Accura Healthcare of Carlisle

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a safe and clean environment throughout the facility's 3 of 3 carpeted hallways (100, 200, and 300 halls), and 1 of 1 residents reported issues of the dirty tiled floor in their rooms and broken sink (Resident #35). The facility reported a census of 78 residents.

Inspectors wroteBased on observation, clinical document review, resident interview, staff interview, and policy review the facility failed to provide food at an appetizing temperature to 1 of 8 residents (Residents #41) reviewed. The facility reported a census of 78 residents.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to prepare food under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 78 residents.

Inspectors wroteBased on observation and staff interviews the facility failed to complete and/or maintain documentation of routine bed rail inspections for 10 of 10 residents with side rails. The facility reported a census of 78 residents.

Inspectors wroteBased on employee personnel record review, staff interview and policy review, the facility failed to ensure a thorough background check had been completed before hire prior to working with dependent adults for 1 of 3 staff personnel files reviewed. The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to report an allegation of abuse in a timely manner for 1 of 2 residents reviewed for abuse allegations(Resident #34). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, policy review, and staff and resident interviews, the facility failed to investigate an allegation of abuse in a timely manner for 1 of 2 residents reviewed for abuse allegations(Resident #34). The facility reported a census of 78 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, document review, policy review, and staff interview the facility failed to complete a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications for 1 of 3 residents reviewed (Resident #82). The facility reported a census of 78 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to complete 1 of 4 residents discharge Minimum Data Set (MDS) assessments when they discharged home from the facility (Resident #50). The facility reported a census of 78 residents. 1. Review of Resident #50 Electronic Health Record (EHR) Census revealed she was admitted on [DATE] and discharged on 12/20/25. Review of Resident #50 Communication With family Note dated 12/17/25 at 11:30 AM documented she will discharge home on [DATE]. Review of Resident #50 Discharge Summary Note dated 12/20/25 at 10:41 AM documented she discharged from the facility on 12/20/25 at 8:30 AM. Review of Resident #50 EHR MDS log on 5/19/26 revealed the facility has completed an Entry MDS on 12/5/25 and admission MDS on 12/11/25, but has not completed a discharge MDS when she discharged on 12/20/25. [...]

Inspectors wroteBased on a record review and staff interviews, the facility failed to ensure all mental health diagnoses were on 1 of 3 residents' Preadmission Screening and Resident Review (PASRR) documents for (Resident #8). The facility reported a census of 78 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for 1 of 5 residents (Resident #2) reviewed for a resident with diuretic medication usage. The facility reported a census of 78.

Inspectors wroteBased on record review, resident and staff interviews, and policy review the facility failed to to provide the necessary care and services to ensure a resident received appropriate clinical monitoring, timely medical provider notification, and consistent administration of prescribed treatments for a Urinary Tract Infection (UTI) for 1 of 1 residents reviewed for UTI (Resident #31). Specifically, facility staff failed to conduct nursing assessments across two separate antibiotic regimens, delayed follow-up with an unresponsive medical provider regarding a recurrence of symptoms, omitted a scheduled antibiotic dose without clinical justification, and failed to update the resident's care plan to reflect a suspected multidrug-resistant infection and use of antibitoics. The facility reported a census of 78 residents.

Inspectors wroteBased on record review, resident and staff interviews, and policy review the facility failed to ensure that an effective pain management regimen was consistently implemented in accordance with professional standards of practice and the comprehensive plan of care for 1 of 1 resident reviewed for pain management (Resident #64). Specifically, the facility failed to administer prescribed pain medication as ordered, resulting in a failure to meet the resident's goals for care and preferences. The facility reported a census of 78 residents.

Inspectors wroteBased on staff interview, observation, document review and facility policy review the facility failed to maintain an effective pest control program so that the facility was free from any infestation of any kind of vermin in the facility. The facility reported a census of 72 residents.

Inspectors wroteBased on document review, electronic health record review (EHR), staff interviews, and policy review the facility failed to report a resident's allegation of sexual abuse (Resident #4) to the State Agency within the required timeframe for 1 of 3 residents reviewed for abuse and dignity. The facility reported a census of 72.

Inspectors wroteBased on facility document review, staff interviews, and policy review the facility failed protect residents from further potential abuse once an allegation of sexual abuse was reported to staff, for 1 of 2 abuse allegations reviewed. An employee meeting the general description of the alleged perpetrator worked and had access to residents after the allegation was were made. The facility reported a census of 72.

Inspectors wroteBased on clinical record review, resident and staff interviews, and policy review, the facility failed to perform proper transfer method as outlined in the Care Plan which contributed to a femur fracture which resulted in the need for surgical intervention for 1 of 4 residents reviewed for transfers (Resident #45). The facility reported a census of 70.

Inspectors wroteBased on clinical record review, staff interview and the Resident Assessment Instrument (RAI) Manual the facility failed to accurately complete a Minimum Data Set (MDS) assessment for four of twenty-three residents reviewed (Residents #1, #3, #6 and #32). The facility reported a census of 70 residents.

Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included focus, goals, or interventions for 2 out 5 residents reviewed (Resident #5, #23). The facility reported a census of 70 residents.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure staff appropriately completed a resident assessment and provide timely intervention for two residents. One resident with Lower Extremity (LE) wraps for 1 of 1 resident reviewed for edema (Resident #55) and one resident with Chronic Obstructive Pulmonary Disease (COPD) for 1 of 2 residents reviewed for oxygen (Resident #62). The facility reported a census of 70.

Inspectors wroteBased on clinical record review, observation, staff interview, and policy review, the facility failed to ensure staff secured and placed a resident's catheter bag below the level of the bladder to minimize the risk of cross-contamination and the risk of acquiring a urinary tract infection for one of two residents observed with a catheter (Residents #1). The facility reported a census of 70 residents.

