Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 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 Another resident's care plan included outdated oxygen therapy, which had been discontinued, yet the care plan was not revised to reflect this change.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.
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 248 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) |
|---|---|---|---|---|
| Carlisle Skilled Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Forest Park Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 9 | 0 |
| Thornwald Home | 1 mi | ★★★★★ | 7 | 0 |
| Chapel Pointe At Carlisle | 1 mi | ★★★★★ | 0 | 0 |
| Sarah A Todd Memorial Home | 1.6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Cumberland Crossings Retirement Community.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.