Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlisle Skilled Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with cognitive impairment, a history of falls, and mobility limitations fell from the bed while being changed after a nurse aide rolled her away from the aide and briefly let go of her hip. The fall resulted in a right femur fracture requiring ED transfer, ORIF with plate and screws, and placement of an external fixator.
Failure to monitor nutrition, fluid restrictions, and significant weight changes: A resident with severe malnutrition and a G-tube order did not have weights tracked or enteral intake documented, and observations showed the pump disconnected with formula remaining while the resident later had significant weight loss. Another resident with CHF and ischemic cardiomyopathy had ordered fluid restrictions, but nursing and meal fluid documentation was incomplete and often exceeded ordered amounts. A third resident with dementia had a significant weight loss, but the re-weigh and required notification were delayed, and later weights were inconsistent.
Failure to Complete Pre-Hire License and Registry Checks: The facility failed to complete license and registry verifications before hire for three of four personnel files reviewed, including an LPN, a nurse aide, and a dietician. Facility policy required screening for abuse history and checking licensing boards and registries, and staff confirmed verifications should be completed prior to or upon hire.
The facility failed to code MDS assessments accurately for three residents. One resident with schizoaffective disorder and bipolar disorder had a psychiatry note stating a GDR was not clinically advisable, but the MDS did not reflect the contraindication. Another resident with parkinsonism, low back pain, and difficulty walking had repositioning documented as a non-pharm pain intervention, yet the MDS said none was received. A third resident with dementia and elopement risk had a wander guard ordered and in the care plan, but the MDS marked the alarm as not used.
Care plans were not consistently reviewed and revised, and care plan meetings were not consistently held with resident participation or the required IDT members. One resident had conflicting code status documentation, another had no documented quarterly care plan meetings, and others had care plans that were not updated to reflect current needs such as pain, hearing loss, contractures, or dependence for repositioning. Representatives also reported not being invited or not seeing the care plan reflect current care.
An LPN failed to follow ordered medication administration procedures for a resident with a G-tube by crushing medications together, not performing hand hygiene, not cleaning the tube port, and not checking placement or residual as ordered. The same LPN gave only part of an ordered MiraLAX dose but documented the full dose, and another LPN administered aspirin from a bottle with an illegible expiration date. In addition, CPAP use for a resident with COPD and sleep apnea was documented inconsistently, with notes stating the resident did not wear or use the CPAP overnight and no documented resident education or care plan detail about self-removal.
Failure to ensure hearing services and devices were properly managed for two residents. One resident with Parkinson's Disease and a cognitive communication deficit had an audiology consult showing cerumen occluding both ears and moderate to severe sensorineural hearing loss, but the recommended Debrox treatment was not implemented when first identified. Another resident with HTN and CKD reported being very hard of hearing, was observed without hearing aids or amplifiers in place, and had MDS data showing highly impaired hearing and hearing appliance use, yet the care plan and physician orders did not document a hearing device.
The facility failed to ensure restorative mobility and ROM programs were provided or accurately documented for four residents with limited mobility. One resident with a hip fracture and weakness had many restorative ambulation entries marked NA, while other residents with osteoarthritis, fibromyalgia, MS, and Parkinson's disease had ordered restorative ROM programs that were missed, not added to the task list, or repeatedly documented as NA instead of refused or completed. Staff and the DON confirmed the programs were expected to be implemented as ordered or documented accurately.
Incomplete dialysis communication and monitoring documentation: A resident with ESRD and dependence on HD had physician orders for dialysis, site monitoring, and pre/post treatment documentation, but the facility repeatedly failed to complete, file, or maintain dialysis communication sheets and had multiple blanks or NA entries for weights, bruit/thrill checks, and site assessments across several shifts. The NHA, DON, and regional clinical support nurse confirmed the expectation for thorough documentation and accurate monitoring records.
Delayed call bell response times were documented across multiple units, with residents reporting waits from 20 minutes up to 1 1/2 hours for assistance. Residents and the resident council also reported staff sometimes entered rooms only to turn off the call bell without providing care, and audits confirmed repeated delays of 29, 39, 49, and 60 minutes before a call light was answered.
Medication Error Rate Exceeded 5 Percent: An LPN crushed and administered two ordered meds together through a resident’s G-tube instead of giving them separately, another LPN gave only part of an ordered MiraLAX dose and administered it without full dissolution, and an LPN gave Tylenol for pain even though that order was for fever. These observed errors resulted in a 16% medication error rate.
Medication storage and labeling practices were not followed when an LPN left prepared meds unsecured on a cart while retrieving another dose, opened octreotide vials and tuberculin solution had no open dates, and a house stock aspirin bottle had an illegible expiration date. Meds for a discharged resident remained in stock, and refrigerator temperature logs in two med rooms were incomplete, with readings missing or documented only once instead of twice daily.
An LPN failed to follow infection control practices during medication administration for multiple residents, including not performing hand hygiene before and after handling meds, not using gloves for eye drop administration, and not maintaining hand hygiene during G-tube medication delivery. During wound care, the LPN changed gloves multiple times without hand hygiene. The facility also did not consistently post EBP signage or keep PPE outside a resident’s room when EBP was ordered for wound-related care.
Missing Abuse Prohibition Training for New Hires: The facility failed to document abuse prohibition training upon hire for an LPN and a nurse aide. Personnel file review showed no evidence that either employee completed new hire orientation or training on the abuse prohibition policy, despite facility policy requiring orientation training that includes abuse prohibition and dementia management/patient abuse prevention. During interview, the NHA, DON, and a regional clinical support nurse confirmed the training should be completed upon hire.
A facility failed to maintain resident dignity when incontinent briefs were stored in open view for two residents. One resident with anxiety and adjustment disorder had seven briefs stacked on a stand visible from the hallway, and another resident with Parkinson’s disease and a cognitive communication deficit had briefs stacked on an HVAC unit in the room on multiple observations. The RCSN stated briefs should be stored out of sight to maintain dignity, and the NHA agreed.
A resident with severe protein-calorie malnutrition and tongue cancer had saline nasal spray left at the bedside and reported that staff gave it to him for use as needed. Although there was an order for ocean nasal spray, the record contained no assessment of the resident’s cognitive or physical ability to self-administer the medication, and the NHA, DON, and an employee confirmed no such assessment had been completed.
Failure to protect privacy in resident mail and packages. Two residents reported that staff opened their mail or Amazon packages without consent before delivering them, including one cognitively intact resident with a BIMS of 15. Staff acknowledged opening packages due to a prior concern about prohibited items, and the NHA stated resident privacy should be honored.
Unsafe Room Conditions and Poor Housekeeping: The facility failed to maintain a clean, comfortable, and homelike environment for three residents. One room had torn wallpaper and wall scratches, another had an overflowing trash can, food debris, spills, stains on the wall, linens, and privacy curtain, and a third resident’s mattress was repeatedly found positioned with the foot end at the head of the bed. The NHA and DON acknowledged the room conditions and that the mattress was incorrectly placed.
A resident with diagnoses including a right femur fracture, muscle weakness, and low back pain did not receive an MDS assessment at least every 3 months. The record showed a quarterly MDS followed by an annual MDS without an intervening quarterly assessment, and the MDS Coordinator and DON both stated assessments should be completed quarterly.
A resident with severe protein-calorie malnutrition and tongue cancer was admitted with multiple skin issues present on admission, including an unstageable hip pressure injury, a stage 1 buttocks pressure injury, and skin tears. The baseline care plan did not include skin-related focus areas or interventions, and the NHA and DON confirmed the skin concerns were not added until later.
Failure to provide scheduled shower care for three residents. One resident with repeated falls and HTN said he did not always get showers per his preferred schedule, and the record showed inconsistent bathing documentation without a clear refusal. A resident with dementia had no documentation of a scheduled shower, and another resident with HTN and DM had shower documentation marked response not required, indicating the shower was not provided as scheduled.
Treatments were not provided as ordered for a resident with dermatitis and seborrheic dermatitis, with multiple blank TAR entries for ordered topical medications and cleansers, and the DON/NHA confirmed the missing documentation could not be justified. The resident also did not have the recommended dermatology follow-up scheduled. In addition, one resident had an incomplete Foley catheter order, and another resident with Parkinson's disease and CKD had a monthly weight order that was not completed as ordered.
A resident receiving wound care had an aseptic field set up on the bed instead of a disinfected bedside surface with a clean barrier, and a biohazard bag touched the clean field; an LPN also changed gloves multiple times without performing hand hygiene each time. Another resident at risk for skin breakdown had a physician order for a pressure-redistribution mattress, but after a room change the bed had a regular mattress instead of the ordered air mattress, and staff said they forgot to move it.
Incomplete Documentation of Foley Voiding Trial: A resident with an indwelling Foley, urinary retention, and obstructive/reflux uropathy was observed still catheterized while orders were in place for a voiding trial, bladder scans, and straight cath parameters. The provider note indicated staff were attempting the trial and the resident required straight cath, but nursing notes and treatment records lacked documentation of the trial’s implementation or findings; the NHA, DON, and regional clinical support nurse stated the facility could not provide the missing details and that the order had been entered incorrectly.
Pain management was not consistently provided or documented for two residents. One resident with parkinsonism and chronic pain received PRN oxycodone without a documented numeric pain scale and without documented non-pharmacological interventions before administration, despite a care plan calling for both. Another resident with osteoporosis and bilateral hip OA had repeated documentation issues with a weekly buprenorphine patch, including unavailable medication, held doses, and missing nursing notes related to patch removal and pharmacy delays.
