Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Claremont Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with diabetes and epilepsy had physician orders for scheduled insulin with specific parameters to hold doses and notify the provider for blood sugars below 150, as well as instructions for monitoring and treating hypo/hyperglycemia. Insulin was documented as given when blood sugars were below the ordered threshold, without evidence of required physician notification. On one occasion, EMS found the resident minimally responsive with a blood sugar of 34, treated with IV dextrose, and documented that facility staff reported the resident was not diabetic and provided paperwork for a different resident with the same first name. The clinical record lacked nursing notes and blood sugar documentation for the event, showing failures to follow orders, accurately communicate the resident’s condition and history, and document the change in condition and interventions.
A resident with dementia, emphysema, PTSD, and a BIMS score of 0.0 was sent by outside transport to an outpatient center for a CT scan without a staff escort, based on an unverified assumption that the spouse would attend. The appointment was not entered on the resident’s calendar, staff did not document the time of departure, and the resident was reportedly sent wearing only a thin jacket in very cold weather. At the outpatient center, the resident became confused and agitated when he realized his spouse was not present, refused the scan, and had to be returned to the facility. Interviews and email correspondence confirmed that the facility was responsible under its agreement with the outside agency to provide an escort unless a family member was arranged to meet the resident, and that these expectations were not met.
A resident with a stage 4 pressure injury to the right buttock did not have consistent weekly wound assessments and measurements documented, despite a physician order for ongoing evaluation. The TAR showed multiple completed wound checks without matching wound evaluation forms or supporting progress notes, and the DON confirmed missing documentation. The resident’s wound clinic also recommended a Roho chair cushion, but the resident was observed sitting on a gel cushion instead.
Improper medication labeling and expired medications were found in multiple medication carts and medication rooms. Surveyors observed unlabeled or partially labeled items, including insulin pens, tuberculin testing solution, supplements, and liquid medications without open dates or legible expiration dates, and also found expired lorazepam, Senna Plus, and Nephro vitamins. LPNs present during the observations confirmed the findings, and the DON stated medications should be labeled properly and discarded when expired.
The facility failed to review and revise care plans for two residents. One resident’s care plan still listed a surgical wound after the incision had healed, and another resident’s care plan did not address a nephrostomy tube despite current orders for site monitoring. The DON confirmed both care plan issues.
Medication was left with a resident after an LPN was interrupted during morning med pass, and the resident was later observed in bed with 7 tablets still in a medication cup on the overbed table. The resident had dementia and an anxiety disorder, and there was no physician order, evaluation, or care plan for self-administration of meds; the DON confirmed no self-administration order existed.
A facility failed to follow ordered treatments and precautions for two residents. One resident with lymphedema had compression wraps and later fitted full-leg garments, but the record lacked timely MD orders and the resident reported not wearing the wraps. Another resident with dementia and a recent pacemaker replacement had left arm restrictions and enabler bars ordered, but the care plan and CNA Kardex did not include the precautions, and staff did not reevaluate the safety of the enablers despite the resident’s severe cognitive impairment and fluctuating cognition.
A resident with HTN and a cognitive communication deficit had a pair of shearing scissors, about 6 to 8 inches long, left on a stand near the TV in the room. The scissors were observed in the room across multiple checks, and the NHA acknowledged they should not have been within resident access.
Inconsistent fluid intake documentation for a resident with CKD and renal dialysis led to a failure to maintain ordered fluid restriction of 720 ml/day. The medication nurse tracked fluids on the TAR while nurse aides documented intake in the EMR task section, but the amounts did not match on any day; the TAR showed overages on 4 days and the task record showed overages on 17 days. The DON and unit manager were unable to determine the resident’s actual fluid intake.
A facility failed to ensure pharmacist MRR irregularities were reviewed and acted upon for two residents. One resident with depression, anxiety, and dementia had PRN senna and senna/docusate orders, and the pharmacist recommended discontinuing one or clarifying use, but there was no evidence the physician reviewed the recommendation. Another resident with HTN and severe protein-calorie malnutrition had duplicate PRN Tylenol orders and conflicting Imodium and Senna orders; although the note was initialed by the CRNP and an RN, no clear order or documentation was provided, and the conflicting orders remained unresolved at the later review.
