Inspection Reports for Accura HealthCare of Carlisle

A revisit for the survey ending July 31, 2025, and complaint investigation for complaints #2579334-C and #2600834-C was conducted from September 8, 2025 to September 10, 2025.

The facility was found to be in substantial compliance.

Complaint investigation for complaints #2579334-C and #2600834-C was conducted; the facility was found to be in substantial compliance.

The inspection was conducted as an annual recertification survey and investigation of multiple complaints and facility reported incidents from July 28, 2025 to July 31, 2025.

The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, incomplete comprehensive care plans, failure to ensure quality of care related to resident assessments and treatments, inadequate infection prevention and control, medication administration errors, and improper handling of resident transfers and catheter care. The facility failed to meet several federal requirements as evidenced by clinical record reviews, staff interviews, and policy reviews.

The inspection included investigation of complaints #1673874-C and #1674423-C which resulted in deficiencies. Facility reported incidents #1674171-I and 2568030-I also resulted in deficiencies.

The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.

The facility was found to be in substantial compliance, and certification in compliance is effective as of April 19, 2025.

This inspection was a revisit of the survey ending March 3, 2025, and an investigation of substantiated complaints #127128-C, #127363-C, and facility reported incident #127380-I conducted from March 31, 2025 to April 3, 2025.

The facility was found to have deficiencies related to ADL care for dependent residents, prevention and treatment of pressure ulcers, range of motion and mobility services, and infection prevention and control. The facility submitted plans of correction and committed to staff education and ongoing quality assurance to ensure compliance.

Complaints #127363-C and facility reported incident #127380-I were substantiated.

The inspection was conducted as a result of investigations into Complaints #126799-C and #126873-C and Facility Reported Incident #126931-I, conducted from February 25, 2025 to March 3, 2025.

The facility was found to have substantiated complaints related to resident rights, quality of care, and treatment to prevent pressure ulcers. Deficiencies included failure to ensure staff treated residents with dignity and respect, failure to carry out medication interventions, and failure to prevent and treat pressure ulcers in residents.

Complaints #126799-C and #126873-C were substantiated. Facility Reported Incident #126931-I was also substantiated.

The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility in compliance.

The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective February 13, 2025.

The inspection resulted from investigation of Complaints #123586-C, #124707-C, and #124709-C conducted January 13, 2025 to January 15, 2025.

The facility was found deficient in multiple areas including failure to treat residents with dignity, improper medication cart security, failure to protect resident records, inadequate infection prevention and control practices, and failure to maintain proper cleaning supplies for shared equipment. The facility implemented corrective actions including staff education, audits, and quality assurance reporting.

Complaints #123586-C, #124707-C, and #124709-C were substantiated.

The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance for the facility.

The facility was found to be in substantial compliance based on the accepted Plan of Correction and will be certified in compliance effective September 20, 2024.

The inspection was conducted as part of the facility's Annual Recertification survey and investigation of multiple substantiated complaints.

The facility was found deficient in multiple areas including failure to provide dignity by leaving a catheter bag uncovered, inaccurate resident assessments, failure to implement comprehensive care plans, improper tube feeding management, insufficient nursing staff and RN coverage, delayed call light responses, and inadequate infection prevention and control practices including improper use of PPE.

Complaints #121792-C, #122641-C, #122407-C, and #122260-C were investigated and all were substantiated.

The document serves as a Plan of Correction following a credible allegation of substantial compliance, leading to certification of the facility in compliance effective May 31, 2024.

The facility was found to be in substantial compliance based on the accepted allegation and Plan of Correction, resulting in certification of compliance.

The inspection was conducted based on facility complaints #118264-C, #118774-C, #119864-C, and #120185-C from April 26, 2024 through May 8, 2024 to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.

The facility was found not in substantial compliance due to failure to treat a resident with dignity and respect regarding vaping rights, failure to follow physician orders for insulin administration for one resident, and failure to maintain hot food temperatures above 140 degrees Fahrenheit during meal service.