The facility failed to provide the pharmacist’s MRR recommendations for two residents. Both residents had completed MRRs with pharmacist comments for physician action, but the clinical records did not include the recommendations or any evidence that the physician was aware of or responded to them. One resident had HTN and dementia, and the other had DM and anxiety.
Nurse aide training records showed two employees did not receive the required annual in-service education, and both lacked abuse prevention training. The facility’s job description required at least 12 hours of continuing education, and the DON stated she expected nurse aides to complete that amount each year and include abuse prevention training.
Two residents experienced deficiencies in care when staff failed to complete ordered weekly skin checks for one resident with complex medical conditions and did not perform timely, comprehensive assessment and monitoring for another resident with dementia and metastatic cancer who had worsening abnormal labs and increasing lethargy. For the first resident, multiple weekly skin checks were marked as not done on the MAR with no supporting progress notes, despite care-plan directives to monitor and report skin changes. For the second resident, abnormal and worsening sodium, chloride, osmolality, potassium, and calcium levels were not adequately addressed, an ordered potassium dose was not documented as given, and when the resident became unresponsive, nursing staff did not document a full assessment, omitted critical lab and treatment information on the SBAR, delayed calling 911 after the physician ordered transfer, and did not remain with the resident, leaving EMS to find the resident alone, in shallow respirations, and without a clear report or code status.
The facility failed to ensure that dental services and dentist recommendations were provided and implemented for three residents. One resident with dementia and progressive multiple sclerosis had a dental consult recommending a special fluoride gel and an oral surgeon referral, but no corresponding physician orders or nursing review were found. Another resident with vascular dementia and muscle weakness lost upper and lower dentures; although Step 1 of denture replacement was documented and a follow-up was scheduled, no further dental notes appeared in the record despite repeated inquiries from the resident’s representative, and the DON confirmed the dentist had not seen the resident again. A third resident with a neurocognitive disorder and heart failure had a periodic oral exam with a prophylaxis visit scheduled, but no subsequent dental documentation existed, indicating that planned routine dental care was not completed or recorded.
A resident with anxiety and depression did not receive scheduled doses of Lorazepam due to a lapse in obtaining a new prescription, resulting in missed medication administration. Documentation was lacking for the missed doses, and the pharmacy did not dispense the refill because the required prescription was not provided in time.
Several residents with dysphagia were served vegetables in a form that did not meet their prescribed diet texture, as kitchen staff provided sliced carrots instead of the required chopped form. This failure to follow physician orders and facility policy was confirmed by dietary and clinical staff, and placed additional residents with similar dietary needs at high risk, resulting in Immediate Jeopardy.
Staff failed to implement suicide precautions for a resident who expressed suicidal ideation, resulting in the resident being left unsupervised and able to self-harm. Additionally, the facility did not conduct thorough fall investigations for another resident with a history of falls, as required by policy.
The facility did not notify the Office of the State LTC Ombudsman about several resident hospital transfers, as required. Multiple residents with complex medical conditions were transferred to the hospital, but documentation and staff interviews confirmed that notifications were not made at the time of transfer.
Surveyors identified that several resident assessments did not accurately reflect the clinical status of four residents, including errors in documenting medication administration, pressure ulcer status, PASRR determinations, and attempts at gradual dose reduction for psychotropic medications. These discrepancies were confirmed through record reviews and staff interviews, with the DON acknowledging the MDS coding errors.
Surveyors identified that several residents did not receive care and services as ordered, including missed laboratory tests, incomplete wound care documentation, administration of medication above recommended dosages, missed insulin doses on dialysis days, delayed response to bleeding in a resident with hemophilia, and undocumented wound treatments. The DON confirmed these deficiencies and was unable to provide explanations for several missed or undocumented interventions.
Two residents with pressure ulcers or at risk for skin breakdown did not receive care consistent with professional standards, as recommended interventions such as pressure off-loading boots were not ordered by a physician, not included in care plans, and not documented as being used, despite wound team recommendations and observations showing the devices were not consistently applied.
The facility did not complete required annual performance reviews for five employees, as confirmed by the Nursing Home Administrator during document review and staff interviews.
Surveyors found that expired Novolog insulin and Afluria influenza vaccine vials were not discarded as required by facility policy and manufacturer guidelines. The DON and Nursing Home Administrator confirmed that medications should be stored and discarded according to policy, but expired medications were observed in both a medication cart and a medication room.
The facility did not ensure its main kitchen dish machine consistently reached the manufacturer-required minimum wash temperature of 160°F, as logs and direct observation showed repeated operation below this standard over several months. Staff were under the mistaken belief that a lower temperature was acceptable, leading to ongoing noncompliance with food service safety standards.
The facility did not consistently review or update care plans to reflect residents' current needs, failed to document care plan meetings, and did not ensure that residents or their representatives were invited to participate. Several residents with complex medical conditions lacked updated care plans or evidence of care plan meetings, and staff interviews confirmed these deficiencies.
A resident admitted with a fracture and scalp laceration did not have a baseline care plan developed within 48 hours that addressed all assessed needs, including urinary incontinence and pain management preferences. Additionally, neither the resident nor their representative received a summary of the baseline care plan as required by facility policy.
A resident with muscle weakness, obesity, and a chronic foot ulcer did not consistently receive scheduled bathing assistance as required by her care plan and facility policy. Documentation showed missed or unrecorded showers, and the resident reported not always receiving showers. Facility leadership confirmed expectations for care and documentation were not met.
A resident with chronic kidney disease and hypothyroidism experienced hearing difficulties and requested medical attention. Although a practitioner ordered an audiology referral for hearing loss, the resident was not placed on the audiology list as required, resulting in a delay in evaluation.
Two residents with limited ROM did not receive or have documentation of restorative nursing care as required by their care plans and therapy recommendations. For one, passive ROM interventions were not documented due to a system error, and for the other, tasks related to palm guards and ROM were not properly entered or documented. The DON confirmed these lapses in both implementation and documentation.
Three residents experienced deficiencies in pain management, including missed doses of prescribed pain medication due to unavailability, lack of timely reordering, and failure to use emergency supplies. One resident's care plan lacked a comprehensive approach and did not include non-pharmacological interventions as ordered. Another resident's pain goals were not specified, and refusals of topical pain patches were not documented or communicated to the physician. Ongoing reports of severe pain were not promptly addressed or followed up by nursing staff.
A resident with anxiety disorder and dysphagia experienced difficulty eating due to ill-fitting new dentures. Despite insurance approval for new dentures, no follow-up dental appointment was scheduled, resulting in a delay in necessary dental care.
Staff failed to follow infection control protocols during medication administration, including handling oral medications with contaminated gloves and not cleansing the rubber seal of an insulin pen before attaching a new needle. The DON confirmed these lapses in infection control procedures.
The facility did not provide enough nursing staff on one unit, leading to multiple residents reporting long wait times for call bell responses. Grievances and Resident Council Meeting minutes confirmed ongoing concerns about delayed assistance, and direct observation showed call bells going unanswered for over 25 minutes.
The facility consistently failed to meet the required nurse aide (NA) staffing ratios across multiple shifts and days. On several occasions, the NA ratios were below the mandated levels for day, evening, and night shifts, with specific deficiencies noted on January 5, 6, 10, and 11, 2025. This indicates a pattern of inadequate staffing to meet the needs of the residents.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day for four days due to staff call-offs related to illnesses and weather. The Nursing Home Administrator confirmed the shortfall in care hours.
Failure to Provide Adequate Supervision During Bed Care
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent accidents for one resident who had a history of falls, repeated falls, cognitive impairment with a BIMS score of 9 out of 15, and diagnoses including displaced fracture of the lateral condyle of the femur. The resident’s care plan identified her as at risk for falls and included safety precautions, and her mobility status was documented as a full mechanical lift for transfers and one assist for bed mobility. During care on the resident’s bed, a nurse aide and another aide positioned her in bed for changing. The nurse aide stated she was standing on the door side of the bed, rolled the resident toward the window, and took her hand off the resident’s hip to adjust the brief. The resident then scooted toward the edge of the bed, rolled onto the floor, and was found to have fallen from the bed. The incident led to x-rays, transfer to the emergency department, and a hospital diagnosis of a closed bicondylar fracture of the distal right femur requiring ORIF with plate and screws and placement of an external fixator.
Failure to monitor nutrition, fluid restrictions, and significant weight changes
Penalty
Summary
The facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, resulting in actual harm for one resident with severe protein-calorie malnutrition and tongue cancer. The resident had an order for continuous Jevity 1.5 tube feeding via pump at 80 mL per hour for 20 hours per day, with flushes while the feeding infused, and the dietitian documented that this regimen was intended to provide 2400 kcal, 102 g protein, and 2376 mL total fluids. The resident was also identified as being at risk for malnutrition and had a care plan intervention for weights per facility protocol, but the record did not contain documentation of additional weights after admission or documentation of the amount and duration of enteral feedings received. Observations showed the resident's feeding pump was off and disconnected from the G tube on multiple occasions, with formula remaining in the bottle and staff stating the feeding had been disconnected or was finished. The facility could not provide additional information explaining why the resident was not receiving the full amount of feeding recommended by the dietitian or why the resident's weight had not been obtained. A later documented weight showed a 12-pound loss, reflecting a 7.18% weight loss in 35 days, and the resident's admission weight had been 172.8 pounds. The facility also failed to adequately monitor and document fluid restrictions for another resident with CHF and ischemic cardiomyopathy. That resident had an order for 1800 mL of fluid per day, with nursing responsible for 720 mL per day and dietary responsible for 1080 mL per day, but meal intake documentation did not include fluid intake during meals or snacks. The MAR showed multiple instances in June and July where the resident received more than the ordered amount on day, evening, and night shifts, along with several instances where no fluid amount was documented. In addition, the facility failed to reweigh and notify the physician and dietitian of significant weight loss for a resident with dementia and hypothyroidism. The resident had a documented 20-pound weight loss, but no re-weigh was obtained until several days later, despite the facility policy requiring re-weighing when body weight was not as expected and notification of the physician/APP and dietitian for significant weight changes. Subsequent weights recorded by mechanical lift were inconsistent, and staff stated the scales would be checked for accuracy and proper functioning due to the significant weight changes.
