Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Accura Healthcare Of Carlisle during CMS and state inspections, most recent first.
Food was not kept at an appetizing temperature for one resident who ate in her room and reported that meals were often cold when delivered. A tray observation showed hot items below the facility’s required 135-degree F standard, and the CDM stated hot foods were expected to be held at 135 degrees F or above.
Unsanitary kitchen conditions and contaminated ice machine. Surveyors observed heavy dust, debris, buildup, and splatters throughout the pantry, dish machine area, stove area, refrigerator, and on stored items. The ice machine had black substance on the interior ceiling with water dripping into the ice, and the CDM stated it appeared to be water mold and that he would not want residents to consume the ice. A follow-up kitchen visit found dust and debris still present on multiple surfaces, while the CDM acknowledged surfaces and vents should be clean.
Missing Bed Rail Inspection Documentation: The facility failed to complete and/or maintain routine bed rail inspection records for all residents with side rails. A resident with bilateral half rails used for repositioning and safety due to frequent falls out of bed was observed with upper quarter-length rails, and maintenance staff from a sister facility later checked the rails without prior facility documentation. An undated bed entrapment inspection form showed 10 beds passed, but it did not identify who completed the assessments.
The facility failed to maintain an effective pest control program, resulting in an ongoing mice infestation affecting resident rooms, staff areas, and common spaces. An LPN reported mice eating food stored in a staff locker, and work orders documented a mouse in a resident room. Surveyors observed mice droppings in multiple drawers of a resident’s clothing dresser and in a vacant room near a heat register. A housekeeping aide reported that mice had chewed and torn stored activity items and that a recliner in a resident’s room contained extensive mice droppings and contaminated soft toys. In the Activity Room, where three residents were present, surveyors observed numerous black and green mice droppings near the entrance and a nightstand, along with debris behind the furniture, despite a facility policy stating it would maintain an effective pest control program for pests and rodents.
A resident with severe cognitive impairment, dependent on staff for personal care and transfers, made repeated statements over two mornings alleging rape by a male individual. Multiple CNAs heard and variably reported these allegations to an RN, but there was confusion about who notified nursing leadership. The DON stated they did not learn of the allegation until the following morning via an LPN, and the abuse report was not submitted to the State Agency until later that morning, exceeding the facility’s policy requirement to report abuse allegations within 2 hours.
A resident reported to a CNA that a male staff member, described by race and role, had raped them and another resident during the night. The CNA informed an RN, who stated they notified the DON that morning, but the DON reported not learning of the allegation until the following day. Review of staffing schedules showed a CNA matching the general description of the alleged perpetrator had worked consecutive night shifts and continued to work and have access to residents after the allegation was first reported to staff. This conflicted with facility policy requiring immediate protective measures, such as suspension or segregation of an employee accused of abuse, upon receipt of an abuse allegation.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that the environment was not maintained safely and supervision was lacking, but does not provide further specifics.
The facility inaccurately completed MDS assessments for several residents by misclassifying antiplatelet medications as anticoagulants and incorrectly coding active diagnoses and PASRR status. These errors were identified through record review and staff interviews, revealing gaps in staff knowledge and documentation practices.
The facility did not develop or implement comprehensive care plans for two residents, one with severe cognitive impairment and dementia, and another with recurrent UTIs. Both residents' care plans lacked focus areas, goals, or interventions for their respective diagnoses, despite documented medical histories and ongoing treatment needs.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
Staff did not consistently secure and position a resident's catheter bag below the bladder as required by policy and the care plan. The resident, who had a suprapubic catheter and multiple health conditions, was observed with the catheter bag on the floor and above bladder level, and reported difficulty with the catheter while using a wheelchair. The DON confirmed the catheter bag should always be below bladder level.
A resident with diabetes received insulin from an LPN who did not follow manufacturer and facility procedures for insulin pen use. The LPN failed to keep the needle in the skin for the required time after injection, which is necessary to ensure the full dose is delivered. This action did not comply with the physician's orders or the manufacturer's instructions for insulin administration.
Staff failed to properly disinfect a stethoscope and a glucometer after use on two residents, and did not follow glove-changing protocols during care. An LPN placed a used stethoscope on a resident's blanket and over her neck without cleaning it, while an RN inadequately cleaned a glucometer used on multiple residents. These actions did not meet facility infection control policies or manufacturer guidelines.
The facility did not accurately submit direct care staffing data to CMS, as the PBJ report for the specified quarter omitted agency staff who worked on weekends. This omission resulted in the report triggering for excessively low weekend staffing, despite the facility maintaining a census of 70 residents.
A resident with severe cognitive impairment and total dependence for ADLs was observed with chapped, peeling lips despite a physician order for Aquaphor Lip Repair and a care plan for frequent oral hygiene. Documentation showed the lip treatment was not applied for at least 30 days, and staff interviews revealed inconsistent notification to nursing staff about the resident's condition.
Two residents at high risk for pressure ulcers did not consistently receive physician-ordered pressure-relieving devices, such as Prevalon boots and knee wedges, as observed and confirmed by staff interviews and record review. Staff failed to apply these devices as ordered, and there was no documentation of resident refusal or clinical justification for non-compliance, despite clear care plans and facility policy requiring their use.
Two residents with severe mobility and cognitive impairments did not consistently receive their physician-ordered hand splints or palm devices as required to prevent further contractures. Staff failed to apply the DME as ordered, with documentation and observations showing lapses in use and no evidence of resident refusal or medical justification for the omissions.
Staff did not wear required PPE, such as gowns and gloves, while providing direct care to two residents on Enhanced Barrier Precautions for MDRO risk. Despite clear signage and care plans indicating the need for PPE during high-contact activities, CNAs entered rooms and performed care without donning appropriate protective equipment, and staff interviews revealed confusion about EBP requirements.