The visit was complaint-related based on four facility complaints conducted from April 26, 2024 through May 8, 2024. The complaints involved resident rights violations, quality of care issues including medication administration, and food temperature concerns.

The document serves as a Plan of Correction following acceptance of a credible allegation of substantial compliance by the facility.

The facility was certified in compliance effective August 31, 2023, based on acceptance of the credible allegation and Plan of Correction.

The inspection was conducted as a result of investigation of complaint #113801-C and facility reported incident #113815-I from August 9 to August 10, 2023.

The facility failed to properly destroy Resident #6's narcotic medication upon discharge to the hospital, violating drug storage and destruction protocols. The complaint was substantiated and deficiencies were identified related to narcotic handling and destruction procedures.

Complaint #113801-C was substantiated. Facility reported incident #113815-I was substantiated.

A revisit of the survey ending June 15, 2023 was conducted on August 7, 2023 to August 8, 2023 to verify correction of previous deficiencies.

All deficiencies were corrected and the facility is in substantial compliance effective July 7, 2023.

An annual recertification survey and investigation of complaints #113349-C, #112889-C, #112316-C, #111921-C and facility reported incident #113224-I were conducted from June 12, 2023 to June 15, 2023.

The facility was found to have multiple deficiencies including failure to provide required Medicaid Liability Notices timely, incomplete comprehensive care plans for residents, failure to obtain physician orders for oxygen therapy, inadequate supervision leading to resident injury, pain management deficiencies, medication errors, infection control lapses, and pest control issues. The facility reported a census of 71 residents throughout the survey.

Complaints #113349-C and #112889-C were substantiated. Incident #113224-I was substantiated.

The document is a plan of correction submitted following a survey to address deficiencies and certify compliance of the facility.

The facility was found to be in compliance based on acceptance of a credible allegation of compliance and plan of correction effective April 16, 2023.

The inspection was conducted as an investigation of complaint #111791-C from March 23, 2023 to March 29, 2023. The complaint was substantiated.

The facility failed to revise a care plan to reflect the ongoing needs of Resident #2, who sustained a large bruise related to sliding down in her wheelchair and being hoisted improperly by staff. The facility also failed to provide adequate supervision to prevent accidents, resulting in the resident sliding out of her chair and sustaining bruises. Unsafe repositioning techniques were used by staff.

Complaint #111791-C was substantiated based on interviews, observations, and record review. The complaint involved Resident #2 sustaining a large bruise from sliding down in her wheelchair and improper staff handling.

A second revisit was conducted regarding multiple complaints and a facility reported incident to verify correction of previous deficiencies.

The revisit identified that all deficiencies were corrected and the facility was in substantial compliance effective March 15, 2023.

The revisit was related to complaints #104936-C, #104971-C, #106818-C, #108588-C, #108807-C, #109355-C and facility reported incident #107507-I.

The inspection was conducted to investigate Complaint 111174.

The complaint was investigated and found to be not substantiated during the visit from February 23 to 28, 2023.

Complaint 111174 was investigated and not substantiated on February 23 - 28, 2023.

The inspection was a revisit conducted on February 13-15, 2023, related to the investigation of multiple complaints and a facility-reported incident.

The facility failed to ensure a safe environment free of accident hazards, including electrical outlet overheating and discolored outlets posing fire risks. Additionally, staff qualifications and maintenance of a safe, functional environment were inadequate, with issues found in call light functionality and environmental conditions.

The revisit was related to complaints #104936-C, #104971-C, #106818-C, #108588-C, #108807-C, #109355-C and a facility-reported incident #107507-1. The investigation found substantiated issues with accident hazards and environmental safety.

The inspection was conducted as a complaint investigation based on multiple complaints (#104936-C, #104971-C, #106818-C, #108588-C, #108807-C, #109355-C, and facility reported incident #107507-I) regarding resident rights, quality of care, and safety concerns.

