Deficiency Records for Carlisle Center For Wellness and Rehab
Updated as of March 01, 2024
A list of the most recent deficiencies for Carlisle Center For Wellness and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-10 | 2023-08-31 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-06-15 | 2023-07-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-15 | 2023-07-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-06-15 | 2023-07-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-15 | 2023-07-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-15 | 2023-07-07 | N |
| Provide or obtain dental services for each resident. | Health | 2023-06-15 | 2023-07-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-15 | 2023-07-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-15 | 2023-07-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-06-15 | 2023-07-07 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-06-22 | 2023-06-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-22 | 2023-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-15 | 2023-06-29 | Y |
| Install proper backup exit lighting. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-22 | 2023-06-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-22 | 2023-06-27 | N |
| Use approved construction type or materials. | Fire Safety | 2023-06-22 | 2023-06-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-22 | 2023-06-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-22 | 2023-06-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-29 | 2023-04-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-29 | 2023-04-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2023-03-15 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-12-15 | 2023-03-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-15 | 2023-03-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-15 | 2023-01-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-15 | 2023-01-19 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-12-15 | 2023-01-19 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-13 | 2022-06-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-04-13 | 2022-06-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-13 | 2022-06-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-13 | 2022-05-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-04-13 | 2022-05-09 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-04-13 | 2022-05-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-11 | 2022-05-05 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-04-11 | 2022-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-11 | 2022-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-11 | 2022-05-05 | Y |
| Report COVID19 data to residents and families. | Health | 2022-04-11 | 2022-05-05 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-04-13 | 2022-04-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-13 | 2022-04-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-04-13 | 2022-04-22 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-13 | 2022-04-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-13 | 2022-04-21 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-04-13 | 2022-04-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-13 | 2022-04-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-13 | 2022-04-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-20 | 2022-01-16 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-20 | 2022-01-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-20 | 2022-01-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-08 | 2021-04-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-11-24 | 2021-01-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-11-09 | 2020-12-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-11-09 | 2020-12-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-11-09 | 2020-12-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-11-09 | 2020-12-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-11-24 | 2020-11-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-11-24 | 2020-11-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-11-09 | 2020-11-25 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-11-09 | 2020-11-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-11-09 | 2020-11-20 | N |
| Use approved construction type or materials. | Fire Safety | 2020-11-09 | 2020-11-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-11-09 | 2020-11-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-11-09 | 2020-11-09 | N |