The facility failed to prevent and treat pressure ulcers for three residents, leading to the development and worsening of Stage 3 ulcers. A resident with Alzheimer's developed a sacral ulcer, but treatment was delayed and supplies were unavailable. Another resident with dementia had a healed ulcer but developed a new one due to inconsistent use of pressure-relieving cushions. A third resident with Alzheimer's developed a gluteal ulcer, with treatment delayed by a week. The facility's lack of timely intervention and documentation contributed to the deterioration of the residents' conditions.
The facility failed to treat residents with dignity and respect, affecting three residents. A resident with paraplegia was hurt during bathing and called 'whiny' by a CNA. Another resident with heart failure was told by the same CNA that she was done helping her. A third resident with diabetes was instructed to urinate in her brief instead of being assisted to the bathroom. These incidents were reported to the DON, but the facility's policy on resident dignity was not followed.
A resident with severe cognitive impairment and anxiety did not receive prescribed lorazepam due to a delay in pharmacy delivery and lack of emergency kit availability. The facility's policy did not address obtaining medications for new orders, leading to the resident experiencing labored breathing and requiring emergency services. The medication arrived as emergency services did, and the resident received her first dose.
A medication cart was found unattended and unlocked in a resident hall, contrary to the facility's policy requiring medication storage to be secured when not attended by authorized staff. An LPN acknowledged the oversight and locked the cart upon returning. The DON confirmed the expectation for staff to lock medication carts when unattended.
The facility failed to secure resident-identifiable information, as observed when a laptop with multiple residents' EHRs was left unattended by an LPN. The facility lacked a policy for securing resident records, and the DON acknowledged the need for staff to ensure information is not displayed when unattended.
The facility failed to implement effective infection control policies, leading to potential cross-contamination risks. Staff were unable to locate necessary sanitizing wipes for cleaning PPE goggles and shared equipment, and improper hand hygiene practices were observed. The absence of sanitizing supplies and adherence to hand hygiene protocols contributed to the deficiencies.
A resident with mental health conditions and incontinence issues was left without timely toileting assistance, leading her to call out for help in the hallway. Despite staff presence, her request was not promptly addressed, violating the facility's dignity policy.
The facility did not maintain the required eight-hour RN coverage on nine days within a month, affecting 71 residents. On six days, there was no RN coverage, and on three days, only four hours of coverage were provided. Staff interviews confirmed the deficiency, with the CNA noting that management could not be counted towards RN coverage, and the Administrator admitting the absence of a policy for eight-hour RN staffing.
The facility failed to provide adequate nursing staff, resulting in delayed call light responses for residents. Observations and interviews revealed significant delays, with some residents waiting up to two hours for assistance. The DON admitted that call light audits had not been conducted for two months, despite the facility's 15-minute response expectation.
The facility failed to implement proper infection control measures, including Enhanced Barrier Precautions (EBP) and PPE usage, for residents at risk of MDRO and those with COVID-19. Staff did not wear gowns during high-contact care for two residents with MDRO risk, and a CNA failed to use eye protection and changed PPE improperly while caring for two COVID-19 positive residents. Interviews confirmed these actions were against facility policy and CDC guidelines.
A resident with moderate cognitive impairment and paraplegia was observed without a dignity cover on their catheter bag on multiple occasions. The resident stated that the cover went missing a long time ago and was not replaced. Staff interviews confirmed that dignity covers should be used, and the DON expected them to be in place, but the facility lacked a specific policy for their use.
The facility inaccurately assessed two residents' statuses in their MDS. One resident was incorrectly documented as having an indwelling catheter, which they never had at the facility, while another resident's use of bed rails was misclassified as a restraint. The DON confirmed these were coding errors, and the facility lacked a specific policy for MDS accuracy.
A facility failed to implement a comprehensive care plan for a resident with moderate cognitive impairment, who required supervision during meals. Despite the care plan's requirement, CNAs left the resident unsupervised during meals while she was in isolation. Staff interviews revealed a lack of awareness about the resident's supervision needs, and the facility lacked a policy on following care plans, leading to the deficiency.
A facility failed to follow procedures for a resident with a PEG tube, who had diagnoses including traumatic brain dysfunction and malnutrition. A physician's order required checking the tube's placement and residual before administering medications. An LPN administered medications without verifying placement or obtaining residual, contrary to the order. The DON confirmed the expectation for these checks, and the facility lacked a policy on enteral feedings.
The facility failed to maintain hot food served at a temperature greater than 140 degrees Fahrenheit during a meal service. Observations and interviews revealed that several food items were below the required threshold, and multiple instances were found where food temperatures were not checked. Residents and staff confirmed that food trays were often served cold, both in resident rooms and dining areas. The facility's Food Temperatures policy was not adhered to, leading to the deficiency.
A resident was not allowed to vape an electronic nicotine device, despite staff being permitted to smoke and two other residents being grandfathered into the facility's no-smoking policy. The resident, who was cognitively intact, felt her rights were violated, and the Volunteer Ombudsman noted inconsistent enforcement of the smoking policy.
The facility failed to follow physician orders for a resident with Diabetes Mellitus, leading to improper administration of Lispro insulin. The resident's blood sugar was checked at 8 a.m., but the insulin was administered at 9:14 a.m., which was not in accordance with the physician's orders. Additionally, Resident Council Meeting Minutes revealed ongoing concerns about the timely administration of medications.
Food Served Below Required Hot-Holding Temperature
Penalty
Summary
The facility failed to provide food at an appetizing temperature for 1 of 8 residents reviewed, Resident #41. Resident #41’s MDS dated [DATE] showed a BIMS score of 15, indicating intact cognitive functioning. During interview on 5/18/2026 at 10:25 AM, Resident #41 stated that she eats in her room and that the food is often cold when brought to her. During observation on 5/19/26 at 12:03 PM, a sample tray showed the creamy pork chop at 122.7 degrees and the broccoli at 132.3 degrees. The facility’s Food Temperatures policy dated 2021 stated hot food items should not fall below 135 degrees Fahrenheit after cooking, and at 12:37 PM the CDM stated he expected hot foods held at 135 degrees Fahrenheit or above.
