Inspection·April 24, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, facility document review, staff interviews, and facility policy review, it was determined that the facility displayed past non-compliance by failing to implement interventions, supervision, and effective safety measures to prevent elopement of a resident identified as being at risk for elopement and exhibiting exit seeking behaviors (Resident 1). Resident 1 was found approximately one half mile from the facility approximately 17.5 hours following his elopement with injury to his forehead. This failure placed an additional 16 residents, who were identified as being at risk on their elopement risk evaluations, in an immediate jeopardy situation (Residents 2, 4, 5, 6, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20). Findings include: Review of facility policy, titled Elopement, revised June 2023, read, in part; It is the policy of this facility to provide a safe and secure environment for our residents and to be proactive in preventing resident elopement. Residents at risk for elopement will be appropriately monitored to reduce the potential for injury . Residents that are identified at moderate or high risk for elopement will have an intervention implemented for their safety. Those residents identified as low risk will have an Interdisciplinary review to determine if intervention/s are necessary . Elopement risk will be care planned with individualized approaches to reduce the potential for elopement and/or to redirect the resident in the event that an elopement attempt is made .Electronic monitoring systems may be implemented as possible interventions as appropriate. Review of Resident 1's clinical record revealed diagnoses that included alcohol dependence with alcohol-induced persisting dementia (caused by long-term, excessive consumption of alcohol, resulting in neurological damage and impaired cognitive function) and Alzheimer's disease (progressive neurological disorder characterized by a gradual decline in memory, thinking, and behavior due to the build-up of proteins in the brain, leading to death of brain cells). Further review of Resident 1's clinical record revealed that he was admitted to the facility from the hospital on April 9, 2025. Review of hospital treatment notes dated March 31, 2025, through April 4, 2025, indicated that Resident 1 required a sitter as an elopement precaution while hospitalized . Review of Resident 1's elopement/wander risk evaluation completed on April 9, 2025, revealed a score of 11 (high risk) with suggested care plan intervention to provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 395784 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395784 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Letort Spring Nursing and Rehab LLC 801 N. Hanover Street Carlisle, PA 17013 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)