Accura Healthcare of Carlisle

In the surveyor’s words

From the most serious findings on record at Accura Healthcare of Carlisle, in the surveyor’s own words.

• Immediate jeopardy, patternF689Dec 15, 2022

  Based on observation, clinical record and facility policy review, and staff and resident interviews, the facility failed to ensure employees followed the fire emergency policy on 12/03/22, when smoke and the smell of melting plastic was discovered in Resident #8's room. Staff determined the smoke and odor emitted from an electrical outlet near the bed in which a wall heater was plugged, but failed to move the resident out of danger. Staff removed the plug from the live outlet while the resident remained in the room. Although the outlet sparked, staff still did not remove Resident #8 from the room or activate the fire alarm system, which potentially exposed additional residents to the hazard. This situation constituted an Immediate Jeopardy to resident health and safety. […]

• Actual harm, isolatedF689Jul 31, 2025

  Based 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. Findings include: The Quarterly Minimum Data Set (MDS) Assessment completed on 6/12/25 revealed Resident #45 with a Brief Interview Mental Status score of 14, which indicated intact cognition. Diagnoses listed on the MDS include paraplegia, anxiety disorder, diabetes, and orthostatic hypotension (low blood pressure). The MDS noted the presence of a urinary catheter and a colostomy. […]

• Actual harm, isolatedF686Mar 3, 2025

  Based 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. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. […]

• Actual harm, isolatedF689Jun 15, 2023

  Based on clinical record review, policy review, and staff interviews, the facility failed to ensure staff were handling laundry carts in a safe manner and in accordance with facility policy. This failure resulted in a resident (Resident #56) being bumped with the cart, falling and breaking a hip and arm. The facility reported a census of 71 residents. Findings include: Resident #56's Minimum Data Set (MDS) dated [DATE] documented an admitted [DATE]. The MDS documented a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. The MDS documented diagnosis included vascular dementia. Review of the Progress Note dated 5/6/23, the nurse was sitting at the nurse's station at 2:05 PM and heard a resident cry out for help. […]

• No harm, potential for more than minimal, widespreadF727Aug 28, 2024

  Based 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. Findings include: Review of untitled documents of the facility's daily staffing schedule provided by the facility revealed there was no RN coverage 7/30/24, 7/31/24, 8/5/24, 8/12/24, 8/14/24, and 8/15/24. These documents further revealed there was only 4 hours of RN coverage 8/19/24, 8/20/24, and 8/21/24. During an interview 8/28/24 at 9:02 AM with Staff A Certified Nurse Aide (CNA) revealed that the facility did not have 8 hour RN coverage every day. […]