Unsanitary kitchen conditions and contaminated ice machine
Penalty
Summary
The facility failed to prepare food under sanitary conditions during 2 of 2 kitchen observations. During the initial kitchen tour on 5/17/26 at 10:38 a.m., surveyors observed a thick debris and dust layer on the floor under the shelves in the pantry, a thick black dust layer on the ceiling vent above and diagonal to the clean side of the dish machine room, a thick crusty-looking white buildup on the outside of the dishwasher, dust particles hanging from 2 spigots of the fire suppression system above the stove burners, heavy dust buildup on the wall slats behind the stove burners, orange splatters between the bottom of the stove and the stove door, and heavy dust buildup on a shelf holding multiple steam table pans face down. They also observed multiple pudding-like splatters on the right side floor of the Arctic Air #2 refrigerator, clear plastic bowls sitting face down in crumbs on a red tray, and a white plastic piece on the interior ceiling of the ice machine covered with a black substance. Water dripped from the black areas into the ice in the bottom of the ice machine, and the Certified Dietary Manager stated it appeared to be water mold and that he would empty the ice and would not want residents to consume it. On 5/19/26, a follow-up kitchen visit showed dust and debris still remained on the shelves, ceiling vents, dishwasher, fire suppression spigots, and wall slats behind the stove. During that visit, the CDM stated he thought the sanitation in the kitchen was pretty good and agreed that surfaces and vents should be clean. The undated dietary cleaning schedule directed staff to clean items including refrigerators, the pantry, the dishwasher, and dish racks.
Missing Bed Rail Inspection Documentation
Penalty
Summary
The facility failed to complete and/or maintain documentation of routine bed rail inspections for 10 of 10 residents with side rails. The report states the facility had a census of 78 residents. Resident #32 had bilateral half rails used to aid in repositioning and safety due to frequent falls out of bed, with a care plan goal initiated on 6/27/25 for the resident to remain free of falls out of bed and to assist with repositioning through the review date. A care plan intervention also directed staff to assist the resident with independence in repositioning. On 5/20/26, the Administrator observed that a resident had both upper quarter-length rails and stated the Housekeeping and Laundry Supervisor currently oversaw maintenance due to a recent staff changeover. Later that day, the Maintenance Director and Maintenance Assistant from a local sister facility were in Resident #32's room evaluating the bed rails, and one rail was removed and placed on the floor. They presented empty maintenance inspection sheets and stated facility staff had not provided prior documentation of bed rail assessments, and corporate management had called them in that day to check all bed rails in the facility. They stated they did not see anything wrong with Resident #32's bed rails, but were not used to this type and were not verifying that the entrapment zone measurements were correct. The Administrator later provided an undated Bed Entrapment Inspection form showing 10 resident beds passed, but the form did not identify who completed the assessments.
Failure to Maintain Effective Pest Control Resulting in Mice Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free from vermin infestation. Staff interviews revealed an ongoing mice problem in multiple areas, including the staff break room and resident care areas. An LPN reported that mice had eaten a snack stored in her personal locker in the break room about a week prior, and facility work orders documented a mouse in a resident room that was marked as closed. During observations, surveyors found mice droppings in four of six drawers of a resident’s clothing dresser, where socks, jeans, and personal items were stored, and in the corner of a vacant resident room near the heat register. Additional staff interviews and observations showed that the mice problem extended to common and storage areas. The Maintenance Director acknowledged an ongoing mice issue and reported that staff had recently caught live mice in their work area. A housekeeping aide stated that the mice problem was so severe that multiple items in the Activity Room storage closets, including Christmas decorations, were torn and chewed, and staff saw a live mouse jump out of one of the boxes. She also reported that when a recliner cushion in a resident’s room was pulled out, a large amount of mice droppings and some soft toys had to be discarded. During an observation of the Activity Room with three residents present, multiple mice droppings, both black and green, were noted around the room near the entrance door and a nightstand, with debris behind the nightstand. The Administrator confirmed that mice droppings were first noted at the beginning of the month and that the facility had a pest control policy stating it would maintain an effective pest control program for common household pests and rodents.
Failure to Timely Report Resident Sexual Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s allegation of sexual abuse to the State Agency within the required 2-hour timeframe. Resident #4, who had severe cognitive impairment with a Brief Interview for Mental Status score of 4 and was dependent on staff for personal care and transfers, made multiple statements over two consecutive mornings alleging rape by a male individual. On the morning of 1/21/26, several CNAs (Staff F, G, and H) reported that Resident #4 stated a black man had raped them, with one CNA documenting that the resident also mentioned a black girl and identified the man as the one who comes in and turns the light on. Staff H’s written statement indicated they informed Staff I, an RN, at approximately 8:00 AM on 1/21/26 of the allegation. Staff I later acknowledged that Staff H reported the allegation to them that morning and stated they then called the DON around 7:30–8:00 AM to report it. Despite these reports, the DON stated they were not contacted on 1/21/26 and first became aware of the allegation the morning of 1/22/26 via a phone call from an LPN. The facility’s Incident Investigative Report showed that the online report of sexual abuse involving Resident #4 was submitted to the Iowa Department of Inspections, Appeals, and Licensing on 1/22/26 at 8:13 AM. Staff interviews revealed confusion and uncertainty among CNAs about who had notified nursing leadership on 1/21/26, with some staff believing others had reported the allegation to a nurse or the DON but unable to confirm this. The facility’s abuse policy, updated 10/19/22, required that allegations of resident abuse be reported to the State Agency no later than 2 hours after the allegation is made, which did not occur in this case.
