Cumberland Crossings Retirement Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Carlisle, Pennsylvania.
- Location
- 1 Longsdorf Way, Carlisle, Pennsylvania 17013
- CMS Provider Number
- 395876
- Inspections on file
- 16
- Latest survey
- April 16, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Cumberland Crossings Retirement Community during CMS and state inspections, most recent first.
A review of staff records revealed that three nurse aides did not complete the required 12 hours of annual in-service training, with missing documentation for dementia management and abuse prevention education. The NHA and DON confirmed that these trainings were expected to be completed annually.
Surveyors found that care plans for three residents were not updated to reflect their current conditions and interventions. One resident using fall mats and a specialty mattress for fall prevention did not have these measures documented in the care plan. Another resident with a history of syncope and recent episodes had no mention of these events or diagnoses in the care plan. A third resident prescribed Seroquel for psychosis related to depression did not have antipsychotic medication use addressed in the care plan.
Two residents with heart failure experienced significant overnight weight gains as documented in their records, but the facility did not notify the practitioner as required by physician orders and discharge instructions. The DON confirmed there was no evidence of practitioner notification for these events.
Two residents with chronic wounds, including a stage 4 pressure ulcer and a diabetic foot ulcer, did not have Enhanced Barrier Precautions (EBPs) implemented as required. An LPN was observed performing a dressing change without a gown, and neither resident had EBPs included in their care plans or physician orders. The DON confirmed the facility did not recognize the need for EBPs in these cases.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documentation. A resident's MDS inaccurately reflected bowel and bladder continence, another's failed to document antibacterial medication use, and a third's incorrectly recorded insulin injections instead of Victoza. These errors were confirmed by staff interviews.
The facility failed to update the comprehensive care plans for two residents. One resident with venous wounds did not have a care plan addressing these wounds, despite recommendations for treatment. Another resident's care plan included outdated oxygen therapy, which had been discontinued, yet the care plan was not revised to reflect this change.
A facility failed to provide appropriate urinary catheter care for a resident with hypertension and stage 4 CKD. Observations revealed the resident's catheter bag was on the floor, contrary to facility policy. The DON confirmed this was inappropriate.
A resident experienced a significant weight loss while being COVID-positive, with symptoms like nausea and lack of appetite. The facility's policy required immediate notification to the dietitian for such weight changes, but the nursing staff failed to do so, delaying the dietitian's assessment and intervention.
Failure to Provide Required Annual Nurse Aide Training
Penalty
Summary
The facility failed to provide required in-service training to nurse aides, as evidenced by a review of personnel and training records for three of five nurse aide employees. Specifically, Employees 1, 2, and 3 did not complete the mandated 12 hours of annual training within the past 12 months. Additionally, there was no documentation that Employee 1 received dementia management training, and Employees 1 and 2 did not complete abuse prevention training during the same period. These findings were confirmed through record review and interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged the expectation for annual completion of these trainings.
Failure to Update and Revise Resident Care Plans
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of three residents. For one resident with protein-calorie malnutrition and bipolar disorder, observations showed the use of a specialty mattress and fall mats, but these interventions were not documented in the care plan addressing fall risk. Another resident, admitted with syncope, collapse, muscle weakness, and unsteadiness, experienced multiple syncopal and unresponsive episodes, yet her care plan did not mention her diagnosis of syncope or the actual episodes she experienced. Additionally, a third resident with depression and anxiety disorder had a physician order for Seroquel to address psychosis and visual hallucinations, but the care plan did not include a focus area related to antipsychotic medication use. These deficiencies were identified through clinical record reviews, observations, and staff interviews, indicating that the care plans were not consistently updated to reflect significant changes in residents' conditions or treatments.
Failure to Notify Practitioner of Significant Weight Gain in Residents with Heart Failure
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice for two residents diagnosed with congestive heart failure. Both residents had physician orders and hospital discharge instructions requiring daily weights and prompt notification to the practitioner if there was a weight gain of 2-3 pounds overnight or 5 pounds in one week. For one resident, the clinical record showed a weight gain of 3.2 pounds overnight, and for the other, a weight gain of 3.1 pounds overnight. In both cases, there was no evidence in the clinical records that the practitioner was notified of these significant weight changes as required by the orders. Interviews with the Director of Nursing confirmed that there was no documentation or evidence of practitioner notification regarding the residents' overnight weight gains. The failure to notify the practitioner as ordered resulted in the facility not following the prescribed care plan for residents with heart failure, as required by professional standards and facility policy.