Failure to Complete Pre-Hire License and Registry Checks
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to ensure that residents were protected from the potential for abuse by not completing licensure or registry verifications before hire for three of four personnel files reviewed. The personnel files reviewed were for Employee 7, an LPN hired on April 28, 2026, whose license verification was completed on July 13, 2026; Employee 8, a nurse aide hired on May 12, 2026, whose registry verification was completed on May 13, 2026; and Employee 9, a dietician hired on July 6, 2026, whose license verification was completed on July 9, 2026. The facility policy, OPS300 Abuse Prohibition, stated that the Center would screen potential employees for a history of abuse, neglect, or mistreating patients, including attempting to obtain information from previous and/or current employers and checking with the appropriate licensing boards and registries. During interview on July 22, 2026, the NHA, DON, and Employee 1 confirmed that license and registry verification should be completed prior to or upon hire. The NHA stated that the facility had identified issues in its hiring process and had implemented a Performance Improvement Plan.
Inaccurate MDS Coding for GDR, Pain Intervention, and Wander Guard Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for three residents. For one resident with schizoaffective disorder and bipolar disorder, the clinical record showed physician orders for risperidone, bupropion HCL XR, and mirtazapine, and a psychiatry note documented that a gradual dose reduction was not clinically advisable because of a high risk for relapse of target symptoms related to depression, bipolar disorder, and schizoaffective disorder. However, the resident’s significant change MDS dated May 15, 2026, did not document that a GDR had been contraindicated by the physician, and staff later acknowledged that the MDS was incorrect. For another resident with parkinsonism, low back pain, and difficulty walking, the admission and 5-day MDS assessments marked that no non-medication intervention for pain had been received, even though the July 2026 MAR documented repositioning as a non-pharmacological pain intervention during the lookback period. For a third resident with hypertension and dementia, the physician ordered a wander guard/elopement device due to poor safety awareness, and the care plan identified the resident as an elopement risk with a wander guard intervention, but the quarterly MDS marked the wander/elopement alarm as not used. Staff interviews confirmed that each of these MDS assessments was coded incorrectly.
Care plans were not kept current and care plan meetings were not consistently held or properly attended
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for four residents and failed to ensure that care plan meetings were held with resident participation and the required interdisciplinary team members for three residents. Facility policy required care plans to be reviewed and revised after each assessment, including comprehensive and quarterly assessments, and required care plan meetings to include the physician or APP as part of the interdisciplinary team, with invitations sent in advance and resident participation facilitated. For one resident with severe protein-calorie malnutrition and malignant neoplasm of the tongue, the clinical record showed conflicting code status documentation. The physician order and POLST indicated DNR with comfort measures, while the comprehensive plan of care still listed full code. A social services care plan meeting note documented that advance directives were reviewed and that the resident did not want CPR. Staff interviews indicated they would check the physician order or POLST for code status, and facility leadership acknowledged that the resident had recently decided to change code status from full code to DNR and that care plans were expected to be revised timely. For another resident with a displaced intertrochanteric fracture of the right femur, muscle weakness, and low back pain, the resident stated she did not have quarterly care plan meetings. The last documented care plan meeting was a phone call involving family members, with the daughter attending in person, but the record did not show that the resident attended or was invited. For a resident with Parkinson’s disease and cognitive communication deficit, the resident stated he had not participated in any care plan meetings, and the record showed a meeting with social services and the nursing unit manager, but no evidence of a meeting after the annual assessment and no documentation that the resident was invited. The record also showed care plan meetings with social services only, without other interdisciplinary team members present. Additional record review showed that one resident with dementia and demyelinating disease had a comprehensive care plan that was not updated after the care plan meeting, and the resident’s representative stated the care plan did not reflect what was being done for her. Another resident with Parkinson’s disease and chronic kidney disease had a representative who reported not receiving invitations to care plan meetings for several months; the record showed one care conference sign-in sheet with nursing, social services, and the representative, but no documentation of additional care plan meetings. For a resident with paraplegia and a motor vehicle accident history, the care plan included a trapeze for repositioning in bed even though the bed safety evaluation showed the resident was dependent for turning and repositioning, and staff confirmed the care plan should not have included the trapeze.
Medication Administration and Respiratory Care Documentation Failures
Penalty
Summary
Medication administration was not provided in accordance with professional standards for multiple residents. For one resident with severe protein-calorie malnutrition, cancer of the tongue, and a gastrostomy tube, an LPN crushed two ordered morning medications together in a single plastic pouch, mixed them with water in the resident’s bathroom, and administered them through the G-tube without performing hand hygiene before donning gloves. The nurse disconnected the tube feeding bag, used a syringe to push water and then the medication mixture through the tube by gravity, and then flushed with water. The nurse did not clean the G-tube port before attaching the syringe, did not verify placement or check for residual as ordered, and did not date the new syringe that was opened and later placed in a graduate on the bedside stand. Although the MAR documented a gastric residual volume, flush amount, and bowel sound assessment, the observation showed those ordered steps were not performed as documented. For another resident with constipation and hypertension, the ordered daily dose of MiraLAX 17 grams was not administered as prescribed. During observation, the LPN poured the powder into the cap, measured a full dose, removed one spoonful with a plastic spoon, and returned the remainder to the bottle. The nurse stated she only gives the resident a spoonful because giving the full dose would cause the resident to be incontinent. Despite giving only a partial dose, the nurse documented that the resident received the ordered dose. A third resident with hypertension and hyperlipidemia received chewable aspirin from a house stock bottle even though the manufacturer expiration date on the bottle was illegible. The LPN confirmed the date could not be read, administered one tablet to the resident, and then placed the bottle in his pocket to discard later and obtain a new bottle for the medication cart. In addition, a resident with COPD, sleep apnea, and hypertension had CPAP use documented inconsistently: the TAR showed repeated entries of NN for morning removal, and linked nurses’ notes stated either that the resident did not wear the CPAP overnight or did not use it overnight. The record contained no documented education for the resident regarding CPAP use, and the care plan did not note that the resident refused the CPAP or removed it during the night. During interview, staff stated the resident actually wore the CPAP and self-removed it during the night, but the documentation reflected that he did not wear it.
Failure to Provide Hearing Treatment and Hearing Devices
Penalty
Summary
The facility failed to ensure that two residents received proper treatment and assistive devices to maintain hearing abilities. One resident with Parkinson's Disease and a cognitive communication deficit reported hearing loss and was awaiting hearing aids. An audiology consultation completed after the resident reported hearing loss found cerumen occluding both ears and moderate to severe sensorineural hearing loss in both ears. The audiologist recommended a 7-day treatment plan using a softening agent such as Debrox, but the report did not show that the primary physician reviewed the recommendations, and the resident did not receive the recommended treatment when it was first identified. A second resident with hypertension and chronic kidney disease stated that she was very hard of hearing and had difficulty communicating because of it, and she said she had hearing aids but left them in the dining room. Observation showed she did not have hearing aids or amplifiers in place during the interview. Her quarterly MDS indicated highly impaired hearing and that a hearing aid or other hearing appliance was used, but her care plan did not include any intervention or documentation for hearing device use, and her physician orders did not include an order for a hearing device. An audiology consult also documented moderate to severe sensorineural hearing loss and that she would benefit from hearing aids.
Failure to Provide and Document Restorative Mobility and ROM Programs
Penalty
Summary
The facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for four residents reviewed for limited ROM and mobility. Facility policy for restorative nursing required individualized, nurse-supervised restorative programs, measurable goals, implementation according to the care plan, and documentation of daily restorative records and quarterly evaluations. Surveyors found that the restorative programs for the affected residents were either not completed, not added to the task list, or repeatedly documented as not applicable rather than being provided or accurately documented as refused. Resident 6 had diagnoses including a displaced intertrochanteric fracture of the right femur, muscle weakness, and low back pain. Her OT discharge summary stated maximum potential achieved and referred her for restorative nursing. Her care plan included restorative ambulation with a goal to walk 150 feet with a rolling walker and supervision for verbal cueing and walking alongside the patient. However, her restorative nursing documentation from May through July showed numerous dates marked not applicable. During interview, staff stated they sometimes marked refusals as not applicable, and the DON stated restorative programs were expected to be implemented or documented as refused if refused. Resident 7 had osteoarthritis and fibromyalgia, and her care plan included restorative ROM for loss of ROM in the lower extremities with active and active-assisted ROM. Her OT discharge summary also referred her for RNP/FMP, but the record did not show restorative ROM being completed. Resident 11 had progressive multiple sclerosis, osteoarthritis, and weakness, and her care plan included active-assisted ROM to both upper extremities twice daily with ADLs; multiple entries were documented as not applicable. Resident 34 had Parkinson's disease and cognitive communication deficit, and her care plan included active ROM to both lower extremities twice daily during ADLs; many entries were documented as not applicable. Staff and the DON confirmed that restorative programs were expected to be provided as ordered or accurately documented when not provided.