The facility failed to refund resident fund account balances and overpayments within the required 30-day period for three residents. Despite the facility's policy and admission agreement stipulating timely refunds, delays occurred due to the need for corporate office approval. This resulted in violations of state regulations.
The facility failed to maintain a clean and safe environment, as evidenced by a stained hallway with a urine odor, uncleaned food debris in a resident's room, a soiled wheelchair, and a dirty toilet bowl. Interviews with the NHA and DON confirmed that these issues were not addressed in a timely manner, contrary to facility policy.
The facility did not perform required criminal history background checks for a Registered Nurse, a Nurse Aide, and an LPN before hiring them, as mandated by their policy on abuse, neglect, and exploitation. This oversight was acknowledged by the Nursing Home Administrator.
A resident with congestive heart failure and obstructive sleep apnea did not receive proper respiratory care due to a lapse in CPAP/BIPAP orders from November 2023 to October 2024. The resident's CPAP machine was not cleaned as required, and the Director of Nursing confirmed the absence of necessary orders during this period.
The facility failed to provide care according to professional standards for two residents. One resident did not receive ordered Ace wraps for edema, despite documentation indicating they were applied. Another resident had undated dressings on their elbow without current treatment orders, and required weekly skin assessments were not documented. The DON confirmed the lack of documentation and communication regarding the care provided.
A resident with chronic kidney disease and hypertension did not receive scheduled vision services due to a time constraint and miscommunication. The resident was not informed of any rescheduling after missing appointments on two occasions.
A facility failed to provide appropriate care for a resident receiving tube feedings. Despite a physician's order for specific enteral feeding and water flush rates, observations revealed that the resident was not receiving the prescribed water flushes. The Director of Nursing acknowledged the expectation for adherence to the physician's orders, indicating a lapse in following the facility's policy on feeding tube care.
A facility failed to conduct a risk-benefit analysis and obtain informed consent for a resident's use of enabler bars. The resident, with morbid obesity and chronic heart failure, had bilateral enablers on their bed without documented consent or evaluation. The facility's policy requires comprehensive assessment and informed consent, which were not completed, as confirmed by the DON.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist and timely action on irregularities for two residents. One resident's antipsychotic medication lacked a documented diagnosis, with the physician delaying response for over four months. Another resident missed a monthly review, and a similar delay occurred in addressing a pharmacy recommendation.
A resident with a history of atherosclerosis and diabetes had a deteriorating wound on the left lower extremity, which was found to contain maggots. Despite initial assessment and prescribed treatment, the facility failed to document the presence of maggots and did not continue to monitor or assess the wound. Staff interviews confirmed the oversight, and the Director of Nursing acknowledged the issue.
The facility failed to maintain an effective pest control program, leading to maggots being found in a resident's wound. The resident had a history of atherosclerosis and type two diabetes. The pest control records showed no visit in May 2024, contributing to the deficiency.
The facility failed to report two incidents of sexual abuse involving residents with cognitive impairments to the State Agency within the required timeframes. In one case, a resident was observed engaging in non-consensual contact with another resident in the dining room. In another incident, two residents were found in a compromising situation in a resident's room. Both incidents were not reported as per the facility's policy, resulting in a deficiency.