Inspectors wroteBased on clinical record review, observation, staff interview, manufacturer's instructions, and competency review the facility failed to administer insulin according to the physician's orders and per manufacturer instructions to ensure the proper amount of insulin administered for one of two residents observed who received insulin during medication pass (Resident #1). The facility reported a census of 70 residents.

Inspectors wroteBased on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1st to March 31st) review, facility staffing reports review, and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 70 residents.

Inspectors wroteBased on record review, observation, staff interview, and policy review the facility failed to ensure staff properly disinfected resident care devices such as a glucometer machine and a stethoscope after resident use for 1 of 2 residents observed for a blood sugar check (Resident #40) and 1 of 2 residents observed for a gastrostomy (g-tube) tube (Resident #7). The facility staff also failed to follow infection control practices in order to prevent and control the onset and spread of infection within the facility by not removing soiled gloves for 1 of 2 units. The facility reported a census of 70 residents.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to provide the necessary services to maintain personal cares of oral hygiene for 1 of 3 residents reviewed (#11). The facility reported a census of 75 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and policy review, the facility failed to provide treatment and services to prevent the development of a pressure ulcer for 2 of 3 residents reviewed (#4 & #11). The facility reported a census of 75 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and policy review, the facility failed to use ordered Durable Medical Equipment (DME) to prevent a further decrease in Range-of-Motion (ROM) for 2 of 3 residents reviewed. (provide treatment and services to prevent the development of a pressure ulcer for 2 of 3 residents reviewed (#4 & #11). The facility reported a census of 75 residents.

Inspectors wroteBased on observations, clinical record review, staff interview, and policy review, the facility failed to don appropriate Personal Protective Equipment (PPE) when providing direct resident care for 2 of 2 residents who were on Enhanced Barrier Precautions (EBP) (#11 & #15). The facility reported a census of 75 residents.

Inspectors wroteBased on observations, clinical record review, policy review, and staff interviews, the facility failed to prevent the development and worsening of a facility acquired pressure ulcer for 3 of 3 residents reviewed with pressure ulcers(Residents #1, #3, and #4). The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to ensure staff treated residents with dignity and respect for 3 of 7 residents reviewed for resident rights (Resident #2, #7 and Resident #8). The facility reported a census of 75 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, the facility failed to carry out a medication intervention for 1 of 3 residents reviewed for a change in condition (Resident #1). The facility reported a census of 75 residents.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to properly secure medications from unauthorized access for one of one medication cart observed. The facility reported a census of 73 residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to properly protect resident information from unauthorized access for one of one laptop reviewed. The facility reported a census of 73 residents.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to implement infection control policies to prevent cross-contamination. The facility reported a census of 73 residents.

Inspectors wroteBased on resident observations, record review, staff interview, and policy review, the facility failed to treat residents with dignity by failing to provide an alternate method of obtaining toileting assistance which resulted in the resident walking to the unit hallway intersection and yelling for help to be changed. Dignity was reviewed for eleven residents, concerns were found for Resident#8. The facility reported a census of 73.

Inspectors wroteBased on document review, and staff interview the facility failed to ensure a Registered Nurse (RN) was in the facility for eight (8) consecutive hours for 9 of 32 days reviewed (July 28th through August 28th 2024). The facility reported a census of 71 residents.

Inspectors wroteBased on Electronic Health Records (EHR), resident interview, resident council documentation, and observations the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 4 of 18 residents reviewed (Resident #2, #35, #38, and #41). The facility reported a census of 71 residents.

Inspectors wroteBased on observation, Staff interview, and infection control policy the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during cares for 2 of 3 residents reviewed for infection control (Residents # 2, and #7). The facility further failed to properly wear proper personal protective equipment (PPE) while caring for 2 of 2 Residents reviewed with a positive Covid diagnosis. (Resident #49 and #60) The facility reported a census of 71 residents.

Inspectors wroteBased on document review, observations, resident interview, and staff interview the facility failed to provide dignity by leaving a catheter bag uncovered for 1 of 8 residents reviewed (Resident #2). The facility reported a census of 71 residents.

Inspectors wroteBased on Medication Administration Record (MAR)- Treatment Administration Record (TAR), resident interview and staff interviews the facility failed to represent an accurate assessment of the resident's status during the observation period of the MDS by not accurately assessing need for restrains and utilization of catheter for 2 of 18 residents reviewed (Resident #2 and #38). The facility reported a census of 71 residents.

Inspectors wroteBased on electronic record review (EHR), staff interviews, and policy review the facility failed to implement a comprehensive care plan when staff left a resident that had a care plan of supervision with meals unsupervised during meals for 1 of 5 residents reviewed (Resident #60). The facility reported a census of 71 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by not verifying gastrostomy tube (feeding tube) is functioning properly before beginning a feeding for 1 of 1 residents (Resident #7) reviewed. The facility reported a census of 71 residents.

Inspectors wroteBased on observation, record review, staff interview, resident interview, review of Steamtable Temperature logs, review of Resident Council Meeting Minutes and facility policy review the facility failed to maintain hot food served at a temperature greater than 140 degrees during a meal service.

Inspectors wroteBased on observation, clinical record review, staff interview, resident interview, a volunteer ombudsman interview, review of the facilities Employer Handbook and review of the facilities Residents' [NAME] of Rights the facility failed to treat 1 of 3 residents with dignity and respect while preserving her rights. (Resident #1) The facility identified a census of 65 residents

Inspectors wroteBased on observation, clinical record review, resident interview, staff interview and review of Resident Council Meeting Minutes the facility failed to follow physician orders for 1 of 3 residents reviewed with an acute and chronic illness. (Resident #4) The facility identified a census of 65 residents.