Carlisle Manor Health Care Inc

In the surveyor’s words

From the most serious findings on record at Carlisle Manor Health Care Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 2, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on closed medical record review, hospital visit summary review, facility self-reported incident and investigation review, and staff interview, the facility failed to ensure residents were safely transported on and off the facility vehicle. Actual harm occurred on 06/05/24 when Resident #91, who was in a wheelchair, sustained a fall resulting in multiple fractures including a fracture to his left leg and fractures to his ribs on the left side when staff were assisting him off the facility bus. […]

• No harm, potential for more than minimal, widespreadF921May 28, 2026

  Based on observation, resident and staff interviews and record review, the facility failed to maintain exterior exit egress stairs. This affected Resident #9 and #13 and had the potential to affect all 45 residents residing in the facility. Findings include:Review of the facility's State Fire Marshal report dated 03/19/26 revealed the facility received a violation for exit accesses, exits and a exit discharge not being maintained. The report stated the exterior exit staircase was breaking apart.Review of the facility's undated exit egress map revealed the exterior stairwell that was crumbling was an exit egress for residents.Interview with Resident #9 on 05/26/26 at 10:21 A.M. […]

• No harm, potential for more than minimal, patternF550Feb 23, 2023

  Based on observation, staff interview, and record review, the facility failed to cover residents' catheter bags to promote privacy and dignity. This affected four (Residents #192, #33, #34, and #39) of four residents reviewed for dignity. The facility's census was 42. Findings include: 1. Review of the medical record revealed Resident #192 admitted to the facility on [DATE] and had diagnoses of type II diabetes, non-pressure chronic ulcer, unspecified major depressive disorder, and peripheral vascular disease. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, had no behaviors, did not wander, and did not reject care. […]

• No harm, potential for more than minimal, patternF761Feb 23, 2023

  Based on observation, staff interview, and policy review, the facility failed to ensure medications were disposed of safely. This had the potential to affect four (Residents #11, #30, #34, and #36) who the facility identified as independently mobile and cognitively impaired. The facility census was 42. Findings include: Observation on 02/22/23 at 8:08 A.M. revealed Registered Nurse (RN) #312 threw away medications in the trash can on the 200-Hall medication cart. Medications thrown away included isosorbide 60 mg, amlodipine 5 mg, metoprolol 100 mg, metoprolol 50 mg, losartan 50 mg, and dicyclomine 20 mg. Interview on 02/22/23 at 8:09 A.M. […]

• No harm, potential for more than minimal, isolatedF645May 28, 2026

  Based on record review, policy review and staff interview, the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) was accurate and included the resident's mental health diagnoses. This affected one (#36) of one resident reviewed for PASARR. The facility census was 45. Findings include:Review of Resident #36's medical record revealed Resident #36 admitted to the facility on [DATE]. Diagnoses included with dementia severe with other behavioral disturbance, anxiety disorder, and psychosis not due to a substance or known physiological condition. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was severely cognitively impaired. […]