Failure to Immediately Remove Alleged Perpetrator After Sexual Abuse Allegation
Penalty
Summary
The facility failed to protect residents from further potential abuse after an allegation of sexual abuse was reported. On the morning of 1/21/26, a CNA (Staff H) reported that Resident #4 stated a black man raped me and the black girl when asked how they had slept, and further identified the alleged perpetrator as the man who comes in and turns the light on. After completing personal cares, Staff H informed an RN (Staff I) of the allegation. Staff I acknowledged being approached by Staff H that morning and stated they called the DON at approximately 7:30 AM to report the allegation. However, the DON reported they were not contacted on 1/21/26 and first became aware of the allegation on the morning of 1/22/26. Upon becoming aware of the allegation on 1/22/26, the DON reviewed staffing schedules from the previous day and identified a CNA (Staff J) whose general description matched that provided by Resident #4 and who had worked the night shift on 1/21/26. Staffing schedules showed Staff J worked the night shifts of 1/20/26 and 1/21/26. Staff J was not suspended until 1/22/26, meaning they continued to work and had access to residents after the allegation was initially reported to staff. This sequence of events conflicted with the facility’s written Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, which requires the facility to immediately implement measures to prevent further potential abuse upon receiving an allegation, including suspending or segregating the accused employee or otherwise ensuring no resident contact while an investigation is in process. The facility submitted an online report of the sexual abuse allegation involving Resident #4 to the state agency on 1/22/26 at 8:13 AM.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific details regarding the nature of the hazards, the supervision provided, or the individuals affected are not included in the report.
Inaccurate MDS Assessments Due to Medication and Diagnosis Coding Errors
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for four out of twenty-three residents reviewed. Specifically, the MDS assessments incorrectly documented that certain residents were taking anticoagulant medications when, according to the electronic health records and physician orders, they were actually prescribed antiplatelet medications such as Clopidogrel (Plavix), which should not be classified as anticoagulants. Additionally, there were inaccuracies in coding active diagnoses, such as viral hepatitis, and in documenting PASRR (Pre-admission Screening and Resident Review) status for residents with mental health diagnoses. These errors were identified through clinical record review, staff interviews, and comparison with the Resident Assessment Instrument (RAI) Manual guidelines. The MDS Coordinator, who had been in the role since December, reported using the RAI Manual, staff input, and a medication classification list to complete assessments but demonstrated a lack of understanding regarding the correct classification of medications and the criteria for coding active diagnoses. For example, the coordinator incorrectly coded antiplatelet medications as anticoagulants and was uncertain about the look-back period for active diagnoses such as viral hepatitis. The facility's documentation practices did not align with the requirements outlined in the RAI Manual, leading to inaccurate MDS assessments for multiple residents with complex medical histories, including those with coronary artery disease, cerebrovascular accident, quadriplegia, and mental health conditions.
Failure to Develop Comprehensive Care Plans for Residents with Dementia and Recurrent UTIs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two out of five residents reviewed. For one resident with severe cognitive impairment and a diagnosis of non-Alzheimer's dementia, the care plan did not include any focus area, goals, or interventions related to the dementia diagnosis, despite this being documented in the resident's Minimum Data Set (MDS). For another resident with a documented history of recurrent urinary tract infections (UTIs), the care plan similarly lacked any focus area, goals, or interventions addressing the UTI diagnosis, even though the resident had multiple recent episodes of UTIs treated with antibiotics and this condition was noted by the physician. Clinical record reviews, staff interviews, and policy review confirmed these omissions. The Director of Nursing acknowledged that care plans are expected to accurately reflect residents' health conditions, including specific diagnoses and related interventions. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes for all identified needs, but this standard was not met for the residents in question.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established plan or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Properly Position Catheter Bag Below Bladder Level
Penalty
Summary
Staff failed to properly secure and position a resident's catheter bag below the level of the bladder, as required by facility policy and the resident's care plan. The resident, who had a history of renal insufficiency, obstructive uropathy, diabetes, and a suprapubic catheter, was observed on multiple occasions with the catheter bag either lying on the floor under the wheelchair or hung above the level of the bladder. These observations were made during routine checks and included instances where the catheter bag contained yellow urine and was not properly secured, as well as when the resident reported difficulty accessing the call light due to running over the catheter tubing with the wheelchair. Further review of the clinical record and staff interviews confirmed that the facility's policy required the catheter bag to be kept below the level of the bladder at all times to ensure proper drainage and minimize infection risk. The Director of Nursing acknowledged that the catheter bag should be positioned below the bladder. The care plan for the resident specifically directed staff to maintain this positioning, but staff failed to consistently follow these instructions, as evidenced by the surveyor's observations.
Insulin Administration Not Performed per Manufacturer and Physician Instructions
Penalty
Summary
A deficiency occurred when staff failed to administer insulin according to both physician's orders and manufacturer instructions for a resident with diabetes and diabetic neuropathy. During a medication pass, an LPN used a new Novolog insulin flexpen, labeled and dated it, attached a needle, and primed the pen by dialing to 2 units and expelling insulin. The LPN then set the pen to 3 units, donned gloves, and injected the insulin into the resident's abdomen. However, the LPN removed the needle from the injection site within 1-2 seconds, rather than following the required procedure to keep the needle in the skin for at least 6 seconds to ensure the full dose was administered. Facility competency guidelines and manufacturer instructions both specify that after pressing the injection button, the needle should remain in the skin for a specified period to ensure the complete dose is delivered. The LPN did not adhere to this step, potentially resulting in an incomplete dose. The DON confirmed the correct procedure for insulin pen use, including the importance of priming and ensuring the full dose is administered, but the observed practice did not align with these standards.
