Inspection Reports for
Chapel Pointe at Carlisle
770 SOUTH HANOVER STREET,, CARLISLE, PA, 17013
Back to Facility Profile22 Reports
Inspection Report — Apr 30, 2026
Follow-Up
Date: Apr 30, 2026
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction for the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction related to timely reporting of suspected abuse, medication administration timing, and resident assessment documentation. Several deficiencies were identified and corrected with education and updated procedures.
Citations (4)
15a - Resident Abuse Report: The facility failed to immediately report suspected abuse to the Local Area Agency on Aging as required by law.
16c - Written Incident Report: The facility failed to report the incident to the Department's complaint hotline within 24 hours as required.
187d - Follow Prescriber's Orders: Medications scheduled for 8:00 AM were administered late, between 9:34 AM and 10:08 AM, outside the required time window.
225a - Assessment 15 Days: Resident initial assessment did not include the use of a walker despite the resident utilizing one.
Report Facts
Residents Served: 46
Residents Served in Secured Dementia Care Unit: 11
Inspection Report — Sep 10, 2025
Renewal
Date: 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.
Citations (13)
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
Residents Served: 41
Secured Dementia Care Unit Residents Served: 11
Hospice Residents: 1
Total Daily Staff: 41
Waking Staff: 31
Inspection Report — May 27, 2025
Follow-Up
Date: May 27, 2025
Visit Reason
The inspection was a partial, unannounced incident investigation conducted due to an incident involving alleged resident abuse.
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.
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.
Citations (5)
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
Residents Served: 43
Residents Served in Secured Dementia Care Unit: 10
Staffing Hours - Total Daily Staff: 55
Staffing Hours - Waking Staff: 41
Inspection Report — Mar 11, 2025
Date: 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
Residents Served: 43
Secured Dementia Care Unit Residents Served: 11
Current Hospice Residents: 1
Residents with Mobility Need: 11
Residents Age 60 or Older: 43
Inspection Report — Sep 5, 2024
Renewal
Date: 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.
Citations (9)
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
Residents Served: 46
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 — May 11, 2023
Renewal
Date: 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.
Citations (3)
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
Residents Served: 41
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 — Jun 23, 2022
Renewal
Date: 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 — Apr 26, 2022
Renewal
Date: 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.
Citations (5)
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
Residents Served: 33
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 — Aug 4, 2021
Routine
Date: 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 — Jun 3, 2021
Date: 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
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 |
Inspection Report — Aug 26, 2020
Follow-Up
Date: Aug 26, 2020
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to locking poisonous materials was fully implemented. The facility demonstrated compliance with requirements to keep hazardous materials locked and inaccessible to residents who cannot safely use or avoid them.
Citations (1)
82c - Locking Poisonous Materials: The assessment dated 7/16/2020 indicated Resident #1 cannot safely use or avoid poisonous materials. On 8/24/2020, Resident #1 consumed approximately 3 oz. of mouthwash from a 4 oz. bottle.
Report Facts
Residents Served: 41
Residents Served in Dementia Unit: 12
Hospice Current Residents: 2
Inspection Report — Mar 4, 2020
Renewal
Date: Mar 4, 2020
Visit Reason
The document is a renewal application and license issuance for Chapel Pointe at Carlisle Personal Care Home. The Department will conduct an onsite inspection within the next twelve months as part of the annual inspection requirement.
Findings
No inspection findings are reported in this document. It primarily communicates the license renewal and the Department's intent to conduct an inspection within twelve months.
Inspection Report — Feb 4, 2020
Follow-Up
Date: Feb 4, 2020
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction related to medication administration and compliance issues. The visit was unannounced and included elements of renewal and complaint investigation.
Findings
The submitted plan of correction was determined to be fully implemented as of the follow-up inspection dates. Continued compliance must be maintained.
Report Facts
Residents Served: 43
Residents Served in Secured Dementia Care Unit: 11
Notice — Jun 18, 2019
Date: Jun 18, 2019
Visit Reason
The document serves to notify the facility of a granted waiver related to resident medical evaluation and health care documentation under Pennsylvania Code 55 Pa.Code § 2600.141(a).
Findings
The waiver allows Chapel Pointe at Carlisle to use documentation from 'MatrixCare' instead of the Department's medical evaluation form. The waiver remains effective as long as conditions are met and will be reviewed annually during the facility's annual inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacqueline L. Rowe | Director | Signed the waiver approval letter. |
Inspection Report — Mar 27, 2019
Renewal
Date: Mar 27, 2019
Visit Reason
The inspection was a renewal licensing inspection conducted by the Pennsylvania Department of Human Services Bureau of Human Services Licensing on March 27, 2019.
Findings
The inspection identified multiple violations related to equipment maintenance, safety features in resident bathrooms, medication labeling, medication administration accountability, and resident record documentation. Plans of correction were submitted and partially or fully implemented for all violations.
