Deficiency Records for Carlisle Skilled Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Carlisle Skilled Nursing and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-31 | 2023-10-30 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-31 | 2023-10-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-31 | 2023-10-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-31 | 2023-10-30 | 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 | 2023-08-31 | 2023-10-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-31 | 2023-10-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-31 | 2023-10-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-31 | 2023-10-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-31 | 2023-10-30 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-08-31 | 2023-10-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-31 | 2023-10-30 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-08-31 | 2023-10-30 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-08-31 | 2023-10-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-08-31 | 2023-10-30 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-08-31 | 2023-10-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-31 | 2023-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-31 | 2023-10-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-31 | 2023-10-30 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-08-31 | 2023-10-30 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-17 | 2023-10-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-17 | 2023-10-30 | N |
| Meet other general requirements. | Fire Safety | 2023-08-17 | 2023-09-28 | N |
| Use approved construction type or materials. | Fire Safety | 2023-08-17 | 2023-09-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-17 | 2023-09-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-08-17 | 2023-09-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-17 | 2023-09-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-08-17 | 2023-09-28 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-08-17 | 2023-09-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-15 | 2022-10-22 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-15 | 2022-10-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-15 | 2022-10-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-15 | 2022-10-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-15 | 2022-10-22 | 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 | 2022-09-15 | 2022-10-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-15 | 2022-10-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-15 | 2022-10-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-15 | 2022-10-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-15 | 2022-10-22 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-09-15 | 2022-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-15 | 2022-10-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-15 | 2022-10-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-15 | 2022-10-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-15 | 2022-10-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-15 | 2022-10-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-20 | 2022-10-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-20 | 2022-10-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-03 | 2022-06-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-06-03 | 2022-06-24 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-13 | 2022-06-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-13 | 2022-06-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-13 | 2022-06-24 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-13 | 2022-06-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-05 | 2022-06-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-19 | 2022-02-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-15 | 2022-01-19 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-08-19 | 2021-09-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-19 | 2021-09-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-19 | 2021-09-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-19 | 2021-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-19 | 2021-09-29 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-08-19 | 2021-09-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-19 | 2021-09-29 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-08-19 | 2021-09-29 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-08-19 | 2021-09-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-08-19 | 2021-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-19 | 2021-09-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-04 | 2021-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-04 | 2021-08-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-04 | 2021-08-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-04 | 2021-08-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-19 | 2021-06-22 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-19 | 2021-06-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-19 | 2021-06-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-05 | 2021-03-25 | Y |