Failure to Follow Insulin Orders, Monitor Hypoglycemia, and Provide Accurate Information to EMS
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and to accurately assess, monitor, and document a resident’s change in condition. Resident 1 had diagnoses including epilepsy and diabetes and a physician’s order dated April 3, 2026, for Insulin Aspart 28 units subcutaneously twice daily, with instructions to hold insulin and notify the provider if blood sugar was less than 150 or if the resident was NPO/not eating, and to notify the provider if blood sugar was greater than 400. The orders also included parameters for monitoring blood sugars for signs and symptoms of hypo/hyperglycemia and use of glucagon for blood sugar less than 50 in an unresponsive resident, with repeat blood sugar checks and physician notification. Review of the Medication Administration Record showed that insulin was administered when blood sugars were below the ordered parameter of 150 on multiple dates, and there was no documentation that the physician was notified of these low blood sugars as required by the orders. On April 10, 2026, EMS documentation showed that EMS arrived at 6:40 PM and found Resident 1 in bed, conscious and breathing without difficulty but not alert and not responding normally, after staff reported the resident had suddenly slumped over in a wheelchair. EMS recorded a blood sugar of 34 at 6:45 PM, administered IV dextrose, and documented that the blood sugar rose to 177 by 6:50 PM, after which the resident was able to answer questions and reported being “a really bad diabetic,” with identifying information that did not match the paperwork provided by the facility. The EMS report indicated that facility staff told EMS the patient was not a diabetic, had no seizure history, and only had extensive cardiac history, and the paperwork given to EMS was for a different resident with the same first name. Review of Resident 1’s clinical record revealed no nurses’ notes on April 10, 2026, documenting the change in condition, the call to EMS, the EMS response, or any physician notification, and no blood sugar readings were recorded after 12:00 PM that day. Facility leadership later confirmed that the paperwork provided to EMS was for another resident and that they would have expected nurses to complete all necessary documentation at the time of occurrence and to follow physician orders.
Failure to Escort and Appropriately Manage Cognitively Impaired Resident for Outside Appointment
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and services, including an escort, for a cognitively impaired resident during an outside medical appointment, as required by contract and facility expectations. The facility had a care agreement with an outside agency stating that providers would furnish medically necessary services authorized under the agreement. The resident had diagnoses of dementia, emphysema, and PTSD, and a BIMS score of 0.0 indicating severe cognitive impairment. Review of the clinical record showed a nursing note documenting the resident’s return from an appointment with no new orders, but there was no documentation of the time he left the unit, and his appointment was not entered on his calendar in the health record. On the day of the appointment, the outside transport driver arrived at the facility, picked up the resident, and transported him to the outpatient center without a facility escort. Staff interviews revealed that the unit secretary recalled hearing that the resident’s wife would attend the appointment but could not identify the source of this information. The nurse unit manager acknowledged speaking with the resident’s wife afterward, when she expressed upset that no escort had accompanied him, and also acknowledged that staff do not always document the time residents leave for appointments. The assistant DON stated the resident left the unit around midday, but the exact time was unknown, and confirmed that the appointment was not on the resident’s calendar and that a note documenting departure time should have been written. At the outpatient center, the resident was dropped off at the entrance, greeted by staff or volunteers, and brought to the registration area for his CT scan. During the process, he became agitated, asked where his wife was, and displayed confusion and belligerence, ultimately refusing the scan. Outpatient staff contacted his wife, who reported she was not at the appointment and had not arranged to attend, and stated that someone from the facility should have accompanied him. The outpatient center case manager later emailed the NHA, stating that the resident had been sent without a staff escort, that the CT scan could not be completed, and reiterating the policy that residents transported by the outside agency must have an escort from the facility unless a family member is arranged to meet them. The email also relayed the spouse’s concern that the resident had been sent wearing only a thin jacket in 10-degree weather. The NHA confirmed that the resident did not have an escort, that staff believed the wife would meet him, and that he expected cognitively impaired residents to be escorted, with proper documentation of departure and return times and appropriate clothing for outside appointments.