Failure to Disinfect Resident Care Devices and Follow Infection Control Practices
Penalty
Summary
Facility staff failed to properly disinfect resident care devices and adhere to infection control practices as observed during routine care of two residents. In one instance, a resident with a history of pneumonia, on antibiotics, and receiving tube feeding via a gastrostomy tube was attended by an LPN who donned appropriate personal protective equipment but placed a used stethoscope on the resident's blanket and later draped it over her neck without disinfecting it. The LPN also handled trash and opened the resident's door with gloved hands, then continued care activities without changing gloves as required. The care plan for this resident indicated the need for enhanced barrier precautions due to the risk of multidrug-resistant organisms (MDRO) related to the indwelling tube. In another instance, an RN checked a resident's blood sugar and cleaned the glucometer with an alcohol swab for less than five seconds before storing it, despite the device being used on multiple residents. Facility policy and manufacturer instructions required the use of a specific disinfectant wipe with a two-minute wet contact time for proper disinfection. Interviews with the Director of Nursing confirmed expectations for staff to follow these infection control protocols, which were not met in these observed cases.
Failure to Accurately Report Weekend Staffing in PBJ Submission
Penalty
Summary
The facility failed to submit accurate direct care staffing information to CMS for the Payroll Based Journal (PBJ) Staffing Data Report covering January 1st to March 31st, 2025. The PBJ report triggered for excessively low weekend staffing during this period. Upon review, it was determined that the facility's PBJ data submission did not include staffing agency staff who worked on weekends, despite the facility maintaining a census of 70 residents. The Administrator confirmed in an interview that the omission of agency staff led to the inaccurate reporting, and the Regional Director later submitted a PBJ report that did not reflect concerns, but the original deficiency remained due to the incomplete data submission.
Failure to Provide Ordered Lip Care and Oral Hygiene Assistance
Penalty
Summary
A resident with severe cognitive impairment, quadriplegia, and total dependence for all activities of daily living was observed with chapped and peeling lips while reclined in a Geri chair. The resident had a physician order for Aquaphor Lip Repair to be applied as needed for dry, chapped lips, and the care plan included oral hygiene assistance every two hours while awake. Despite these interventions, the Medication Administration Records for the previous 30 days showed no documentation that Aquaphor had been applied. Staff interviews revealed that CNAs were responsible for checking the resident's lips during oral hygiene and notifying the nurse if chapped lips were observed, but there was uncertainty among staff regarding notification requirements. The resident's brother had previously expressed concerns about the resident's dry, chapped lips, and a progress note indicated some improvement at one point, but no further documentation was available regarding ongoing treatment. On the day of observation, the resident's lips remained chapped and peeling, and the assigned nurse was not notified of the condition. The facility did not have a specific policy for activities of daily living, and the Director of Nursing confirmed that staff should have notified the nurse to apply Aquaphor.
Failure to Provide Ordered Pressure Ulcer Prevention Devices
Penalty
Summary
The facility failed to provide appropriate pressure ulcer prevention and care for two residents who were at high risk for developing pressure ulcers. For one resident with severe cognitive impairment, quadriplegia, and protein-calorie malnutrition, physician orders and the care plan required the use of Prevalon boots at all times except during transfers. However, observations showed the resident was repeatedly without the prescribed boots while seated in a Geri chair in the television area, and the boots were found stored in the resident's room instead of being worn. Staff interviews confirmed that the boots were not applied as ordered, and there was no documentation of resident refusal or any clinical justification for not following the order. Another resident, who had Alzheimer's disease, joint contracture, and a history of a Stage 3 sacral pressure ulcer, also had physician orders for Prevalon boots and a knee wedge to be used at all times except during transfers. Observations revealed this resident was in the dining room and later in bed without the required pressure-relieving devices in place. Staff expressed uncertainty about when the devices should be used, and the care plan and task lists did not provide clear or consistent guidance. There was no documentation of resident refusal or any reason for not using the devices as ordered. Both residents were identified as high risk for pressure ulcers according to their Braden Scale assessments, and their care plans and treatment records reflected the need for pressure-reducing interventions. Despite this, staff failed to consistently implement physician-ordered interventions, and documentation did not reflect any refusals or clinical reasons for non-compliance. Facility policy required interventions to be implemented according to physician orders, but this was not followed in these cases.
Failure to Consistently Apply Ordered DME for Residents with Limited ROM
Penalty
Summary
The facility failed to ensure that ordered Durable Medical Equipment (DME) was used as prescribed to prevent further decline in range-of-motion (ROM) for two residents with significant mobility impairments. In the first case, a resident with severe cognitive impairment, quadriplegia, and a history of stroke was observed multiple times without the required palm DME, despite a physician's order for it to be worn at all times except for pain, hygiene, or skin checks. Documentation in the electronic health record and treatment administration record indicated inconsistent application of the DME, and staff interviews confirmed lapses in following the order, with one CNA admitting to forgetting to apply the device after transporting the resident. In the second case, another resident with Alzheimer's disease, joint contracture, and severe communication limitations was observed without her bilateral hand splints, which were ordered to be worn every shift with removal allowed for two hours per day. Review of the electronic health record showed minimal documentation of splint or brace assistance over the previous 30 days, and the treatment administration record indicated the order was in place. Staff interviews revealed that the splints had been removed for a shower and were not reapplied within the prescribed timeframe, exceeding the allowed period without the splints. Both residents were dependent on staff for all activities of daily living and had documented bilateral ROM impairments. The facility's own restorative program process required licensed nurses to monitor compliance with restorative interventions, but observations and documentation revealed that staff did not consistently apply or monitor the use of prescribed DME, and there was no documentation of resident refusal or medical justification for the lapses.