Incomplete dialysis communication and monitoring documentation
Penalty
Summary
The facility failed to maintain complete and accurate dialysis communication records and failed to appropriately monitor a resident receiving dialysis services. Resident 4 had diagnoses including end-stage renal disease and dependence on renal dialysis, and had physician orders for dialysis on Monday, Wednesday, and Friday, along with orders to monitor the hemodialysis site for signs and symptoms of complications and to document pre-dialysis vital signs, weight, bruit, and thrill assessments. Review of the resident’s dialysis communication sheets for May through July 2026 showed multiple missing, incomplete, undated, or improperly filed forms. Several facility dialysis communication sheets were missing entirely, several were not completed upon the resident’s return from dialysis, and some were attached to dialysis center reports rather than completed as required upon return to the facility. The record also showed missing or incomplete documentation for pre-dialysis weights, post-dialysis weights, hemodialysis site monitoring, and shunt thrill and bruit assessments across multiple shifts in May, June, and July 2026. During interview, the NHA, DON, and Regional Clinical Support Nurse confirmed that the dialysis communication sheets should be completed thoroughly and that the resident should be monitored according to physician orders with accurate documentation reflecting the care provided. The Regional Clinical Support Nurse stated there was no additional information regarding the resident’s dialysis shunt monitoring and that education would be completed on how to properly document.
Delayed Call Bell Response Times
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs on three nursing units: East, West, and Arcadia. Review of the facility’s call light policy stated that staff will respond to call lights and communication devices promptly, but multiple residents reported long wait times for assistance. Resident 6, Resident 18, Resident 138, and Resident 2 each voiced concerns about delayed call bell responses, and Resident 138 reported waiting up to 60 minutes for help. During a resident council meeting, six of six residents reported concerns with long call bell wait times and staff entering rooms to turn off call bells without providing care. The grievance log showed complaints about long call bell wait times over the prior four months, and call bell audits documented repeated delays, including waits of 29 minutes, 39 minutes, 49 minutes, and 60 minutes before staff answered. One audit noted a resident waited from 1:14 PM until 2:14 PM for help getting changed before bingo. Resident council minutes from multiple meetings also documented continued concerns, including wait times up to 1 1/2 hours and call bells being out of reach on the floor. The Nursing Home Administrator stated that call bells should be answered timely.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent, with four medication errors identified during 25 observed opportunities for a 16 percent error rate. Facility policy required crushed medications not be combined and to be administered separately through a feeding tube with flushing between medications, and medications to be given in accordance with prescriber orders. During observation of an LPN administering medications to a resident with a G-tube, both ordered morning medications were crushed together in a single plastic pouch and given through the tube at the same time. During another observation, an LPN failed to administer the full ordered dose of MiraLAX to a resident with constipation, instead giving only a spoonful after measuring a full dose and returning the remainder to the bottle; the solution was also observed to be clear rather than cloudy, indicating it was not fully dissolved. In a separate observation, an LPN administered Tylenol to a resident for left arm and hand pain even though the order was for fever greater than 101 degrees F, while the resident also had a standing Tylenol order for arthritis pain. The LPN later confirmed she gave the medication for pain despite the order indicating it was for fever.
Medication Storage, Labeling, and Temperature Monitoring Failures
Penalty
Summary
Medication storage and labeling practices were not followed in two medication rooms and one medication cart. During a medication pass, an LPN prepared medications for a resident, placed a cup of pills inside the medication cart, covered a cup containing MiraLAX with a tissue, and left the medications on the cart while she went to retrieve another medication. In the [NAME] Wing medication room, two boxes of opened octreotide acetate vials had no opened date indicated, and the resident for whom the medication had been ordered had been discharged from the facility on April 2, 2026. In the Arcadia Unit medication room, an opened bottle of tuberculin skin test solution also had no opened date indicated on the vial or box. A house stock bottle of aspirin 81 mg in the East Wing D Hall medication cart had an open date of July 17, 2026, but the manufacturer expiration date was illegible. The LPN confirmed the date was illegible and administered one tablet from the bottle to a resident before placing the bottle in his pocket and stating he would discard it and get a new bottle for the cart. The report also noted that medications and biologicals were to be stored properly and that outdated, discontinued, or deteriorated medications were to be removed from stock and disposed of according to facility procedures. Medication refrigerator temperature logs were incomplete in both the [NAME] Wing medication room and the Arcadia Unit medication room. In the [NAME] Wing, temperatures were not recorded on multiple days in May, June, and July 2026, and on all other dates were recorded only once in the morning slot. In the Arcadia Unit, temperatures were also recorded inconsistently, with several dates missing and other dates documented only once in either the morning or evening slot. The NHA, DON, and Regional Clinical Support Nurse acknowledged that medications should be stored and discarded properly, and the NHA confirmed that medication refrigerator temperatures should be taken and recorded twice daily.
Infection Control Failures During Medication Administration, Wound Care, and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow infection control practices during medication administration for two residents. One resident had diagnoses including severe protein-calorie malnutrition, cancer of the tongue, and a gastrostomy tube, and had physician orders for Enhanced Barrier Precautions related to the feeding tube and indwelling urinary catheter. During medication preparation and administration, an LPN did not perform hand hygiene before preparing medications, touched the inside of a medication cup with a finger, handled medications and packaging without hand hygiene, and did not perform hand hygiene before entering the resident’s room. The LPN donned gloves only after entering the room to administer medications through the gastrostomy tube, then removed the gloves, rinsed the syringe in the bathroom, returned the syringe to the bedside, and left the room without performing hand hygiene. During another medication pass, the same LPN prepared medications for a second resident, placed a tissue over a cup containing MiraLAX while leaving the cup on the medication cart, and later returned to the cart, retrieved the cup, added medication, removed the tissue, and administered the medications without performing hand hygiene after returning from the medication room. During a hallway observation, the LPN administered medications and eye drops to a third resident without performing hand hygiene before or after and was not observed wearing gloves while administering the eye drops. Facility staff later confirmed they expected nurses to follow appropriate infection control practices during medication administration. In wound care for the resident with the gastrostomy tube, who also had an unstageable pressure ulcer on the left hip, an LPN performed dressing care and changed gloves multiple times without performing hand hygiene after each glove change. The resident had an order to cleanse the pressure ulcer, apply Medihoney, and cover it with calcium alginate and foam dressing daily and as needed. In addition, one resident with diabetes and anxiety had Enhanced Barrier Precautions ordered for a wound infection and diabetic foot ulcers, but observations showed no EBP signage posted outside the room on one occasion and no PPE outside the room on another. Staff stated the PPE for that room was kept inside the bathroom, and the NHA stated she would have expected EBP signage outside the room.
Missing Abuse Prohibition Training for New Hires
Penalty
Summary
The facility failed to ensure abuse training upon hire was completed for two of five employees reviewed, identified as Employee 7, an LPN, and Employee 13, a nurse aide. Facility policy, OPS300 Abuse Prohibition, stated that the Center would implement an abuse prohibition program through employee training for new hires and ongoing training for all employees, including the Abuse Prohibition policy and dementia management and patient abuse prevention. The policy also stated that training and reporting obligations would be provided to all employees through orientation, Code of Conduct training, and at least annually. Review of Employee 7’s personnel file showed a hire date of April 28, 2026, but no documentation that she completed new employee orientation or training on the facility abuse prohibition policy. Review of Employee 13’s personnel file showed a hire date of June 16, 2026, but likewise no documentation that he completed new employee orientation or training on the abuse prohibition policy. During an interview with the NHA, DON, and Employee 1, Employee 1 confirmed that abuse prohibition training should be completed upon hire as part of orientation and had no additional information to provide. The NHA stated the facility had identified issues in its hiring process and had implemented a Performance Improvement Plan.
Resident dignity not maintained by storing incontinent briefs in view
Penalty
Summary
The facility failed to promote an environment that enhances each resident’s dignity by storing incontinent briefs in open view for two residents reviewed. Facility policy OPS206, Resident Rights Under Federal Law, states that residents are to be treated with respect and dignity in an environment that promotes maintenance or enhancement of self-esteem and self-worth. The deficiency was identified during review of clinical records, observations, and staff interview. Resident 30 had diagnoses including anxiety and adjustment disorder. On July 22, 2026, at 9:15 AM, seven incontinent briefs were observed stacked on a stand in the resident’s room and visible from the hallway. Resident 34 had diagnoses including Parkinson’s Disease and cognitive communication deficit. On July 20, 2026, at 11:25 AM, six incontinent briefs were observed stacked on the resident’s heating and air conditioning unit; on July 21, 2026, at 1:20 PM, five briefs were observed in the same location; and on July 22, 2026, at 12:50 PM, four briefs were still observed stacked there. During interview on July 22, 2026, the RCSN confirmed that incontinent briefs should be stored out of sight to maintain resident dignity, and the NHA agreed.
Failure to Assess Resident’s Ability to Self-Administer Medication
Penalty
Summary
The facility failed to determine whether a resident’s right to self-administer medication was clinically appropriate for one resident reviewed. Facility policy stated that residents may self-administer medications only when specifically authorized by the prescriber and the interdisciplinary team, and only after evaluation of the resident’s functionality and health condition, with an order, care plan, and instruction in self-administration when applicable. The policy also required that capability be evaluated initially, quarterly, and with any significant change in condition. The resident’s record showed diagnoses of severe protein-calorie malnutrition and malignant neoplasm of the tongue. During observation, a bottle of saline nasal spray was seen on the resident’s bedside table, and the resident stated that staff had given him the bottle so he could use it when needed. The physician order was for ocean nasal spray twice daily for dry nasal passages. The clinical record did not contain any assessment of the resident’s cognitive or physical ability to self-administer the medication. During interview, the Nursing Home Administrator, DON, and another employee confirmed that no assessment had been completed to determine the resident’s ability to self-administer the medication.