Missing wound assessments and failure to follow wound clinic equipment recommendation
Penalty
Summary
The facility failed to ensure that a resident with a stage 4 pressure injury to the right buttock received necessary treatment and services consistent with professional standards of practice to promote wound healing. The resident was admitted with diagnoses including severe protein-calorie malnutrition and cognitive communication deficit, and had a physician order for weekly wound evaluation and measurement. Although the TAR showed multiple wound evaluations as completed from August through November 2025, several of those entries did not have corresponding wound evaluation forms, and one entry referenced a progress note that was not found in the record. The DON confirmed that there were missing wound evaluations. The resident’s most recent wound clinic consult recommended use of a Roho chair cushion, but observation on November 21, 2025, showed the resident sitting in a wheelchair on a gel cushion instead. During interviews, the RN/Wound Nurse stated that when a resident is followed by an off-site wound clinic, unit nurses are responsible for completing the weekly wound assessment and measurements. The DON stated she would expect nursing staff to have assessed, measured, and documented the findings accordingly, and also expected the wound clinic to share its measurements and assessment findings.
Improper Medication Labeling and Expired Medications Found in Storage Areas
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles, and expired medications were found stored in medication carts and medication rooms. Surveyors observed unlabeled or improperly labeled items in three of six medication carts and two of four medication rooms, including opened bottles and vials without open dates, resident names, or legible expiration dates. The observations included an opened bottle of DermaRite Liquid Protein Supplement with no open date, a bottle of geritussin with no legible manufacturer expiration date, an opened vial of tuberculin testing solution with no open date, and an opened Lantus insulin pen with no resident name or open date. Additional unlabeled or improperly labeled items were found in the First Floor, C-Wing C Hall, Transitions East Hall, Third Floor [NAME] Hall, and Heritage Harbor medication storage areas. Surveyors also found expired medications in three of six medication carts and one of four medication rooms. These included an unopened box of lorazepam liquid with a manufacturer expiration date of September 2025, a bottle of Senna Plus with an opened date of June 25, 2025 and a manufacturer expiration date of October 2025, an opened bottle of Nephro Vitamins C and B Complex with an opened date of October 18, 2025 and a manufacturer expiration date of August 2025, and an opened bottle of DermaRite Liquid Protein Supplement with no open date indicated. The facility's policies required medications to be labeled with open dates and expiration information, and staff members who were present during the observations confirmed the findings.
Failure to Update Care Plans for Changed Resident Conditions
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised for two residents. Review of the facility policy on comprehensive care plans showed that each resident should have a comprehensive person-centered care plan developed and implemented based on the resident’s assessment. For one resident with diagnoses including vitamin D deficiency and osteoporosis, the care plan still included a focus for a surgical wound related to bilateral femur fractures even though the resident no longer had any healing surgical incisions. The DON confirmed that the care plan should have been revised when the surgical wounds healed. For another resident with diagnoses including CHF and obstructive uropathy, observation showed the resident lying in bed with the nephrostomy tube and bag lying next to him. Current physician orders included monitoring the left nephrostomy tube site for signs and symptoms of infection, but the care plan did not identify the nephrostomy tube or include related care. The DON stated that the resident should have had a care plan that included nephrostomy care.
Medication Left With Resident Without Self-Administration Order
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards for one resident. Resident 4 had diagnoses including dementia and an anxiety disorder. Facility policy on medication administration stated that after a nurse prepares medication for a resident, the nurse must observe the resident consuming the medication. Pennsylvania Nursing Practice Act Chapter 21.145 also states that an LPN may accept a written order for medication and therapeutic treatment from an authorized practitioner. On November 18, 2025, Resident 4 was observed lying in bed with a cup on the overbed table containing 7 tablets in a medication cup. At a later observation the medication was still there, and the resident refused an interview because she said she did not feel good. Review of the resident's physician orders did not reveal an order for self-administration of medications, and the care plan did not include self-administration of medications. An LPN stated that while administering the resident's morning medications, she was interrupted and called away to another task and left the medications with the resident. The DON confirmed that Resident 4 did not have an evaluation or physician's order for self-administration of medications.