Failure to Implement Enhanced Barrier Precautions for Residents with Chronic Wounds
Penalty
Summary
The facility failed to implement infection control policies, specifically Enhanced Barrier Precautions (EBPs), for two residents with chronic wounds. According to facility policy and federal guidance, EBPs, including the use of gowns and gloves during high-contact care activities, are required for residents with chronic wounds such as pressure ulcers and diabetic foot ulcers. For one resident with a stage 4 pressure ulcer and diabetes, there was a physician order for daily dressing changes, but no order or care plan for EBPs. During observation, an LPN performed a dressing change on this resident without wearing a gown, contrary to policy requirements. Another resident with a diabetic foot ulcer and additional wounds also had physician orders for dressing changes and a care plan for wound management, but there was no care plan or order for EBPs. The Director of Nursing confirmed that the facility did not interpret these wounds as chronic and therefore did not implement the required enhanced barrier precautions for either resident.
Inaccurate Resident Assessments in MDS Documentation
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. For Resident 30, the MDS inaccurately reflected bowel and bladder continence, despite the resident having an indwelling urinary catheter. This error was confirmed by the Nursing Home Administrator during an interview. Resident 40's MDS failed to document the use of an antibacterial medication, methenamine Hippurate, prescribed for a history of urinary tract infections, which was also acknowledged as an error by the Nursing Home Administrator. Resident 44's MDS inaccurately recorded the use of insulin injections, although the resident was actually receiving Victoza, a hypoglycemic injection that is not insulin. This mistake was confirmed by the Registered Nurse Assessment Coordinator and the Nursing Home Administrator, who expected accurate MDS coding. These inaccuracies in the MDS assessments indicate a failure in the facility's processes to ensure that resident assessments accurately reflect their medical status and treatment regimens.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for two residents was reviewed and revised according to their needs. Resident 40, who has diagnoses including type 2 diabetes mellitus and peripheral vascular disease, developed two venous wounds on the lower right leg. Despite a consultant wound evaluation recommending treatment, the comprehensive care plan for Resident 40 did not include any focus, goals, or interventions for these wounds. This omission was confirmed during a staff interview with the Director of Nursing. Resident 45, diagnosed with bronchopneumonia, cerebral infarction, and muscle weakness, had an outdated care plan that included an intervention for five liters of oxygen therapy, which was discontinued earlier. Observations revealed no oxygen use or equipment in Resident 45's room, yet the care plan had not been updated to reflect the discontinuation of oxygen therapy. This discrepancy was acknowledged by the Director of Nursing during an interview.
Inappropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for a resident with an indwelling urinary catheter. The facility's policy, revised in September 2017, mandates appropriate care and monitoring for residents with such catheters. However, observations on May 14, 2024, revealed that the resident was in bed asleep with the catheter bag laying on the floor beside the bed, which is against the facility's policy. The resident has a medical history that includes hypertension and stage 4 chronic kidney disease. During an interview on May 16, 2024, the Director of Nursing acknowledged that the catheter bag should not have been on the floor.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure proper monitoring and maintenance of nutritional status for a resident, identified as Resident 44, who experienced a significant weight loss. According to the facility's policy, any weight change of 5% or more should be retaken the next day for confirmation, and if verified, the dietitian must be notified immediately in writing. However, despite a confirmed weight loss of 5.3% over a two-day period, the nursing staff did not notify the dietitian as required. This lack of communication resulted in the dietitian not assessing the resident until several weeks later, on April 15, 2024, after discovering the weight loss independently. Resident 44, who was COVID-positive at the time of the weight loss, reported symptoms such as nausea, lack of appetite, and abdominal pain, which contributed to her weight loss. Despite these symptoms being documented in nursing progress notes, there was no timely intervention from the dietitian due to the failure in communication. The Director of Nursing acknowledged that the dietitian could run reports to evaluate significant weight loss and emphasized that it should be a team effort rather than solely relying on nursing staff for notification.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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