Failure to Protect Privacy in Resident Mail and Packages
Penalty
Summary
The facility failed to ensure residents had privacy in their written communications when receiving mail and packages for two residents. The facility policy stated that residents have the right to privacy in written communications and to send and promptly receive unopened mail and other materials, and that mail should be delivered unopened or postmarked within 24 hours. Despite this, Resident 4 reported during the resident council meeting that staff had opened her mail because they thought it was insurance papers and then returned it to her opened with a note, and she stated she did not give consent for staff to open her mail. Resident 110 also reported that staff opened her Amazon packages without her present before giving them to her. She stated that her friend ordered snacks, hygiene items, and clothing for her, that she could track when the packages were delivered, and that she sometimes did not receive them until two or three days later and had to ask staff for them. She said staff told her they needed to check for knives because of a prior issue with another resident ordering them, and she stated she did not consent to staff opening her packages. Her record showed a BIMS score of 15, indicating she was cognitively intact. An Activities Assistant confirmed she had previously opened Resident 110's packages before giving them to her, and the NHA stated resident privacy should be honored and packages should not be opened by staff prior to delivery.
Unsafe Room Conditions and Poor Housekeeping
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for three residents by not maintaining resident rooms in a sanitary and orderly condition. Facility policy OPS200 Safe and Homelike Environment stated that residents have the right to a safe, clean, comfortable, and homelike environment and that housekeeping and maintenance services are necessary to maintain a sanitary, orderly, and comfortable interior. In one resident’s room, observations over several days showed torn wallpaper and two large black scratch marks along the wall. In another resident’s room, the trash can contained an incontinent brief smeared with a brown substance and was overflowing onto the floor, with a potato chip bag under the nightstand, an empty juice container on the floor, a light brown spill stain down the wall at the foot of the bed, a brown substance on the bed linens, and brown smears on the privacy curtain; later observations showed food debris on the floor, the chip bag still under the nightstand, and the stains still present on the wall and curtain, along with brown and yellow discoloration on the bedspread. In the third resident’s room, the mattress was repeatedly observed with the foot end positioned at the head of the bed, and the NHA confirmed that the mattress was incorrectly placed and that there was no reason for it to be positioned that way.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to complete a quarterly review assessment at least once every 3 months for one resident. Resident 6 had diagnoses including displaced intertrochanteric fracture of the right femur, initial encounter for a closed fracture, muscle weakness, and low back pain. Her clinical record showed a Quarterly MDS assessment completed on March 10, 2026, followed by an Annual MDS assessment completed on July 16, 2026, with no quarterly assessment completed in between. During an interview, the MDS Coordinator stated the resident should have had an assessment completed every 3 months, and the DON stated she would expect MDS assessments to be completed at least quarterly.
Baseline Care Plan Not Completed for Skin Concerns
Penalty
Summary
The facility failed to ensure that a baseline care plan containing the minimum healthcare information needed to properly care for a resident was developed and implemented within 48 hours of admission for one resident. Facility policy required the admitting nurse or supervising nurse to gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident or representative, and to initiate interventions addressing current needs, including health and safety concerns and special needs such as wound care. The resident had diagnoses including severe protein-calorie malnutrition and malignant neoplasm of the tongue and was admitted from the hospital on June 16, 2026. The admission skin assessment documented an unstageable left hip pressure ulcer/injury, a stage 1 buttocks pressure ulcer/injury, a right antecubital skin tear, and a left forearm skin tear present on admission. The baseline plan of care did not include a focus area or interventions for skin concerns or treatments, and during interview the NHA, DON, and another employee confirmed that the resident's skin concerns were not included in the baseline care plan and were not added until July 17, 2026.
Failure to Provide Scheduled Shower Care
Penalty
Summary
The facility failed to provide necessary ADL care to maintain personal hygiene for three residents who were unable to carry out ADLs. The facility policy required that, based on the comprehensive assessment and the resident’s needs and choices, necessary care and services be provided so ADL abilities are maintained or improved, and that hygiene includes bathing, dressing, grooming, and oral care. The policy also stated ADL care must be documented in the medical record in real time and reflect the care provided by nursing staff. Resident 2 had diagnoses including repeated falls and hypertension and stated during interview that he does not always get showers per his preferred schedule. His care plan included assistance to bathe/shower as needed, but did not indicate that he refuses care. His shower documentation showed a preferred schedule of Monday and Thursday evenings, with one shower marked not applicable and another documented as a bed/sponge bath; however, the record did not show that he refused a shower on the date the bed/sponge bath was documented. Resident 3 had diagnoses including hypertension and dementia, with shower days scheduled for Wednesday and Saturday evenings, but there was no documentation that she received a shower on one scheduled day. Resident 28 had diagnoses including hypertension and diabetes, with shower days scheduled for Monday and Thursday evenings, but her shower documentation on one date was marked response not required, indicating she did not receive a shower as scheduled. The Nursing Home Administrator stated she would expect residents to receive their showers as scheduled.
Missed Treatments, Incomplete Catheter Order, and Unscheduled Follow-Up
Penalty
Summary
Treatments were not provided as ordered for Resident 99, who had diagnoses including dermatitis and seborrheic dermatitis and was observed with a red facial rash with multiple opened and scabbed areas and reported that his face was itchy. His treatment orders included multiple topical medications and cleansers for the skin condition, but the Treatment Administration Record showed repeated blank entries across May, June, and July 2026 for several ordered treatments, including ammonium lactate, Cetaphil, clobetasol, Hibiclens, ketoconazole shampoo, and tacrolimus. A regional clinical support nurse stated that the holes in the TARs could not be justified, and staff confirmed that the treatments should have been provided as ordered or documented if not given. Resident 99 also had a dermatology consultation report that directed a follow-up appointment in eight months, but the clinical record did not show any subsequent dermatology appointments after that report. During interview, the NHA confirmed that the follow-up appointment should have been scheduled as recommended by the dermatologist. The record therefore showed both missed treatment documentation and failure to schedule the recommended specialty follow-up for the resident's skin condition. Resident 1's clinical record showed diagnoses including obstructive and reflux uropathy and benign prostatic hyperplasia with lower urinary tract symptoms, and the care plan indicated an indwelling Foley catheter was required due to neurogenic bladder. However, the physician order for the catheter was incomplete, with missing information in the order details. In addition, Resident 106, who had Parkinson's disease and chronic kidney disease stage 3A, had a physician order for monthly weight checks, but no weight was documented for July 2026. Staff confirmed that the weight had not been obtained as ordered and that physician orders were expected to be followed.
Infection Control and Pressure Redistribution Failures
Penalty
Summary
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing was identified for two residents. For one resident with diagnoses including difficulty walking and severe protein-calorie malnutrition, the clinical record showed an unstageable pressure ulcer on the left hip with an order for daily and as-needed wound treatment using wound cleanser, Medihoney, calcium alginate, and a foam dressing. During observed wound care, two LPNs set up the aseptic field on the resident’s bed beside him rather than on a clean, disinfected surface with a clean barrier on the over-bed table as required by facility policy. A red biohazard bag and a clear garbage bag were placed on the foot of the bed and touched the towel that was to be the clean field, and one LPN changed gloves multiple times during the dressing change without performing hand hygiene each time. For a second resident with osteoporosis and bilateral osteoarthritis of the hip, the physician ordered a pressure-redistribution mattress, and the care plan identified the resident as at risk for skin breakdown with an intervention for a pressure redistribution surface on the bed and chair. After the resident changed rooms, observations showed a regular mattress on the bed on two separate occasions, and the resident stated the air mattress was not moved with her. Facility records documented the pressure-redistributing mattress as being in place on several dates, but staff later stated they forgot to move the air mattress during the room change and that maintenance moved it to the new room later. The NHA stated it was the facility’s expectation that physician orders be followed.
Incomplete Documentation of Foley Voiding Trial
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling Foley catheter was accurately assessed for removal of the catheter. The resident had diagnoses including severe protein-calorie malnutrition, cancer of the tongue, and obstructive and reflux uropathy. On observation, the resident still had an indwelling Foley catheter in place. Physician orders included a voiding trial, bladder scans every eight hours, straight catheterization for a post-void residual greater than 400 milliliters, and reinsertion of the indwelling Foley catheter if three straight catheter insertions were required within 24 hours. The physician services provider note stated the resident had a history of urinary retention with an indwelling Foley and that staff were attempting a voiding trial, with the resident requiring straight catheterization that afternoon. However, review of the nursing progress notes and treatment records did not reveal documentation of the implementation or findings of the voiding trial by nursing staff. During interview, the Nursing Home Administrator, DON, and Regional Clinical Support Nurse stated the facility could not provide documentation regarding the specifics of the voiding trial beyond the provider note, and that the order had been entered incorrectly, resulting in missing documentation.
Failure to Provide and Document Pain Management
Penalty
Summary
Safe, appropriate pain management was not provided for two residents who required pain services. Resident 47 had diagnoses including parkinsonism, low back pain, and difficulty walking. Her physician ordered oxycodone 5 mg every 6 hours as needed for severe pain, along with non-pharmacological interventions documented every shift and effectiveness documented. Her care plan included using a pain scale and attempting non-pharmacological interventions for pain. During interview, Resident 47 stated she had been in a lot of pain all night and that her pain was not always managed. Review of the July 2026 MAR showed PRN oxycodone was given on multiple days without a numeric pain scale documented to support severe pain, the order did not include a numeric pain scale parameter, and non-pharmacological interventions were not attempted before PRN oxycodone was administered on several occasions. Resident 122 had diagnoses including osteoporosis and bilateral hip osteoarthritis and was ordered a weekly buprenorphine patch for pain management. Review of the MAR and nursing progress notes showed multiple documentation problems related to the patch, including entries marked as not available or held, notes that the patch was awaiting pharmacy delivery, and missing notes for some patch removal entries. The record also showed periods when the patch was not available after being ordered, and the nursing notes did not consistently document patch removal or related events on several dates. During interview, the NHA, DON, and an employee stated the patch was unavailable for approximately four days after it was ordered in April 2026, and the DON stated it was the facility's expectation that the physician be notified when medication is not available and that documentation be correct.