The facility was found to have failed to respect resident rights, including dignity and freedom from abuse, with substantiated complaints involving staff misconduct and improper restraint. Quality of care deficiencies included inadequate assessment and intervention for a resident's fall, failure to ensure accident-free environment due to electrical hazards, and insufficient in-service training for nurse aides. Immediate jeopardy related to fire safety was identified and removed after corrective actions.

Complaints #104971-C, #106818-C, #108588-C, #108807-C, and #109355-C were substantiated. Facility reported incident #107507-I was substantiated. Complaint #104936-C was not substantiated.

The document serves as a plan of correction following a survey, indicating acceptance of the facility's credible allegation of compliance.

The facility will be certified in compliance effective 05/05/22 based on acceptance of the plan of correction; no specific deficiencies are detailed in this document.

The inspection was conducted as part of the facility's annual recertification survey and included investigation of multiple complaints and a facility reported incident.

The facility was found deficient in multiple areas including failure to update care plans timely, inadequate nursing supervision to prevent accidents, improper use and assessment of bed rails, lapses in infection prevention and control practices, and failure to notify residents and families timely about COVID-19 infections.

Complaints #101528-C and 101788-C were substantiated. Facility reported incident #101778-I was substantiated.

A COVID-19 Focused Infection Control Survey was conducted from 10/28 to 12/20/21, including investigation of multiple complaints and facility-reported incidents.

The facility was found to be in compliance with CDC recommended COVID-19 practices. Deficiencies were identified related to bed-hold policy notification, failure to follow physician orders for 1 of 19 residents, and failure to maintain accurate narcotic medication records for 2 of 5 residents reviewed.

Investigation of complaints #97617-C, #100008-C, and facility-reported incident #97427-M resulted in deficiencies. Complaints #98116-C, #99474-C, #99901-C, #100096-C, #100542-C and facility-reported incidents #96772-I and #96777-I did not result in deficiency. Complaint #100067-C was substantiated without deficiency.

The inspection was conducted as part of the facility's investigation of multiple complaints, including complaint 94932-C which was substantiated, while others were not substantiated.

The facility failed to provide a timely involuntary discharge notice for one of four discharged residents reviewed (Resident #5). The resident had diagnoses including Alzheimer's disease and dementia, required long term care placement, and was discharged following a hospital stay. The facility had no policy or procedures related to discharge planning and notice.

The visit was complaint-related involving multiple complaints (94932-C, 95787-C, 95189-C, 95072-C, 95056-C, 94740-C, 94616-C, and 94439-C). Complaint 94932-C was substantiated; the others were not substantiated.

The inspection was conducted as part of the facility's annual health survey and included investigation of multiple substantiated and unsubstantiated complaints and facility reported incidents, along with a COVID-19 Focused Infection Control Survey.

The facility was found in compliance with COVID-19 infection control practices but had deficiencies related to medication administration, restorative care, and accident prevention. Specifically, staff failed to follow professional medication administration standards for one resident, failed to provide appropriate restorative treatment for a resident with limited range of motion, and failed to provide adequate supervision and assistive devices to prevent accidents for two residents, resulting in a fall with injury.

Complaints 94369-C, 86987-C, 88314-C, 93050-C, 94033-C, 94373-C, and 94439-C were substantiated. Complaint 94496-C was not substantiated. Facility reported incidents 87328-I, 92585-I, and 93739-I were substantiated. Facility reported incidents 87605-I and 88566-I were not substantiated.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/23/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

Investigation of a facility self-reported incident involving Resident #1 ingesting non-food items, including puzzle pieces, resulting in immediate jeopardy to the resident's health and safety.

The facility failed to provide adequate nursing supervision to prevent Resident #1 from ingesting non-food items, including puzzle pieces, toilet paper, and cotton, despite known cognitive impairments and prior incidents. The resident required hospitalization and surgery to remove puzzle pieces from his esophagus. The facility lacked adequate staff education and communication regarding the resident's risk behaviors and failed to remove all choking hazards from the unit.

The visit was triggered by a complaint related to Resident #1 ingesting foreign objects, including puzzle pieces, toilet paper, and cotton balls, resulting in immediate jeopardy to the resident's health and safety.