Failure to Use PPE During Enhanced Barrier Precautions
Penalty
Summary
Staff failed to don appropriate Personal Protective Equipment (PPE) when providing direct care to two residents who were on Enhanced Barrier Precautions (EBP). Observations showed that multiple Certified Nurse Aides (CNAs) entered the rooms of these residents without wearing gloves or gowns, despite clear signage on the doors indicating the need for such precautions during high-contact activities such as dressing, bathing, transferring, changing linens, providing hygiene, and device or wound care. The EBP orders and care plans for both residents specifically directed the use of these precautions due to their risk of multidrug-resistant organism (MDRO) colonization or infection. Interviews with staff revealed a lack of understanding regarding the requirements of EBP, with some CNAs unsure about when to use gowns and gloves or which resident the precautions applied to. Both residents involved had significant medical conditions, including quadriplegia, pressure ulcers, feeding tubes, and severe cognitive impairment, making them highly dependent on staff for all activities of daily living. The facility's policy on EBP, updated prior to the incidents, clearly outlined the need for targeted gown and glove use during high-contact care, but this was not followed during the observed care activities.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development and worsening of pressure ulcers for three residents. Resident #1, who had Alzheimer's and severe cognitive impairment, developed a new Stage 3 pressure ulcer on her sacrum. Despite the identification of the ulcer, there was a delay in implementing a treatment plan, and the necessary wound care supplies were not available in a timely manner. The resident's wound deteriorated, and there was a lack of documentation for the implementation of prescribed treatments and the use of a pressure-relieving cushion. Resident #3, who had dementia and depression, was identified with a Stage 3 pressure ulcer on the right buttock. The facility's records indicated that the ulcer was initially healed, but a new ulcer developed. There was inconsistency in the use of pressure-relieving cushions, and the facility failed to ensure the resident had the appropriate cushion in her chair, which may have contributed to the development of the new ulcer. Resident #4, who had Alzheimer's disease and severe cognitive impairment, developed a new Stage 3 pressure ulcer in the left gluteal cleft. The facility did not start treatment for the ulcer until a week after it was identified, and there was a lack of documentation regarding the implementation of the treatment plan. The facility's failure to promptly address and document the treatment of pressure ulcers contributed to the worsening of the residents' conditions.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to ensure that staff treated residents with dignity and respect, affecting three residents. Resident #2, who has paraplegia, anxiety, and depression, reported that a CNA accidentally hurt her arm during bathing and called her 'whiny' when she expressed pain. The resident's cognitive status was intact, as indicated by a BIMS score of 15 out of 15. Another incident involved Resident #7, who has heart failure, depression, and a psychotic disorder, and was reported to have been told by the same CNA that she was done helping her, although the CNA later returned to assist the resident. Resident #7 had a BIMS score of 9, indicating moderately impaired cognition. Resident #8, who has diabetes, Parkinson's, and anxiety, reported that a CNA instructed her to urinate in her brief instead of assisting her to the bathroom. This resident also had intact cognition with a BIMS score of 15. Staff interviews revealed that these incidents were reported to the Director of Nursing, although the DON stated she was not informed about the incident involving Resident #8. The facility's policy on promoting and maintaining resident dignity was not adhered to, as evidenced by these interactions.
Failure to Administer Prescribed Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to administer a prescribed medication intervention for a resident with severe cognitive impairment and multiple diagnoses, including hemiplegia, diabetes, and anxiety. The resident had a physician's order for lorazepam to be administered every six hours for anxiety/agitation. However, the medication was not administered as scheduled on two occasions because it had not been delivered by the pharmacy and was not available in the facility's emergency kit. This resulted in the resident experiencing labored breathing, prompting the family to request emergency medical services. The facility's policy on medication ordering and receiving did not provide guidance on obtaining medications for new orders, contributing to the delay in administration. The Director of Nursing indicated that the facility followed standards of care but acknowledged that nurses should special order medications and contact the pharmacy for delivery times if there were delays. The medication was eventually delivered at the same time emergency services arrived, and the resident received her first dose of lorazepam.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to properly secure medications from unauthorized access, as observed with an unattended and unlocked medication cart in a resident hall. This incident occurred when a Licensed Practical Nurse (LPN) exited a resident's room and returned to find the medication cart unlocked. The LPN then locked the cart and acknowledged that it should not have been left unlocked. The facility's policy, revised in November 2018, mandates that medication rooms, carts, and supplies must be locked when not attended by authorized personnel. The Director of Nursing (DON) confirmed that staff are expected to ensure medication carts are locked if they are leaving them unattended.
Failure to Secure Resident Information
Penalty
Summary
The facility failed to protect resident-identifiable information, as observed during a survey. On January 13, 2025, a laptop was found open with a resident's Electronic Health Record (EHR) visible, unattended by any staff. A Licensed Practical Nurse (LPN) later accessed the laptop, revealing EHR information for 16 residents, and then left the laptop unattended again. On January 14, 2025, another observation noted a laptop with a resident's EHR visible, which was later secured by another staff member. The facility lacked a policy for securing resident records, as confirmed by the Administrator, and the Director of Nursing (DON) acknowledged that staff should ensure resident information is not displayed when unattended.