Missing Pharmacist MRR Recommendations for Two Residents
Penalty
Summary
The facility failed to provide the licensed pharmacist’s report of medication irregularities for two residents reviewed. The facility policy, Medication Monitoring Medication Regimen Review and Reporting, stated that resident-specific MRR recommendations and findings are to be documented and acted upon, and that the consultant pharmacist’s observations and recommendations are to be made available in an easily retrievable format to nurses, physicians, and the care planning team within 48 hours of MRR completion. However, the clinical record for one resident with diagnoses of hypertension and dementia showed that an MRR was completed and the pharmacist made comments and recommendations for the physician, but the record did not include what those recommendations were or any evidence that the physician was aware of or responded to them. The clinical record for a second resident with diagnoses of diabetes and anxiety showed the same issue. An MRR was completed and the pharmacist made comments and recommendations for the physician, but the record did not contain the pharmacist’s recommendations or any evidence that the physician was aware of or responded to them. During interview, the Regional Clinical Support Nurse and Nursing Home Administrator were unable to provide the pharmacy recommendations for either resident.
Nurse Aide Annual Training Deficiencies
Penalty
Summary
The facility failed to ensure required in-service training for nurse aides sufficient to maintain continuing competence of at least 12 hours per year and failed to include resident abuse prevention training for two of five nurse aide files reviewed. Review of the facility’s job description for Nursing Assistant, last revised November 23, 2020, stated that nurse aides must attend a minimum of 12 hours of continuing education programs provided by the center to maintain certification. Employee 10’s annual education record showed only 2.38 hours of annual education and no abuse prevention training, and Employee 11’s annual education record also showed no abuse prevention training. During an interview, the DON stated she would expect nurse aides to complete at least 12 hours of required in-service training per year and include resident abuse prevention training.
Failure to Complete Skin Checks and Inadequate Response to Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to complete ordered and care-planned skin assessments for one resident and failure to provide timely, comprehensive assessment and response to a change in condition for another resident. For the first resident, who had multiple sclerosis, diabetes mellitus, dementia, and zoster encephalitis, the care plan included interventions to observe skin for abnormalities and report changes in skin integrity to the Nurse Practitioner, with these interventions initiated in 2019. The January 2026 Medication Administration Record documented that weekly skin checks were not completed on four separate dates, and there were no corresponding progress notes regarding these missed skin checks. A regional clinical support staff member confirmed that the weekly skin check should have been completed for this resident. For the second resident, who had Alzheimer’s disease, thyroid cancer, and metastatic cancer of the liver, colon, and lymph nodes, the facility did not provide timely and comprehensive care and services after a documented change in condition. Laboratory results showed abnormal and worsening values for sodium, chloride, calculated osmolality, potassium, and calcium over several days, consistent with dehydration and electrolyte disturbances. The Nurse Practitioner documented lethargy and non-responsiveness to verbal stimuli and ordered IV D5W for hypernatremia/dehydration and a one-time dose of potassium chloride 40 mEq on two separate dates. The March Medication Administration Record did not show that the ordered potassium dose was administered, and the Director of Nursing’s later assertion that the potassium was placed on hold by the Nurse Practitioner was not supported by any documentation. On the day of acute decline, nursing documentation noted lethargy, refusal of meals with minimal fluid intake, and later an acute visit by the physician who found the resident unresponsive and ordered transfer to the emergency room. An SBAR completed by the RN supervisor documented fever and unresponsiveness as the change in condition, with limited vital signs and no repeat vitals after the change in condition except for blood pressure. The SBAR omitted the abnormal laboratory results, new medications, and IV fluids, and indicated that respiratory and neurological assessments were not clinically applicable, despite the resident’s altered responsiveness. There was no nursing assessment documented of the resident’s condition after the change in status. EMS records indicated a delay in gaining access to the locked unit, absence of staff in the resident’s room on arrival, shallow breathing requiring immediate oxygen via non-rebreather, and difficulty obtaining report, code status, and medical history from staff. EMS documented that care was delayed due to waiting for access, that staff were initially on their phones and not answering the door, and that a nurse present knew only limited information about the resident’s condition and medications. Hospital records showed the resident required intubation and was admitted to the ICU with acute respiratory failure, failure to thrive, cardiac arrest, hypocalcemia, and hypokalemia, and the facility’s failures were cited as not assessing the resident after a change in condition, delaying the 911 call by approximately 54 minutes after the physician’s order to send the resident out, not remaining with the resident to monitor for further decline, not assessing respiratory status despite respiratory distress, and not providing EMS or the ED with timely and thorough report. The cited regulatory violations included 28 Pa. code 201.14(a) Responsibility of licensee, 28 Pa code 201.18(b)(1) Management, and 28 Pa code 211.12(c)(d)(1)(3)(5) Nursing services. These citations were based on the failure to complete routine and weekly skin checks as ordered and care-planned for one resident, and the failure to provide timely, accurate, and comprehensive assessment, monitoring, documentation, and communication in response to another resident’s significant change in condition, including omission of critical clinical information on the SBAR and lack of appropriate respiratory assessment and presence of staff during EMS arrival and transfer.
Failure to Provide and Follow Through on Dental Services and Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that routine and 24-hour emergency dental services were provided and that dental recommendations were implemented for three residents. For one resident with dementia and progressive multiple sclerosis, a care plan meeting note documented that the resident wished to be seen by a dentist for possible dentures. A subsequent dental consultation recommended use of Prevident 5000 Dry Mouth gel and referral to an oral surgeon for extraction of all non-restorable teeth. The consultation lacked any review signature by nursing staff or the resident’s physician, and the physician orders contained no orders for the oral surgeon consultation or the Prevident gel. For a second resident with vascular dementia and generalized muscle weakness, a dental consultation documented that the resident had lost upper and lower dentures and that Step 1 of the denture replacement process had been completed, with a follow-up visit scheduled for Step 2. Facility-provided information from the contracted dental services provider indicated the resident was seen for Step 1 and scheduled for Step 2, but the clinical record contained no additional dental consultations or visit notes over several months. Progress notes showed that the resident’s representative repeatedly inquired about the status of the denture replacement, and was told the resident was in Step 2, while the DON later confirmed the resident had not been seen by the dentist since the initial consultation. For a third resident with a neurocognitive disorder with Lewy bodies and heart failure, a dental consultation documented a periodic oral exam and scheduled a prophylaxis visit for a later date. The clinical record contained no further dental consultations after that exam. The NHA confirmed there was no additional information in the record regarding the scheduled prophylaxis visit and reported contacting the contracted dental services provider to investigate what had happened with that visit. Overall, the records and staff interviews showed that scheduled dental services and dentist recommendations were not carried out or documented for all three residents.
Failure to Provide Timely Pharmaceutical Services for Anxiolytic Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident diagnosed with generalized anxiety disorder and major depressive disorder. The resident had a physician's order for Lorazepam to be administered three times daily for anxiety. Review of the medication administration record showed that on two occasions, the Lorazepam was not administered as indicated by 'NN' (no/see nurse notes), and there were no corresponding nursing progress notes documenting the missed doses. Further investigation revealed that the pharmacy did not dispense the Lorazepam refill because a new prescription was required, and the necessary prescription was not obtained and sent to the pharmacy before the resident ran out of medication.
Failure to Provide Prescribed Altered Texture Diets for Residents with Dysphagia
Penalty
Summary
The facility failed to provide altered texture diets as prescribed by physicians for multiple residents with dysphagia. Specifically, six residents who were ordered a dysphagia advanced texture diet received round slices of carrots that exceeded the recommended size for their diet, rather than the required chopped carrots no larger than ½-inch by ½-inch pieces. This was observed during meal service, and the meal tickets for these residents clearly indicated the need for chopped carrots, but the kitchen staff served sliced carrots instead. Facility policies required that residents with swallowing difficulties receive appropriate diet modifications, and the master menu diet guide sheets specified the correct form and size for vegetables on dysphagia advanced diets. Despite these guidelines, the kitchen staff did not follow the prescribed diet texture, and the dietary manager confirmed that the carrots served did not meet the required specifications. The speech language pathologist also confirmed that no changes had been made to the menu guidance and that the expectation was for kitchen staff to serve food in the appropriate texture as outlined by the International Dysphagia Diet Standardization Initiative. This failure to provide food in the prescribed form placed an additional fourteen residents with similar dietary needs at high risk, resulting in an Immediate Jeopardy situation. The deficiency was identified through observations, record reviews, and staff interviews, which confirmed that the facility did not follow its own policies or physician orders regarding diet texture for residents with dysphagia.
