Chapel Pointe at Carlisle.

“The home's annual quality management review was last completed on 12/20/2023 and had not been conducted since then, failing to meet the requirement for an annual review.”

“Emergency telephone numbers for the nearest hospital, police department, fire department, ambulance, poison control, local emergency management and personal care home complaint hotline were not posted on or by the telephone in resident #1's bedroom.”

“There was no thermometer in the refrigerator or freezer located in the secure dementia care unit where resident food is stored.”

“The administrator does not have and is not familiar with the emergency preparedness plan for the local municipality (Carlisle Borough).”

“The home's written emergency procedures have not been reviewed or updated since 2021 and have not been submitted annually to the local emergency management agency as required.”

“On 9/10/25 at 9:10 AM, the egress door leading from the Secure Dementia Care Unit to the courtyard was locked with a card-swipe device, obstructing unobstructed egress as required.”

“Staff member B transports residents independently to medical appointments and community outings but has not completed the Department-approved direct care training course and competency test as required for staff transporting residents.”

“Staff members witnessed staff member C kissing a resident on the lips twice while administering medications, and striking a resident on the buttocks numerous times while the resident objected, with a threat to paddle the resident. These allegations of abuse were not reported to the local area agency on aging via ACT 13 form.”

“Two incidents involving physical abuse (kissing resident on lips and striking resident on buttocks with threats) were not reported to the Department within 24 hours as required. One incident was reported late at 12:30 PM and the other was not reported to the Department at all.”

“Staff member C kissed a resident on the lips twice while administering medications and struck a resident on the buttocks numerous times while the resident objected, threatening to paddle the resident if the resident did not leave the kitchen. This constitutes physical abuse and corporal punishment.”

“A resident's initial assessment did not include the resident's mobility needs (documented as requiring limited physical or oral assistance to evacuate in an emergency on the medical evaluation) within 15 days of admission.”

“The resident-home contract for Resident #3 was not signed by the resident.”

“There were periods when no staff persons certified in first aid and CPR were present in the home, violating the requirement that at least one such staff person be present at all times.”

“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.”

“A resident grabbed the arm of and pushed another resident into the wall. This allegation of abuse was not reported to the Area Agency on Aging in accordance with the Older Adult Protective Services Act and reporting requirements.”

“Blood glucose readings for Resident #5 were incorrectly recorded in the Medication Administration Record (MAR). The MAR for Resident #6 contains a blood glucose reading that does not appear on the resident's glucometer.”

“The most recent support plan for Resident #8 does not indicate the need for the enabler bar attached to the resident's bed, the intended use, any risks associated with the use, and the resident's ability to use the device safely.”

“Resident #4 was admitted to the Secure Dementia Care Unit on a certain date; however, the resident's medical evaluation was completed with an exam date that did not meet the requirement of being within 60 days prior to admission.”