Failure to Follow Ordered Treatments and Precautions
Penalty
Summary
The facility failed to provide care and services according to orders, resident preferences, and goals for two residents. One resident had diagnoses including lymphedema and hypothyroidism. A certified lymphedema specialist recommended compression wraps, and a compression vendor later fitted the resident with full-leg garments. However, the resident was observed with compression wraps lying on the floor beside the bed, and the resident stated she did not wear them and that they had been on the floor for multiple days. The clinical record did not contain physician orders or a care plan for the full-leg garments at that time, and the Nursing Home Administrator stated the facility was waiting for the vendor to provide an order after the fitting. A second resident had diagnoses including a cardiac pacemaker, dementia, and muscle weakness, with severe cognitive impairment documented on the admission MDS. After a pacemaker replacement procedure, the resident had physician orders for bilateral enabler bars and left arm restrictions, including not lifting, pushing, or pulling more than 2 pounds with the left arm and keeping the left elbow lower than shoulder height every shift for pacemaker care. The resident’s care plan and nurse aide Kardex did not include the left arm precautions, and nurse aide task documentation showed the resident was coded as independent to needing substantial assistance for bed mobility tasks during the period after the procedure. A nurse note documented that the resident stated she could feel pulling when turned in the wheelchair. During interviews, the NHA and DON stated the left arm restrictions had not been communicated for nurse aides to follow and that the enablers had been removed after surveyor concerns were raised. The DON also confirmed the facility had not reevaluated the resident for safe use of the enablers after the restrictions were ordered, had not considered using only one enabler on the right side, and acknowledged that the left arm restrictions were not care planned for staff to follow.
Unsafe Access to Scissors in Resident Room
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for one resident with diagnoses of hypertension and a cognitive communication deficit. Observation of the resident's room on November 19, 2025, at 9:35 AM revealed a pair of shearing scissors, approximately six to eight inches long, lying on the stand near the resident's television. The same scissors were still observed in the room during subsequent observations on November 20, 2025, at 10:37 AM and 12:37 PM. During an observation at 12:48 PM with the NHA and DON, the NHA acknowledged the scissors were present and confirmed they should not have been within access of residents.
Inconsistent Fluid Intake Documentation for Resident on Fluid Restriction
Penalty
Summary
The facility failed to ensure acceptable parameters of nutrition and hydration for one resident with chronic kidney disease and dependence on renal dialysis. The resident had a physician order for a daily fluid restriction of 720 ml, and the facility policy for hemodialysis required a licensed nurse to monitor and communicate nutritional and fluid management, including compliance with food and fluid restrictions and intake/output measurements as ordered. Review of the resident’s records showed that fluid intake was being tracked in two different parts of the electronic record, with the medication nurse documenting fluid on the TAR and nurse aides documenting fluid in the Task section. In November 2025, the TAR showed the resident exceeded the 720 ml limit on 4 days, while the Task documentation showed the resident exceeded the limit on 17 days. Comparison of the two records showed that the amount of fluid documented as consumed did not match on any day. The DON stated that she and the unit manager reviewed the documented fluid intake and were unable to determine the amount of fluid consumed by the resident.
Pharmacist Medication Review Irregularities Not Reviewed or Acted Upon
Penalty
Summary
The facility failed to ensure that the licensed pharmacist’s medication regimen review irregularities were reviewed and acted upon for two residents. Facility policy required the pharmacist to review each resident’s medication regimen at designated intervals, communicate irregularities in writing, and have those communications become part of the medical record. The policy also stated that facility staff were to act upon recommendations according to procedures for addressing medication regimen review irregularities. For one resident with diagnoses including major depressive disorder, anxiety disorder, and dementia, the record showed active PRN orders for both sennosides and senna-docusate sodium. The pharmacist’s August medication regimen review noted that the resident had PRN orders for senna and senna/docusate with a diagnosis of constipation and recommended discontinuing one order or adding more specific directions if both remained active. The DON later stated there was no signed copy available to show the physician reviewed the recommendation, and during follow-up she said the physician was going to review it later that day, with no evidence it had been responded to before then. For another resident with diagnoses including hypertension and unspecified severe protein-calorie malnutrition, the pharmacist’s July medication regimen review identified duplicate PRN Tylenol orders and conflicting orders for Imodium and Senna. The CRNP and a staff nurse initialed the pharmacist’s note, but no documentation or orders were provided with the CRNP’s initials. The Tylenol orders were later clarified, but the Imodium and Senna orders were not clarified until weeks later. The DON confirmed that no clear order had been given by the CRNP even though the document was initialed, that nursing staff should have followed up when no documentation or order was provided, and that the pharmacist should have identified on the later review that the conflicting diagnoses had not been addressed and should have reissued a report of the irregularity.