Infection Control Deficiencies Due to Lack of Sanitizing Supplies and Poor Hand Hygiene
Penalty
Summary
The facility failed to implement effective infection control policies, leading to potential cross-contamination risks. On multiple occasions, staff were unable to locate purple-top sanitizing wipes (saniwipes) necessary for cleaning Personal Protective Equipment (PPE) goggles and shared equipment like the EZ Stand used for resident transfers. Staff D, E, and F confirmed the absence of saniwipes, which were supposed to be used for cleaning goggles after use in Covid+ resident rooms. Observations revealed that PPE bins contained goggles but lacked saniwipes, and a used earloop mask was improperly stored on a PPE bin. Staff G admitted to the shortage of saniwipes since a vendor change, and the Administrator acknowledged the supply issue. Additionally, Spectrum Advanced hand sanitizing wipes, not suitable for cleaning medical equipment, were found in place of the required saniwipes. Further deficiencies were noted in hand hygiene practices. Staff K, a Certified Med Aide, was observed handling multiple residents' utensils without performing hand hygiene between interactions. This was contrary to the facility's hand hygiene policy, which mandates hand hygiene after touching a resident or their environment. The Director of Nursing confirmed that staff should perform hand hygiene between residents and use saniwipes on shared equipment, highlighting a gap between policy and practice. The facility's failure to ensure the availability of appropriate cleaning supplies and adherence to hand hygiene protocols contributed to the infection control deficiencies.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing an alternative method for obtaining toileting assistance. This deficiency was observed when a resident, who was rarely or never understood due to her mental status, was left without timely assistance for incontinence care. The resident, diagnosed with Chronic Kidney Disease, paranoid Schizophrenia, and PTSD, required moderate assistance for most Activities of Daily Living and was occasionally incontinent of urine and frequently incontinent of stool. On the morning of the incident, the resident was observed asking for help to be changed, but was instructed to follow her normal method of contacting staff, which was ineffective at that time. The resident, unable to receive timely assistance, walked to the main corridor and called out for help. Despite the presence of staff members in the vicinity, the resident's request was not immediately addressed until a CNA arrived and inquired if she wanted to go to breakfast, at which point the resident reiterated her need to be changed. The facility's policy on promoting and maintaining resident dignity requires staff to respond to requests for assistance promptly, yet the resident's care plan lacked specific directives for incontinence care, contributing to the delay in addressing her needs.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was present for eight consecutive hours on nine out of thirty-two days reviewed between July 28th and August 28th, 2024. The facility, which reported a census of 71 residents, lacked RN coverage entirely on six specific days and only had four hours of RN coverage on three additional days. Interviews with staff, including a Certified Nurse Aide (CNA) and the Administrator, confirmed the absence of adequate RN coverage. The CNA noted that management could not be counted towards the required RN coverage, and the Administrator acknowledged the lack of a policy for ensuring eight-hour RN staffing, despite following regulations.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff to ensure timely response to call lights, compromising resident safety. Observations and interviews revealed that residents experienced significant delays in call light responses, with some waiting up to two hours. Resident #35, with no cognitive impairment, reported waiting over 30 minutes for assistance while in the bathroom, ultimately performing peri care and transferring herself back to her wheelchair. Resident #38, also cognitively intact, noted delays of 15 to 30 minutes, corroborated by a resident council meeting where attendees consistently complained about prolonged response times. Further investigation showed that Resident #2, with moderate cognitive impairment and dependent on staff for toileting and dressing, experienced call light delays of nearly two hours. Resident #41, with intact cognition and using a walker, reported waits often exceeding 30 minutes. Continuous observation in Hall 200 confirmed a call light remained unanswered for 20 minutes, as noted by a family member. The Director of Nursing acknowledged that call light audits had not been conducted for two months due to staffing changes, despite the facility's expectation of a 15-minute response time.
Infection Control Deficiencies in PPE Usage
Penalty
Summary
The facility failed to implement universal infection control measures and Enhanced Barrier Precautions (EBP) for two residents at risk for Multi-Drug Resistant Organisms (MDRO). Resident #2, with a diagnosis of paraplegia and chronic obstructive pulmonary disease, had a physician's order for EBP due to the risk of MDRO related to a catheter and wound. However, during an observation, a Certified Nursing Assistant (CNA) did not wear a gown while performing catheter care, contrary to the care plan and facility policy. Similarly, Resident #7, diagnosed with traumatic brain dysfunction and other conditions, had a physician's order for EBP, but staff failed to don gowns during enteral feeding and incontinence care, as observed on multiple occasions. The facility also failed to properly use personal protective equipment (PPE) for two residents with a positive COVID-19 diagnosis. Resident #49 and Resident #60, both with moderate cognitive impairment, were in isolation due to their COVID-19 status. During an observation, a CNA donned a gown, gloves, and mask but failed to wear eye protection while supervising a meal for Resident #60. The CNA then proceeded to move between rooms and the shower room without changing PPE, which is against the expected protocol for transmission-based precautions. Interviews with staff, including the Director of Nursing (DON), confirmed that the expectation was for gowns to be worn during high-contact care activities and for eye protection to be used when required by transmission-based precautions. The facility's policy on Enhanced Barrier Precautions, updated in May 2024, aligns with the Centers for Disease Control and Prevention (CDC) guidelines, which emphasize the importance of PPE in preventing the spread of MDROs and other infections. However, the observations and staff interviews indicate a failure to adhere to these guidelines, leading to the deficiencies noted in the report.
Failure to Provide Dignity Cover for Catheter Bag
Penalty
Summary
The facility failed to uphold the dignity of a resident by not providing a privacy cover for a catheter bag. Resident #2, who has moderate cognitive impairment, paraplegia, and chronic obstructive pulmonary disease, was observed on two separate occasions without a dignity cover on their urinary drainage bag. The resident reported that the facility never covers the drainage bag and that the cover went missing a long time ago. Interviews with staff, including a CNA and CMA, confirmed that urinary drainage bags should have dignity covers. The Director of Nursing expressed that her expectation was for dignity bags to be used, while the Administrator noted that the facility does not have a specific policy for dignity bags, instead following general standards of care.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess and document the status of two residents, leading to discrepancies in their Minimum Data Set (MDS) assessments. For Resident #38, the MDS inaccurately documented the presence of an indwelling catheter, despite the resident stating they had not used a catheter in about two years and had never had one at the facility. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) also showed no physician's order for a catheter, and the resident's care plan did not include any mention of an indwelling catheter. The Director of Nursing (DON) confirmed that this was a coding mistake and that the resident had never had a catheter while at the facility. For Resident #2, the MDS indicated the use of bed rails daily, classifying them as a restraint, despite an assessment in the Electronic Health Record stating that the bed rails were used for positioning purposes. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The DON acknowledged the expectation for MDS assessments to be completed and coded correctly. Additionally, it was noted that the facility lacked a specific policy for ensuring MDS accuracy, relying instead on general regulatory compliance.