Failure to Implement Suicide Precautions and Conduct Thorough Fall Investigations
Penalty
Summary
The facility failed to conduct thorough fall investigations for one resident and did not implement suicide precautions for another resident who expressed suicidal ideation. In the case of the resident with suicidal ideation, staff were made aware that the resident was expressing thoughts of self-harm, including statements about wanting to kill himself and asking for a lawyer before doing so. Despite this, the LPN on duty did not initiate the facility's suicide precautions protocol, which required immediate assessment, one-to-one supervision, notification of the registered nurse supervisor and physician, and removal of potentially dangerous items from the resident's environment. As a result, the resident was left unsupervised in his room, where he was able to obtain a sharp plastic object and cut himself before staff intervened. The clinical record review showed that no orders for suicide precautions or one-to-one supervision were obtained or entered into the electronic health record in response to the resident's expressed suicidal ideation. Staff witness statements confirmed that the resident was not under constant supervision at the time of the self-injury, and that the required safety interventions were not put in place. The facility's policy on suicide precautions outlined specific steps to be taken when a resident exhibits suicidal behavior or ideation, but these were not followed by the staff involved. Additionally, the facility failed to conduct thorough fall investigations for another resident with a history of repeated falls and a recent fracture. Fall reports for this resident on two separate occasions did not include any staff witness statements, and the DON confirmed that she was unable to locate such statements. The facility's falls management policy required thorough assessment and documentation following a fall, but this was not completed as expected.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide required notification to the Office of the State Long-Term Care Ombudsman regarding resident transfers to the hospital for five out of eleven residents reviewed. Clinical record reviews and facility documentation revealed that notifications were not sent for multiple hospitalizations involving residents with diagnoses such as muscle weakness, unsteadiness, hypertension, diabetes, hemophilia, neuromuscular dysfunction of the bladder, dementia, chronic kidney disease, depression, and chronic pain syndrome. Specific instances included residents being transferred to the hospital on several occasions, with no evidence that the Ombudsman was notified as required by regulation. Staff interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that they expected all resident transfers to be reported to the Ombudsman in a timely manner, but documentation and email communications indicated that notifications were not made at the time of the transfers. The deficiency was identified through review of clinical records, facility documentation, and staff interviews, which consistently failed to show timely notification to the Ombudsman for the affected residents' hospitalizations.
Inaccurate Resident Assessments Documented in Clinical Records
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' clinical status for four individuals. For one resident with anxiety disorder, epilepsy, and depression, the Minimum Data Set (MDS) assessments inaccurately documented the administration of antianxiety, anticonvulsant, and opioid medications, with discrepancies between the MDS and the Medication Administration Record (MAR). Another resident with anxiety, post-traumatic stress disorder, and hemophilia was incorrectly coded on the MDS as not having a related condition per the Preadmission Screening and Resident Review (PASRR), despite documentation from the state indicating otherwise. A third resident with chronic pain syndrome and a stage 4 pressure ulcer was not consistently coded on the MDS regarding the presence and admission status of the pressure ulcer, despite clinical records confirming its existence and that it was present upon admission. Additionally, this resident was receiving hospice services. For a fourth resident with schizoaffective disorder, bipolar disorder, and major depressive disorder, the MDS assessments failed to accurately reflect attempts at gradual dose reduction (GDR) for antipsychotic medications, even though clinical documentation and physician orders indicated that GDRs had been attempted and medication dosages had been adjusted. These inaccuracies were confirmed through clinical record reviews, MARs, and staff interviews, with the Director of Nursing acknowledging the errors in MDS coding. The deficiencies were identified during the survey process and were found to be in violation of state regulations regarding medical records and nursing services.
Failure to Follow Physician Orders and Document Care for Multiple Residents
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for several residents, resulting in deficiencies related to medication administration, wound care, and response to acute medical needs. For one resident with cerebrovascular disease and scoliosis, a physician ordered a urine analysis with culture and sensitivity (UA/C&S) after multiple falls, but the test was never completed or documented, and no laboratory results were found. The Director of Nursing (DON) confirmed the order was not fulfilled and could not provide additional information. Another resident with multiple wound care orders for a diabetic toe wound had several days where treatments were not documented as completed on the Treatment Administration Record (TAR). The DON acknowledged that some treatments were performed during wound rounds but were not properly documented, and could not explain other missed entries. Additionally, this resident received more than the recommended daily dose of acetaminophen due to overlapping orders, which were not discontinued as new orders were placed, as confirmed by the DON. A resident with diabetes and end-stage renal disease missed scheduled insulin doses on multiple days when away for hemodialysis, despite the care plan indicating diabetes medication should be administered as ordered. Another resident with hemophilia and a history of hematuria experienced blood in the urine, but staff did not notify the hemophilia treatment center as ordered, and the prescribed medication for bleeding was not administered until nearly 24 hours after the initial observation. The DON confirmed the lack of documentation and delayed response. Finally, a resident with a skin tear did not have wound treatments documented on two occasions, with the DON unable to provide an explanation. These findings demonstrate failures in following physician orders, documenting care, and responding to residents' clinical needs.
Failure to Implement and Document Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to provide care consistent with professional standards to treat and prevent pressure ulcers for two residents. For one resident with osteomyelitis of the left ankle and foot and diabetes, the wound team recommended the use of pressure off-loading boots, but there was no physician order for the boots, no documentation of their use, and the care plan did not include their use. Observation showed the resident in a wheelchair with the boots beside the bed, and the resident reported that staff only occasionally applied the boots at night. The Director of Nursing confirmed that a physician order and care plan revision should have occurred after the wound team’s recommendation, but these steps were not taken. Similarly, another resident with osteomyelitis and a pressure ulcer of the sacral region had a wound team recommendation to float heels in bed, but there was no physician order for off-loading boots, no documentation of their use, and the care plan did not address their use. Observation found the resident in bed with the boots beside the bed, and the DON confirmed that the necessary physician order and care plan revision were not completed after the wound team’s recommendation. In both cases, the facility failed to document or implement recommended interventions for pressure ulcer prevention and care.
Failure to Complete Annual Employee Performance Reviews
Penalty
Summary
The facility failed to complete yearly employee performance reviews for five employees, as required by facility policy and state regulations. On June 25, 2025, the Nursing Home Administrator was unable to provide documentation of performance reviews conducted within the past year for these employees when requested. During a staff interview, the Administrator confirmed that no such reviews had been completed for the identified employees within the required timeframe. This deficiency was identified through facility document review and staff interviews.
Expired Medications Not Discarded per Policy and Manufacturer Guidelines
Penalty
Summary
The facility failed to properly discard expired medications as required by both facility policy and manufacturer guidelines. During an observation of the B Hall medication cart, a Novolog insulin vial was found with an open date of May 24, 2025, which exceeded the 28-day usage period specified in the facility's policy and the manufacturer's instructions. Additionally, in the [NAME] Wing medication room, two open Afluria influenza vaccine vials were found, one opened on December 24, 2024, and the other on May 20, 2025, both of which were also past the 28-day usage period after opening as per manufacturer guidelines. The Director of Nursing confirmed via email that the Afluria multi-dose vials are only good for 28 days once opened and acknowledged that expired vaccines had been removed from the medication refrigerators. During an interview, both the Nursing Home Administrator and the DON confirmed that medications are expected to be stored and discarded according to policy and manufacturer guidelines. These findings indicate that the facility did not consistently follow its own policies or manufacturer recommendations regarding the storage and timely disposal of expired medications.
Failure to Maintain Required Dish Machine Wash Temperatures
Penalty
Summary
The facility failed to operate its main kitchen dish machine in accordance with professional standards for food service safety. Manufacturer guidelines for the CL44e dish machine require a minimum wash temperature of 160°F for proper high-temperature sanitizing. However, direct observation of the dish machine in use showed a wash temperature of only 152°F. Review of the facility's dish machine temperature logs from October 2024 through June 2025 revealed numerous instances across breakfast, lunch, and dinner where recorded wash temperatures were below the required 160°F minimum. This pattern of substandard temperatures was consistent over several months and meal periods. Interviews with the Certified Dietary Manager indicated a misunderstanding of the required minimum wash temperature, as staff believed 150°F was sufficient. The logs and staff statements confirm that the dish machine was routinely operated below the manufacturer's specified temperature, and the staff were not following the correct standard. The deficiency was identified through review of documentation, direct observation, and staff interviews, with no mention of specific residents or patient outcomes related to this deficiency.
Failure to Review, Revise, and Document Care Plans and Resident Participation
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised to reflect residents' current status and did not provide residents or their representatives with the opportunity to participate in the care planning process. Multiple residents with complex medical conditions, such as diabetes, end stage renal disease, dementia, congestive heart failure, hypertension, and mental health disorders, did not have documented evidence of care plan meetings being held or invitations extended to them or their representatives. In several cases, the last documented care plan meetings were many months prior to the survey, and staff could not provide further documentation of more recent meetings or invitations. Additionally, the facility did not update care plans to reflect changes in residents' conditions or physician orders. For example, one resident's care plan continued to list interventions for medications that had been discontinued, and another resident's care plan did not include a newly ordered renal diet. There were also instances where care plans failed to address significant care needs, such as incontinence care for residents who were always incontinent or had discontinued use of a foley catheter but were now frequently incontinent of bowel. Interviews with residents, their representatives, and facility staff confirmed that care plan meetings were not being held as expected, and documentation of these meetings, including invitations and attendance, was lacking. Facility policy required care plans to be reviewed and revised after each assessment and as needed, and for care plan meetings to be documented, but these requirements were not met for several residents during the review period.
Failure to Develop and Communicate Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for a resident. Specifically, for a resident admitted with a right humerus fracture and scalp laceration, the baseline care plan did not address urinary incontinence or incontinence care, despite the resident being assessed with these needs upon admission. Additionally, the care plan included a focus on pain management but did not document what the resident considered an acceptable level of pain. Further, there was no evidence in the clinical record or progress notes that the resident or their representative was provided with a summary of the baseline care plan within 48 hours of admission. This summary should have included initial goals, medications, dietary instructions, and services or treatments to be administered. Staff interviews confirmed these omissions, and facility policy requires that such information be documented and communicated to the resident and their representative.