Delayed Refunds of Resident Funds
Penalty
Summary
The facility failed to convey resident fund account balances and overpayment balances upon discharge in accordance with State law for three residents. The facility's policy and admission agreement both state that refunds of personal funds and overpayments should be made within 30 days of a resident's discharge or death. However, the facility did not adhere to this policy for three residents whose records were reviewed. Resident 1, who expired, had an account balance of $180.24 that was not refunded to the authorized representative until after the 30-day period. Similarly, Resident 2, who was discharged, had a refund of $165.38 that was also delayed beyond the stipulated timeframe. Resident 3, who also expired, had prepaid for an entire month, resulting in an overpayment of $4,370.75. The facility issued a refund check, but it was dated and paid after the 30-day requirement. During an interview, the Nursing Home Administrator acknowledged awareness of the 30-day refund policy but indicated that the corporate office was responsible for final approval of refunds. This delay in processing refunds is a violation of the facility's policy and state regulations, as outlined in 28 Pa. Code 211.5(d) and 28 Pa Code: 201.18(e)(1).
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and home-like environment for several residents and in one of its nursing units, Heritage Harbor. Observations revealed a long, dried liquid stain in the hallway with a strong urine odor, and several dried reddish stains on the courtyard door curtains in the Heritage Harbor dayroom. Resident 156's room had food debris between the bed and nightstand, which had been present for a few days according to the resident. Resident 167's wheelchair was observed with a large amount of a brown, clumpy substance on the seat and lower bar, despite being cleaned recently. Resident 252's bathroom had a dried, brown substance on the front of the toilet bowl, which the resident indicated was an ongoing issue. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility's policy was not followed, as the expectation was for these areas to be cleaned in a timely manner. The NHA acknowledged that routine cleaning and disinfection should have addressed these issues, and that visibly soiled wheelchairs should be cleaned as needed between scheduled deep cleanings. The facility's failure to adhere to its cleaning policy resulted in an environment that did not meet the standards of safety, cleanliness, and comfort expected in a long-term care setting.
Failure to Conduct Background Checks on New Hires
Penalty
Summary
The facility failed to ensure the protection of residents from potential abuse by not conducting required criminal history background checks prior to hiring three employees. The facility's policy, titled 'Abuse, Neglect and Exploitation,' mandates screening potential employees for any history of abuse, neglect, exploitation, or misappropriation of resident property. This includes conducting background, reference, and credentials checks on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. However, the personnel files for a Registered Nurse, a Nurse Aide, and an LPN showed no evidence of completed Pennsylvania State Police or FBI background checks before their respective hire dates. The Nursing Home Administrator acknowledged these concerns during an interview.
Failure to Maintain CPAP Care Protocols
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for a resident with a history of congestive heart failure and obstructive sleep apnea. The resident had a CPAP machine at her bedside, which she reported had not been cleaned since she moved from another unit. The facility's policy required an order for the use and settings of CPAP or similar devices, but there was a gap in the resident's physician orders for CPAP/BIPAP care or use from November 2023 to October 2024. The resident's clinical record indicated a physician's note from August 2024 to continue using a CPAP machine, and her care plan had included CPAP use since July 2022. However, the orders for cleaning the CPAP/BIPAP equipment were only documented starting in October 2024. The Director of Nursing confirmed the absence of orders for CPAP/BIPAP care or use during the specified period, indicating a lapse in maintaining proper respiratory care protocols.