Failure to Implement Comprehensive Care Plan for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with moderate cognitive impairment, as documented in the Minimum Data Set (MDS). The care plan specified that the resident could eat independently in the dining room with supervision after setup. However, during observations, staff members left the resident unsupervised during meals while she was in isolation due to COVID-19. On two separate occasions, Certified Nursing Assistants (CNAs) delivered the resident's meal tray, set it up, and left the room without providing the required supervision. Staff interviews revealed that the CNAs were unaware of the resident's supervision needs during meals. The Director of Nursing (DON) acknowledged that the resident's care plan required supervision during meals, especially during isolation. Additionally, the facility lacked a policy on following care plans, which was considered a standard of care. This oversight led to the resident being left unsupervised during meals, contrary to her documented care plan requirements.
Failure to Verify PEG Tube Placement and Residual
Penalty
Summary
The facility failed to implement policies and procedures regarding the technical aspect of feeding tubes, specifically for Resident #7, who has a diagnosis of traumatic brain dysfunction, pneumonia, malnutrition, and artificial openings of the gastrointestinal tract. The physician's orders for Resident #7 required checking the placement and residual of the Percutaneous Endoscopic Gastrostomy (PEG) tube before administering medications. However, during an observation, a Licensed Practical Nurse (LPN) accessed the resident's PEG tube and administered a flush and medications without verifying the tube's placement or obtaining residual. The LPN later acknowledged that a residual check should have been completed. The Director of Nursing (DON) confirmed that the expectation is for residual checks and placement verification to be completed as ordered. Additionally, the facility lacked a policy related to enteral feedings for review.
Failure to Maintain Proper Food Temperatures
Penalty
Summary
The facility failed to maintain hot food served at a temperature greater than 140 degrees Fahrenheit during a meal service. Observations and interviews revealed that the temperatures of several food items were below the required threshold, including taco casserole at 135 degrees, rice at 137 degrees, and mashed potatoes at 120 degrees. Staff A, the cook, confirmed that the mashed potatoes were not placed on the steam table properly, which contributed to the low temperature. The facility's Steamtable Temperature logs showed multiple instances where food temperatures were not checked for various meals throughout April 2024. Staff B, the Dietary Manager, confirmed that the logs were not completed thoroughly as per facility policy. Interviews with residents and staff further corroborated the issue of cold food being served. Resident #1 and several CNAs/CMA staff members confirmed that food trays were often served cold, both in resident rooms and dining areas. The Resident Council Meeting Minutes also documented complaints about food being served cold or burnt and dry meat. The facility's Food Temperatures policy from 2021 stated that all hot food items must be cooked, held, and served at a temperature of at least 135 degrees Fahrenheit, and temperatures should be periodically checked to ensure compliance. However, the facility failed to adhere to this policy, leading to the deficiency.
Failure to Treat Resident with Dignity and Respect Regarding Smoking Policy
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not allowing her to vape an electronic nicotine device, despite staff members being permitted to smoke and two other residents being grandfathered into the facility's no-smoking policy. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed discontent during an interview, stating that she felt her rights were violated. The resident had signed an Admission Agreement identifying the facility as a non-smoking campus, but she claimed she was not of sound mind at the time due to taking Methadone, which affected her ability to make clear decisions. The Volunteer Ombudsman also voiced concerns about the facility's inconsistent enforcement of its smoking policy, noting that staff members were observed smoking in both designated and non-designated areas. The facility's smoking policy, as outlined in the Admission Agreement and Employee Handbook, prohibits smoking and vaping on the property. However, the policy allowed staff to smoke in designated areas during breaks, which contributed to the resident's perception of unfair treatment. The facility's failure to uniformly enforce its smoking policy and to consider the resident's preference to vape led to the deficiency in treating the resident with dignity and respect.
Failure to Follow Physician Orders for Insulin Administration
Penalty
Summary
The facility failed to follow physician orders for a resident with Diabetes Mellitus, leading to improper administration of Lispro insulin. The Medication Administration Record (MAR) indicated that the resident should receive 3 units of Lispro insulin subcutaneously with meals and to hold if blood sugars were less than 90. Additionally, a sliding scale of Lispro insulin was to be administered based on blood sugar levels. On the observed date, a Licensed Practical Nurse (LPN) administered 3 units of scheduled Lispro insulin along with 2 units of sliding scale Lispro insulin to the resident's left arm after the resident had already eaten breakfast. The blood sugar was checked at 8 a.m. and recorded as 172, but the insulin was administered at 9:14 a.m., which was not in accordance with the physician's orders. The Nurse Practitioner confirmed that this was not the correct procedure for administering the insulin. The Resident Council Meeting Minutes also revealed ongoing concerns about the timely administration of medications. Specifically, residents reported that night medications were not passed on time and that medications were not administered on time on multiple occasions. These concerns were documented in the meeting minutes from January and February. This indicates a pattern of issues related to medication administration within the facility, contributing to the deficiency identified by the surveyors.
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 409 citations issued within 25 miles in the last 12 months — including the 7 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 Carlisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkridge Specialty Care | 7.3 mi | ★★★★★ | 18 | 0 |
| Greater Southside Health And Rehabilitation | 7.3 mi | ★★★★★ | 16 | 1 |
| Accura Healthcare Of South Des Moines | 8.3 mi | ★★★★★ | 1 | 0 |
| Valley View Village | 9.1 mi | ★★★★★ | 4 | 0 |
| The Village | 9.4 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Accura Healthcare Of Carlisle.
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 July 2026) and official state health department websites.