Citations (5)
Regulation 55 Pa.Code §2600.81(b): Resident 1's toilet support bar was rusted and required replacement to ensure it is clean, in good repair, and free of hazards.
Regulation 55 Pa.Code §2600.102(d)(1): Resident 2's toilet lacked a grab bar, hand rail, or assist bar, which are required in toilet and bath areas.
Regulation 55 Pa.Code §2600.184(a): Resident 3's medication label incorrectly stated 450 mg capsules instead of the prescribed 500 mg capsules.
Regulation 55 Pa.Code §2600.185(b): The home had not implemented a system to monitor and reconcile administration of Ativan, a Schedule IV controlled substance.
Regulation 55 Pa.Code §2600.252: Resident records reviewed did not include identifying marks, and the home's face sheet lacked a designated area for this information.
Report Facts
Number of Residents Served: 42
Number of Residents Served in Secured Dementia Care Unit: 11
Number of Current Hospice Residents: 0
Number of Hospice Residents in Past Year: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kent D. Peachey | Executive Director | Named as Administrator and Legal Entity Representative signing plans of correction. |
Inspection Report — Feb 27, 2019
Renewal
Date: Feb 27, 2019
Visit Reason
The document is a renewal application and license issuance for Chapel Pointe at Carlisle, a Personal Care Home, with a requirement for an onsite inspection within the next twelve months as part of the annual inspection process.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and states that the Department will conduct an onsite inspection within the next twelve months.
Notice — Apr 17, 2018
Date: Apr 17, 2018
Visit Reason
The document is a renewal approval letter for the operation of a Personal Care Home, Chapel Pointe at Carlisle, following a renewal application submitted on April 4, 2018. It also notifies the facility of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document as it is a license renewal notice and certificate of compliance.
Report Facts
Inspection Report — Apr 4, 2018
Renewal
Date: Apr 4, 2018
Visit Reason
The inspection was conducted as an annual licensing renewal inspection of Chapel Pointe at Carlisle to assess compliance with 55 Pa.Code Chapter 2600 for Personal Care Homes.
Findings
Two violations were found related to missing items in the vehicle first aid kit and discrepancies in medication counts versus documentation. Plans of correction were submitted and partially implemented to address these issues.
Citations (2)
55 Pa.Code §2600.171(b)(5) - The vehicle first aid kit lacked a thermometer and eye coverings on April 4, 2018.
55 Pa.Code §2600.185(b) - Medication administration procedures were deficient as medication counts did not match documentation on April 4, 2018.
Report Facts
Number of Residents Served: 41
Number of Residents Served in Secured Dementia Care Unit: 11
Total Daily Staff: 52
Waking Staff: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah M. Sprague | Executive Director | Named in medication administration violation and plan of correction |
Inspection Report — Apr 5, 2017
Renewal
Date: Apr 5, 2017
Visit Reason
The document is a renewal license issued to Chapel Pointe at Carlisle for operating a Personal Care Home. The Department of Human Services will conduct an onsite inspection within the next twelve months as required by law.
Findings
This document does not contain inspection findings but confirms the issuance of a regular license renewal for the facility and outlines the requirement for an annual inspection within twelve months.
Report Facts
Inspection Report — Apr 5, 2016
Renewal
Date: Apr 5, 2016
Visit Reason
The inspection was conducted as part of the Department of Human Services' annual licensing renewal inspections on April 5 and April 6, 2016.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 related to Personal Care Homes were found, including issues with resident contracts, medication refusals, medical evaluations, preadmission screening, and contract disclosures. Plans of correction were submitted and partially implemented as of June 24, 2016.
Citations (5)
55 Pa.Code §2600.25(b): The contract for Resident #3 was not signed by the payor.
55 Pa.Code §2600.187(c): Resident #1 refused to take all morning prescribed medications and the home did not contact the resident's doctor.
55 Pa.Code §2600.231(b): Resident #2 admitted to the Secured Dementia Care Unit did not have a medical evaluation completed until nearly three months after admission.
55 Pa.Code §2600.231(c): Resident #2's preadmission cognitive screening was not completed within 72 hours prior to admission to the secured dementia care unit.
55 Pa.Code §2600.231(h): The resident-home contract for Resident #2 did not include special programming disclosures.
Report Facts
Staff Count: 55
Walking Staff: 41
Residents Served in Secured Dementia Unit: 9
Notice — Apr 4, 2016
Date: Apr 4, 2016
Visit Reason
The document serves as a renewal notification and license issuance for Chapel Pointe at Carlisle, a Personal Care Home, confirming compliance with state regulations and informing about the requirement for annual onsite inspections.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license following the renewal application.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deborah M. Sprague | Executive Director | Recipient of the renewal notification letter. |
| Matthew J. Jones | Director | Signed the renewal notification letter. |
| Robert E. Robinson | Issuing Officer | Signed the certificate of compliance. |
Report — April 10, 2017
April 10, 2017
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