Deficiencies in Resident Care and Documentation
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents, leading to deficiencies in their treatment. Resident 25, diagnosed with type 2 diabetes mellitus and edema, had a physician's order for Ace wraps to be applied daily for edema. However, observations over several days revealed that the Ace wraps were not applied, despite documentation indicating otherwise. The Director of Nursing (DON) confirmed the expectation that the Ace wraps should have been applied as ordered, but no further information was available regarding their absence. Resident 136, with diagnoses including dementia, heart failure, and protein-calorie malnutrition, was observed with undated dressings on their left elbow, which had areas of discoloration. There was no current physician order for treatment of the elbow, and previous orders had been discontinued. The clinical record lacked documentation of a current skin issue or weekly skin assessments since August 22, 2024, despite orders for weekly assessments. The DON acknowledged the lack of documentation and confirmed that the weekly skin assessments were not completed as required. The DON and Assistant DON were informed of the deficiencies, and the DON confirmed that the hospice nurse had applied a bandage without communicating with the facility. The DON and Nursing Home Administrator acknowledged that Resident 136 should have received weekly skin assessments and that the documentation was insufficient. The facility's failure to adhere to care policies and maintain accurate records resulted in these deficiencies.
Failure to Provide Scheduled Vision Services
Penalty
Summary
The facility failed to ensure that Resident 240 received proper treatment and assistive devices to maintain vision abilities. Resident 240, who has chronic kidney disease and hypertension, was scheduled to have an eye examination by an optometrist at the beginning of October 2024. However, this appointment did not occur, and the resident was not informed of any rescheduling. A nursing progress note from October 4, 2024, indicated that the resident was supposed to see the optometrist on October 1, 2024, but was not seen due to a time constraint. Further observations revealed that Resident 240 was listed to be seen by the optometrist on October 29, 2024, but this appointment also did not take place. Interviews with the Nursing Home Administrator confirmed that the resident missed both scheduled appointments due to a time constraint on October 1 and a miscommunication between the doctor and staff on October 29. The administrator acknowledged that the resident should have been seen as scheduled.
Failure to Provide Prescribed Water Flushes for Tube Feeding
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings, as identified during a survey. The facility's policy on the appropriate use of feeding tubes requires an interdisciplinary team, with physician support, to review and make decisions regarding feeding tube use. However, observations revealed that the resident, who had diagnoses of aphagia and dysphagia, was not receiving the prescribed water flushes as ordered by the physician. The resident's clinical record indicated a physician's order for enteral feeding and water flushes, but the observed water flush rate was lower than the prescribed amount. The deficiency was noted during observations on two consecutive days, where the resident was found lying in bed with tube feeding and water flush infusing at rates lower than the physician's orders. The Director of Nursing confirmed that the expectation was for the resident to receive water flushes as per the physician's orders. This discrepancy between the physician's orders and the actual care provided to the resident highlights the facility's failure to adhere to its policy and ensure proper care for residents with feeding tubes.
Failure to Obtain Informed Consent for Enabler Bar Use
Penalty
Summary
The facility failed to complete a risk-benefit analysis and obtain informed consent for the use of enabler bars for a resident. The facility's policy requires a comprehensive assessment of the resident's needs and risks associated with bed rail use, as well as informed consent from the resident or their representative. However, for the resident in question, there was no documentation of informed consent or education regarding the risks and benefits of using bilateral enablers. Additionally, the resident's care plan did not reflect the use of these enablers, and there was no physician's order for their use. The resident had diagnoses of morbid obesity and chronic diastolic congestive heart failure. Despite an order for occupational therapy to evaluate the resident's request for bilateral enablers, the facility could not provide evidence of such an evaluation. Observations confirmed the presence of bilateral enablers on the resident's bed, but the necessary assessments and consents were not documented. The Director of Nursing acknowledged the lack of documentation and confirmed that the expected evaluations and consents were not completed according to facility policy.
