Carlisle Skilled Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Carlisle Skilled Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF805Jun 26, 2025

  Based on facility policy reviews, observations, clinical record reviews, review of facility master menu diet guide sheets, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for six residents (Residents 2, 9, 12, 14, 60, and 101) observed. This failure placed 14 additional residents that had similar diet needs at a high risk for death and resulted in an Immediate Jeopardy situation (Residents 12, 13, 39, 50, 51, 62, 68, 73, 74, 78, 98, 108, 110, and 289). Findings include: Review of facility policy, titled Consistency Alterations and Therapeutic Menus dated May 1, 2023, read, in part, Purpose: To provide diets as ordered by the physician/advanced practice provider. […]

• Immediate jeopardy, isolatedF689Jun 26, 2025

  Based on clinical record review, facility document review, policy review and staff interviews, it was determined that the facility failed to conduct thorough fall investigations for one of six residents reviewed for falls (Resident 81) and failed to ensure that residents who expressed suicidal ideations were provided supervision and safety interventions were put into place to prevent serious bodily injury and/or death. This failure resulted in Resident 59 cutting himself and an immediate jeapordy situation. Findings include: Review of facility policy, titled Procedure: Suicide Precautions, last reviewed May 7, 2025, revealed the facility procedure included the following: 1. Evaluate patients with suicidal behavior or ideation. 2. […]

• Actual harm, isolatedF689Jul 23, 2026

  Based on facility policy review, nurse aide competency review, clinical record review, review of select facility documentation, hospital discharge summary, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of 29 residents reviewed (Resident 111), which resulted in actual harm for Resident 111 as evidenced by a femur fracture.Review of facility policy, titled Falls Management last reviewed January 15, 2026, read, in part, Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. […]

• Actual harm, isolatedF692Jul 23, 2026

  Based on review of facility policy, clinical record, observations, and resident and staff interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, which resulted in actual harm as evidence by weight loss for one of five Residents reviewed (Resident 1). Also, the facility failed to adequately monitor and document fluid restrictions for one of five residents reviewed (Resident 8), and failed to reweigh and notify the physician and dietician of significant weight loss for one of five residents reviewed (Resident 21).Findings include: Review of facility policy, titled Weights and Heights, last reviewed January 15, 2026, revealed the following Based on the patient's comprehensive assessment, the Center will ensure… […]

• Actual harm, isolatedF684Mar 20, 2026

  Based on clinical record review select document review and staff interviews, it was determined that the facility failed to complete routine and weekly skin checks for one of five residents reviewed (Resident 1). In addition, the facility failed to provide timely and comprehensive care and services after a change in condition including a respiratory assessment on a resident in respiratory distress, which resulted in harm as evidenced by hospital admission for respiratory failure that required intubation and abnormal labs for one of five residents reviewed (Resident 2).Findings Include: Review of Resident 1's clinical record revealed diagnoses that included multiple sclerosis (a chronic autoimmune disease where the immune system attacks the protective myelin sheath covering nerve fibers in… […]