Inspection Reports for Chapel Pointe at Carlisle
770 SOUTH HANOVER STREET,, PA, 17013
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
49% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
67% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 41
Capacity: 61
Deficiencies: 13
Sep 10, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 09/10/2025 to review compliance with licensing requirements.
Findings
The facility had multiple deficiencies including issues with quality management plan completion, emergency telephone postings, refrigerator/freezer thermometers, emergency preparedness familiarity, emergency procedure updates, unobstructed egress, staff training, medication storage and labeling, medication availability, training record completeness, support plan documentation, and lack of required written approvals for locking systems. All deficiencies had accepted plans of correction with proposed completion dates by 10/10/2025 and were implemented by 10/14/2025.
Deficiencies (13)
| Description |
|---|
| The home's annual quality management review was last completed on 12/20/23. |
| Telephone numbers for emergency services were not posted on or by the telephone in resident #1's bedroom. |
| No thermometer in the refrigerator or freezer located in the secure dementia care unit. |
| Administrator does not have and is not familiar with the emergency preparedness plan for the local municipality. |
| The home's written emergency procedures have not been reviewed or updated since 2021. |
| The egress door leading from the Secure Dementia Care Unit to the courtyard was locked with a locking device requiring a card to be swiped. |
| Staff member B transports residents independently but has not completed the Department-approved direct care training course and competency test. |
| Resident #2's insulin autoinjector pen was open and unlabeled with the date opened; resident #3's insulin pen was expired. |
| Resident #4's prescribed nitroglycerin medication was not available in the home. |
| Staff member C's 2024 annual medication administration training record was incomplete, missing signatures and dates. |
| Resident #5's support plan did not document how total physical assistance with laundry would be met; resident #6's support plan lacked details on halo bed mobility device use and risks. |
| The home lacks written approval from the Department of Labor and Industry, Department of Health, or local building authority for the magnetic door lock and key card locking system used on exit doors from the Secure Dementia Care Unit. |
| The home does not have a manufacturer statement verifying that the magnetic door locks will release upon fire alarm activation, power failure, or override. |
Report Facts
License Capacity: 61
Residents Served: 41
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 11
Hospice Residents: 1
Total Daily Staff: 41
Waking Staff: 31
Inspection Report
Follow-Up
Census: 43
Capacity: 61
Deficiencies: 5
May 27, 2025
Visit Reason
The inspection was a partial, unannounced incident investigation conducted due to an incident involving alleged resident abuse.
Findings
The inspection found multiple violations related to failure to report suspected resident abuse, delayed incident reporting, and deficiencies in resident assessments regarding mobility needs. Plans of correction were accepted and implemented by July 18, 2025.
Complaint Details
The visit was triggered by an incident involving alleged resident abuse witnessed by staff members. The allegations included physical and verbal abuse by a staff member toward a resident. The abuse was not reported timely to the local agency or the Department. The complaint was substantiated with findings of violations.
Deficiencies (5)
| Description |
|---|
| Failure to immediately report suspected abuse of a resident to the local area agency on aging via the ACT 13 form. |
| Failure to report the incident of abuse to the Department within 24 hours as required. |
| Resident was subjected to physical and verbal abuse by staff member, including striking and threatening statements. |
| Resident initial assessment did not include mobility needs as minimal, inconsistent with medical evaluation. |
| Resident annual assessment did not include mobility needs as independent, inconsistent with medical evaluation. |
Report Facts
License Capacity: 61
Residents Served: 43
Residents Served in Secured Dementia Care Unit: 10
Staffing Hours - Total Daily Staff: 55
Staffing Hours - Waking Staff: 41
Inspection Report
Census: 43
Capacity: 61
Deficiencies: 0
Mar 11, 2025
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 54
Waking Staff: 41
License Capacity: 61
Residents Served: 43
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 1
Residents with Mobility Need: 11
Residents Age 60 or Older: 43
Inspection Report
Renewal
Census: 46
Capacity: 61
Deficiencies: 9
Sep 5, 2024
Visit Reason
The inspection was conducted as a renewal review of the facility's license on 09/05/2024 by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
The inspection found multiple deficiencies including failure to post the current license inspection summary, failure to report a resident abuse incident, missing resident contract signatures, lack of certified first aid/CPR staff at times, incorrect recording of blood glucose readings, incomplete support plans for medical devices, missing medical evaluations, lack of documentation of no objection statements for secured dementia care unit admissions, and missing death certificates in resident records. Plans of correction were submitted and accepted with completion dates by 10/11/2024 and implemented by 10/17/2024.
