Health inspection·March 13, 2025

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Few 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. Significant Change Minimum Data Set] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The [Assessment Reference Date] must be within 14 days from the effective date of the hospice election . Review of Resident 45's clinical record revealed diagnoses that included Alzheimer's disease (progressive, irreversible degenerative disease of the brain that results in decreased contact with reality and decreased ability to perform activities of daily living) and hypertension (elevated/high blood pressure). Review of Resident 45's clinical record revealed that on July 22, 2024, Resident 45 entered into hospice services. Review of the Minimum Data Set (MDS) assessment history for Resident 45 revealed that a Significant Change MDS was not completed until September 13, 2024; 53 days after Resident 45 had entered into hospice services. During a staff interview on March 13, 2025, at approximately 11:10 AM, Nursing Home Administrator (NHA) confirmed that the Registered Nurse Assessment Coordinator identified that Resident 45 did not have a Significant Change MDS completed within 14 days, and subsequently completed the Significant Change MDS with an assessment reference date of September 13, 2024. During the interview, the NHA confirmed that it was the facility's expectation that Significant Change MDS assessment are completed within 14 days after the facility identifies significant change in resident condition. 28 Pa code 211.12(d)(1)(3)(5) Nursing services 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 3 Event ID: 395923 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 395923 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapel Pointe at Carlisle 770 S. 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)