Failure to Provide and Document Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide necessary care and services related to hygiene and bathing for one resident, as required by both facility policy and the resident's care plan. The policy mandates that ADL care, including bathing, be provided according to the resident's needs and documented every shift. The resident in question had diagnoses of muscle weakness, obesity, and a non-pressure chronic ulcer on the left foot, and her care plan specified modified independence with bathing. The most recent MDS assessment indicated she required supervision and touching assistance for bathing. Despite these requirements, documentation showed that the resident was scheduled for showers or baths on Wednesday and Saturday evenings but only received one documented shower/bath during the review period. Several scheduled shower/bath days were either marked as non-applicable or had no documentation at all. The resident reported not always receiving her showers, and during interviews, facility leadership confirmed they had no additional information and expected staff to provide and document care as per the care plan.
Failure to Ensure Timely Audiology Referral for Hearing Loss
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and services to maintain hearing abilities. Clinical record review showed that the resident had diagnoses including stage 3 chronic kidney disease and hypothyroidism. The resident reported difficulty hearing and stated she had requested to see a doctor because her hearing aids were no longer effective. A medical practitioner documented an acute visit for hearing loss and ordered a referral to audiology for evaluation. Despite the physician's order for an audiology referral, the resident was not placed on the list to be seen by audiology. The Nursing Home Administrator confirmed that the resident was not added to the audiology list after the order was made and acknowledged that this should have occurred. The audiology provider later confirmed that the resident was not scheduled due to missing information, resulting in a delay in the resident receiving the necessary evaluation for her hearing loss.
Failure to Provide and Document Restorative Nursing Care for Range of Motion
Penalty
Summary
The facility failed to provide restorative nursing care for range of motion (ROM) exercises for two residents with limited ROM. For one resident with diagnoses including dysphagia, vascular dementia, and contractures of the hands, neck, and legs, the care plan and Kardex specified restorative passive ROM for both upper and lower extremities during morning and evening care. However, there was no documentation in the clinical record to indicate that these restorative nursing services were being provided. The Director of Nursing (DON) confirmed that a system glitch prevented the task from being added for staff to complete, and no documentation could be provided to show that the care was delivered prior to a certain date. The DON stated that staff were expected to perform the care, but acknowledged it was not documented anywhere. For another resident with dementia, chronic kidney disease, and depression, an occupational therapy note recommended the use of palm guards and both active and passive ROM as part of a restorative nursing program. The nursing tasks included encouraging the use of palm guards and providing hand hygiene, but there was no documentation to confirm these interventions were carried out. The DON explained that the task was entered incorrectly, resulting in a lack of documentation, and stated that restorative nursing programs should be implemented and documented.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for three residents, as evidenced by review of clinical records, interviews, and facility policy. For one resident with cerebrovascular disease and scoliosis, there were multiple instances where prescribed oxycodone was not administered due to the medication being unavailable and awaiting pharmacy delivery. Documentation showed that the medication was not reordered in a timely manner, and the in-house emergency supply was not utilized as expected. The Director of Nursing confirmed that management was not made aware of the need for a refill, and the responsible LPN did not follow procedures to ensure continuity of pain medication. Another resident, who required assistance with personal care and had muscle weakness and unsteadiness, reported ongoing back pain that was not adequately relieved by current medication. Although a nurse practitioner documented a plan to use an ice pack for pain relief, there was no corresponding physician order or care plan entry for this intervention. The resident's care plan also lacked a comprehensive approach to pain management, and the Director of Nursing acknowledged that the expected process for ordering and documenting non-pharmacological interventions was not followed. A third resident, admitted with a right humerus fracture and scalp laceration, reported that her pain was not managed to her comfort level. Her care plan did not specify her desired pain goal, and there were missed doses of acetaminophen without documentation or physician notification. The resident refused topical pain patches on several occasions, but there was no documentation of the reasons for refusal or physician notification. Additionally, non-pharmacological interventions were not documented prior to administration of as-needed pain medication, and ongoing reports of severe pain were not promptly communicated to the physician or nurse practitioner. The resident's pain management regimen was not adjusted despite continued complaints of inadequate pain control.
Failure to Provide Timely Dental Services After Denture Authorization
Penalty
Summary
The facility failed to provide timely dental services to a resident with anxiety disorder and dysphagia. The resident reported having new dentures that did not fit properly, resulting in difficulty eating. Clinical record review showed that the resident was last seen by the facility's dentist several months prior, at which time a preauthorization for new dentures was submitted. Although the insurance claim for the dentures was approved, no follow-up dental appointment was scheduled for the resident after the approval. The Nursing Home Administrator confirmed that the delay in scheduling or addressing dental services was not expected.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the preparation and administration of medications to four residents. Facility policy directed staff to avoid touching medications unless wearing gloves, but observations revealed that a staff member, after cleansing her hands and donning gloves, touched unclean surfaces such as medication cart keys and drawer handles before handling oral medications. She then pushed pills from blister packs into her gloved hands and placed them into medicine cups, subsequently administering these medications to three residents without changing gloves or performing hand hygiene between tasks. The staff member confirmed during interview that she had touched the medications with the same gloves that had contacted unclean items. Additionally, another staff member was observed preparing an insulin injection for a resident using an insulin pen. The staff member applied a new needle to the pen without cleansing the rubber seal, contrary to manufacturer instructions. The facility's policy on subcutaneous insulin did not include guidance to cleanse the rubber seal before needle application, and the staff member confirmed she had not performed this step. The DON acknowledged that both staff members did not follow appropriate infection control practices as required by facility policy and manufacturer guidelines.
Insufficient Nursing Staff Resulting in Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents on one of its nursing units, specifically the West wing. During the survey, ten residents reported concerns regarding delayed call bell response times and inadequate staffing. Review of facility grievances from April, May, and June 2025 identified three complaints related to extended wait times for call bells to be answered. Additionally, Resident Council Meeting minutes from April and May 2025 documented resident complaints about prolonged call bell wait times. Direct observation on June 23, 2025, showed that call lights in specific rooms remained activated for extended periods, with one call bell not answered for 27 minutes and another for 32 minutes. The Nursing Home Administrator did not provide further information during the interview.
Failure to Meet Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios on multiple occasions, as evidenced by a review of staffing documents and staff interviews. On January 5, 2025, during the night shift, the facility had a census of 141 residents but only maintained a NA ratio of 5.84, falling short of the required 9.40. Similarly, on January 6, 2025, the day shift had a census of 141 residents with a NA ratio of 10.28, not meeting the required 14.10. The night shift on the same day also failed to meet the required ratio, with a NA ratio of 5.73 against the required 9.40. Further deficiencies were noted on January 10, 2025, during the evening shift, where the facility had a census of 140 residents and a NA ratio of 11.97, below the required 12.73. On January 11, 2025, the day shift had a census of 141 residents with a NA ratio of 13.16, not meeting the required 14.10. Additionally, the night shift on January 11, 2025, had a census of 142 residents with a NA ratio of 8.31, failing to meet the required 9.47. These findings indicate a consistent failure to maintain the mandated staffing levels across various shifts and days.
Plan Of Correction
1. No residents affected. Residents received care in accordance with their plan of care and attending physician orders. 2. No residents affected. All residents will continue to receive care in accordance with their plan of care and attending physicians orders. 3. The NHA, Clinical Leadership Team, Human Resources, and Scheduler will review the schedule in daily meetings. In the event of call offs, the facility will follow staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call offs per policy. The facility will continue to hire for all open positions using a new recruitment platform, job fairs, and utilize agency staff as needed. 4. NHA has re-educated the Director of Nursing and Scheduler on Nursing ratios and PPD requirements and the importance of maintaining the schedule as posted. 5. To monitor and maintain ongoing compliance, the NHA/DON/Designee will audit staffing daily x 4 weeks then weekly for 2 months for review and revision as needed. Results of audits will be reported to the QAPI Committee.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the required minimum of 3.2 hours of direct nursing care per resident per day for four out of seven days reviewed. Specifically, on January 5, 2025, the facility provided only 2.90 hours of direct care per resident, 2.52 hours on January 6, 2025, 3.05 hours on January 10, 2025, and 2.89 hours on January 11, 2025. This deficiency was confirmed during an interview with the Nursing Home Administrator, who attributed the shortfall to staff call-offs related to illnesses and adverse weather conditions.
Plan Of Correction
1. No residents affected. Residents received care in accordance with their plan of care and attending physician orders. 2. No residents affected. Residents will continue to receive care in accordance with their plan of care and attending physician orders. 3. The NHA, Clinical Leadership Team, Human Resources, and Scheduler will review the schedule in daily meetings. In the event of call offs, the facility will follow staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to coordinate staffing schedules and replace call offs per policy. The facility will continue to hire for all open positions using a new recruitment platform, job fairs, and utilize agency staff as needed. 4. NHA has re-educated the Director of Nursing and Scheduler on Nursing ratios and PPD requirements and the importance of maintaining the schedule as posted. 5. To monitor and maintain ongoing compliance, the NHA/DON/Designee will audit staffing daily for 4 weeks, then weekly for 2 months for review and revision as needed. Results of audits will be reported to the QAPI Committee.
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 240 citations issued within 25 miles in the last 12 months — including the 6 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) |
|---|---|---|---|---|
| Forest Park Nursing And Rehabilitation | 0.2 mi | ★★★★★ | 10 | 0 |
| Thornwald Home | 0.3 mi | ★★★★★ | 8 | 0 |
| Sarah A Todd Memorial Home | 0.8 mi | ★★★★★ | 2 | 0 |
| Chapel Pointe At Carlisle | 0.8 mi | ★★★★★ | 0 | 0 |
| Cumberland Crossings Retirement Community | 0.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Carlisle Skilled Nursing And Rehabilitation Center.
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 October 2026) and official state health department websites.