Deficiencies (9)
| Description |
|---|
| The home's most recent licensing inspection summary from the 5/11/23 inspection was not posted in a conspicuous and public place in the home. |
| Resident #1 grabbed the arm of and pushed Resident #2 into the wall. This allegation of abuse was not reported to the Area Agency on Aging as required. |
| The resident-home contract for Resident #3 was not signed by the resident. |
| There were times when no staff persons present in the home were certified in first aid and CPR. |
| Blood glucose readings for Resident #5 were incorrectly recorded in the Medication Administration Record (MAR). The MAR for Resident #6 had a blood glucose reading that did not appear on the resident's glucometer. |
| The most recent support plan for Resident #8 did not indicate the need for the enabler bar attached to the resident's bed, its intended use, risks, or resident's ability to use it safely. |
| Resident #4's medical evaluation was completed after admission to the Secure Dementia Care Unit (SDCU), not within 60 days prior as required. |
| The home has no documentation that Resident #3 and Resident #4 and their designated persons have not objected to admission to the SDCU. |
| The resident record for Resident #7, who passed away in the home, does not contain a copy of the death certificate. |
Report Facts
License Capacity: 61
Residents Served: 46
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 12
Total Daily Staff: 56
Waking Staff: 42
Residents 60 Years or Older: 46
Residents with Mobility Need: 10
Inspection Report
Renewal
Census: 41
Capacity: 61
Deficiencies: 3
May 11, 2023
Visit Reason
The inspection was conducted as a renewal review of the facility's license by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 05/11/2023.
Findings
The facility was found to have deficiencies related to refrigerator/freezer temperature, lint removal and duct cleaning, and medication storage procedures. Plans of correction were accepted and implemented with education and cleaning measures completed by early June 2023.
Deficiencies (3)
| Description |
|---|
| Temperature in the freezer located in the memory care unit kitchenette was above required levels (4°F and 2°F instead of at or below 0°F). |
| Accumulation of lint in the lint trap of dryers #1 and #3 in the main laundry room. |
| Medication storage procedures were not properly followed; a nutritional supplement was documented as given but was found unused in the refrigerator. |
Report Facts
License Capacity: 61
Residents Served: 41
Secured Dementia Care Unit Capacity: 12
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 4
Staffing Hours - Total Daily Staff: 52
Staffing Hours - Waking Staff: 39
Residents Age 60 or Older: 41
Residents with Mobility Need: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Personal Care Administrator | Provided verbal education to staff regarding medication administration documentation. | |
| Nursing Supervisor | Responsible for re-educating staff on medication administration and documentation. |
Inspection Report
Renewal
Deficiencies: 0
Jun 23, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 06/23/2022 and 06/24/2022 for the facility Chapel Pointe at Carlisle.
Findings
No regulatory citations or deficiencies were identified as a result of this licensing inspection.
Inspection Report
Renewal
Census: 33
Capacity: 61
Deficiencies: 5
Apr 26, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the facility's license, with an unannounced full inspection on 04/26/2022 and 04/27/2022.
Findings
The facility was found to have several medication-related deficiencies including expired medication kept in the medication cart, missing diagnosis or purpose on medication records, missing staff initials on medication administration records, incomplete preadmission screening forms, and undated opened insulin. Plans of correction were accepted and steps toward compliance were in progress.
Deficiencies (5)
| Description |
|---|
| Expired medication prescribed for Resident #3 was found in the medication cart after discontinuation. |
| Medication administration record for Resident #3 did not indicate the diagnosis or purpose for the medication. |
| Medication administration record for Resident #3 did not include initials of staff who administered medication on specified dates. |
| Resident #2’s preadmission screening form did not include a determination that the resident's needs can be met by the home. |
| Medication for Resident #1 was not dated when opened, risking use beyond expiration date. |
Report Facts
License Capacity: 61
Residents Served: 33
Secured Dementia Care Unit Capacity: 12
Residents Served in Secured Dementia Care Unit: 10
Hospice Residents: 1
Total Daily Staff: 43
Waking Staff: 32
Residents with Mobility Need: 10
Inspection Report
Routine
Deficiencies: 0
Aug 4, 2021
Visit Reason
The inspection was conducted as a routine licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Notice
Capacity: 61
Deficiencies: 0
Jun 3, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Chapel Pointe at Carlisle, a Personal Care Home, following receipt of the renewal application dated February 23, 2021.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation, and enforcement action will be taken if noncompliance is found during that inspection.
Report Facts
Maximum capacity: 61
Secure Dementia Care Unit capacity: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Deborah M. Sprague | CEO | Recipient of the renewal license notification |
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
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