Failure to Conduct Timely Drug Regimen Reviews and Address Irregularities
Penalty
Summary
The facility failed to ensure that the drug regimen of each resident was reviewed at least monthly by a licensed pharmacist, and that any irregularities were reported and acted upon in a timely manner. Specifically, for Resident 100, who had diagnoses including dementia with behavioral disturbance and major depressive disorder, the pharmacist recommended documenting an applicable diagnosis for the antipsychotic agent Seroquel on two occasions. However, the attending physician did not respond to these recommendations until over four months later. Similarly, for Resident 147, who had diagnoses of dementia with psychotic disturbance and depression, the facility did not complete a monthly pharmacy medication regimen review in April 2024. Additionally, a recommendation made in June 2024 regarding the documentation of an applicable diagnosis for Seroquel was not addressed by the physician until October 2024. The Director of Nursing acknowledged the delays in response to the pharmacy recommendations for both residents.
Failure to Monitor and Document Wound Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for a resident with a wound on the left lower extremity. The resident, who had a history of atherosclerosis and type two diabetes mellitus, was found to have a deteriorating wound on June 2, 2024. A registered nurse contacted Gentiva Hospice about the wound's condition and was advised to refer the case to the wound team. However, the clinical record lacked documentation of a wound assessment or the presence of maggots in the wound. On June 3, 2024, a wound consultant nurse practitioner discovered maggots in the resident's wound and prescribed a specific cleansing regimen. Despite this, there was no evidence that the facility's nursing staff continued to monitor or assess the wound after the maggots were identified. Interviews with staff revealed that the wound was initially assessed by a registered nurse supervisor who noted the presence of moving entities in the wound, and later confirmed by a nurse practitioner. The Director of Nursing acknowledged the presence of maggots and stated that the physician was notified, and orders were given to cleanse the wound regularly.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program for one of the four months reviewed, specifically in May 2024. This deficiency was identified through a review of records and staff interviews. A significant incident involved Resident 5, who had a clinical history of atherosclerosis and type two diabetes mellitus. On June 3, 2024, a wound care note indicated the presence of maggots in Resident 5's left anterior shin wound. This was confirmed by a nurse practitioner during wound rounds, following an initial assessment by a registered nurse supervisor who noticed the wound appeared different and observed movement within it. The facility's pest control records revealed that the last pest control visit before the incident was on April 23, 2024, when fruit flies were noted and treated in the kitchen. However, there was no pest control visit documented for May 2024, as the facility typically had monthly visits but skipped May due to having two visits in March 2024. This lapse in pest control measures contributed to the deficiency noted in the report.
Failure to Timely Report Sexual Abuse Incidents
Penalty
Summary
The facility failed to report incidents of sexual abuse to the State Agency within the specified timeframes as required by their policy. The policy mandates that any allegations involving abuse or resulting in serious bodily injury must be reported immediately, but not later than 2 hours after the allegation is made. In cases where the events do not involve abuse or serious bodily injury, the report must be made within 24 hours. However, the facility did not adhere to these timeframes for two separate incidents involving residents. The first incident involved Resident 1, who has severe cognitive impairment, being sexually inappropriate with Resident 10, who has moderate cognitive impairment. Resident 1 was observed pulling up Resident 10's shirt and engaging in non-consensual contact in the dining room. Despite the immediate intervention by staff, the facility failed to notify the State Agency of this incident in a timely manner. The second incident involved Residents 1 and 2, both with moderate cognitive impairments, being found in a compromising situation in Resident 1's room. Staff members witnessed what appeared to be sexual relations between the two residents, with Resident 2 holding onto Resident 1's hips. Again, the facility did not report this incident to the State Agency as required by their policy, leading to a deficiency in compliance with state regulations.
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 205 citations issued within 25 miles in the last 12 months — including the 4 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) |
|---|---|---|---|---|
| Letort Spring Nursing And Rehab Llc | 1 mi | ★★★★★ | 23 | 0 |
| Chapel Pointe At Carlisle | 2.1 mi | ★★★★★ | 0 | 0 |
| Thornwald Home | 2.5 mi | ★★★★★ | 7 | 0 |
| Sarah A Todd Memorial Home | 2.5 mi | ★★★★★ | 2 | 0 |
| Forest Park Nursing And Rehabilitation | 2.6 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.