiated allegations of misappropriation involving a Certified Nurses Assistant (CNA) who was found to have taken photographs of a resident's credit card and used it fraudulently. Multiple unauthorized transactions and stolen checks were documented, with a total fraudulent activity amounting to over $23,000. The CNA was terminated and the facility conducted a thorough investigation including interviews and police involvement.
Findings
The facility failed to develop and implement adequate policies to prevent mistreatment, neglect, and misappropriation of resident property. Investigations revealed multiple instances of resident property theft and fraudulent use of resident credit cards by a staff member.
Deficiencies (1)
19 CSR 30-88.010(23) Develop/Implement A/N Policies. The facility failed to ensure three sampled residents were free from misappropriation and did not thoroughly investigate allegations of misappropriation. The deficient practice had the potential to affect all facility residents.
Report Facts
Facility census: 62
Fraudulent activity amount: 23834
Actual loss amount: 21589
Value of thefts linked to CNA: 23000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurses Assistant | Named as suspect in misappropriation and fraudulent use of resident's credit card |
| Brooke Wilkerson | Administrator | Facility Administrator involved in investigation and plan of correction |
Inspection Report
Plan of Correction
Census: 61
Deficiencies: 2
Date: Nov 16, 2022
Visit Reason
The inspection was conducted to assess compliance with call light system requirements and the plan to safeguard residents, including fall management and use of Low Air Loss Mattresses (LALM).
Findings
The facility failed to ensure timely staff response to call lights and proper use of pagers. The facility also failed to develop and implement an adequate plan to safeguard residents from falls and to properly use LALM for residents requiring pressure relief.
Deficiencies (2)
19 CSR 30-86.032(33) Call Systems Requirements: The facility failed to ensure staff responded timely to call lights and maintain system pagers in use. Residents reported long delays or no staff response to call lights.
19 CSR 30-86.047(28)(J) Plan to Safeguard Residents: The facility failed to outline a plan to ensure safety for residents with multiple falls and to properly use a Low Air Loss Mattress for pressure relief. Documentation and training were lacking.
Report Facts
Census: 61
Deficiencies cited: 2
Inspection Report
Plan of Correction
Census: 52
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
The inspection was conducted to investigate deficiencies related to care for residents with suicidal ideations and to ensure compliance with facility policies and regulatory requirements.
Findings
The facility failed to promptly implement interventions for two residents with suicidal ideations and did not ensure 1:1 staffing for one resident after an attempt. The deficiency was initially classified as Class I but was later lowered to Class II after corrective actions were implemented.
Deficiencies (1)
19 CSR 30-86.047(10) Care to Meet Resident Needs or Discharge: The facility failed to promptly put interventions in place for two residents who voiced suicidal ideations and failed to ensure 1:1 staffing for one resident after an attempt. The facility's census was 52 residents.
Report Facts
Facility census: 52
Inspection Report
Plan of Correction
Census: 64
Deficiencies: 1
Date: May 9, 2019
Visit Reason
The inspection was conducted to investigate a deficiency related to protective oversight and the facility's response to a door alarm triggered by a resident leaving the premises during a severe weather event.
Findings
The facility failed to provide protective oversight for residents departing on voluntary leave, as staff did not respond to a door alarm triggered by Resident #1 who left the facility and was found confused outside. The resident had dementia and was unable to exit the building safely without supervision.
Deficiencies (1)
19 CSR 30-86.047(35) Protective Oversight: The facility failed to respond to a door alarm after Resident #1 exited the building during a severe weather alarm, resulting in the resident being found confused outside. Staff did not perform required follow-up head counts or ensure residents did not exit without an escort.
Report Facts
Facility census: 64
Inspection Report
Plan of Correction
Census: 62
Deficiencies: 1
Date: Mar 5, 2019
Visit Reason
The visit was conducted to investigate a failure by the facility to immediately report an allegation of resident mistreatment as required by regulation.
Findings
The facility failed to immediately report an allegation of resident mistreatment involving Resident #1. The report was delayed, and the staff member responsible for not reporting is no longer employed.
Deficiencies (1)
19 CSR 30-88.010(25) requires immediate reporting of suspected abuse or neglect. The facility failed to report an allegation of resident mistreatment affecting one resident in a timely manner.
Report Facts
Facility census: 62
Inspection Report
Life Safety
Census: 60
Deficiencies: 1
Date: Apr 30, 2018
Visit Reason
The inspection was a fire safety inspection conducted to assess compliance with flame-resistant requirements for curtains and drapes in the licensed facility.
Findings
The facility failed to certify or treat curtains and drapes as flame-resistant as required by regulation. Observations showed no fire-resistant labels on curtains in multiple rooms, and record review confirmed outdated treatment logs.
Deficiencies (1)
19 CSR 30-86.022(13)(D) Curtains/Drapes, Flame Resistant: The facility failed to certify or treat curtains and drapes as flame-resistant as required by NFPA 101, 2000 edition. Observations in rooms 328 and 325 showed no fire-resistant labels on curtains.
Report Facts
Facility census: 60
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