Chapel Pointe at Carlisle

In the surveyor’s words

From the most serious findings on record at Chapel Pointe at Carlisle, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657May 11, 2023

  Based on clinical record review and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for three of 18 residents reviewed (Residents 24, 46, and 55). Findings include: Review of Resident 24's clinical record revealed diagnoses that included major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in daily activities), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and Stage 3 Pressure Ulcer (a full thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed) of the sacral region (the portion of the spine… […]

• No harm, potential for more than minimal, patternF812May 11, 2023

  Based on observations, review of facility policy, and staff interviews, it was determined that the facility failed to store and serve food in a safe and sanitary manner in the main dietary kitchen and in two of three nourishment pantries (Main dietary kitchen, fell owship Place Pantry, and Family Place Pantry). Findings include: Review of facility policy, titled Food Storage, last reviewed July 13, 2022, revealed the policy stated At times food may be opened from its original storage container but not used - these unused food items may be returned to storage if completely wrapped or placed in appropriate storage container with lid to prevent infestation. […]

• No harm, potential for more than minimal, isolatedF637Mar 13, 2025

  Based on clinical record review, staff interview, and Centers for Medicare and Medicaid Services publication, it was determined that the facility failed to complete a Significant Change Minimum Data Set after a significant change was identified for one of two residents reviewed for hospice services (Resident 45). Findings include: Review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.19.1 (instructions on when and how to complete the Minimum Data Set), revealed it stated, An [Significant Change in Status Assessment; a.k.a. […]

• No harm, potential for more than minimal, isolatedF641Mar 13, 2025

  Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 17 residents reviewed (Residents 7 and 20). Findings Include: Review of Resident 7's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should) and Type 2 Diabetes Mellitus (when the body cannot use insulin correctly and sugar builds up in the blood). […]

• No harm, potential for more than minimal, isolatedF641May 11, 2023

  Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 18 residents reviewed (Residents 29 and 46). Findings Include: Review of Resident 29's clinical record revealed diagnoses that included congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety. […]