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: 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 Page 1 of 3 395923 395923 03/13/2025 Chapel Pointe at Carlisle 770 S. Hanover Street Carlisle, PA 17013

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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). Residents Affected - Few 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). Review of Resident 7's Quarterly MDS (Minimum Data Set - an assessment tool to review all care areas specific to the resident such as a resident's physical, mental, or psychosocial needs) dated November 1, 2024, revealed that in Section N, opioid medication (a class of drug used to reduce moderate to severe pain) was not checked as being received by the resident during the last seven days. Review of Resident 7's medication administration record (MAR), dated October 2024 and November 2024, revealed that Resident 7 received Tramadol (an opioid medication) every day. On March 13, 2025, at 11:47 AM, the Nursing Home Administrator (NHA) confirmed that Resident 7 received the Tramadol and that the opioid medication should have been coded on the MDS. Review of Resident 20's clinical record revealed diagnoses that included Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors) and Type 2 Diabetes Mellitus. Further review of Resident 20's clinical record revealed that he was admitted to the hospital on [DATE], and readmitted to the facility on [DATE]. Review of Resident 20's hospital Discharge summary, dated [DATE], revealed that he was diagnosed with a UTI (urinary tract infection) during his hospital admission. Review of Resident 20's physician note, dated January 3, 2025, revealed that Resident 20 was diagnosed with a UTI during his hospitalization. Review of Resident 20's MAR, dated January 2025, revealed that Resident 20 received Levaquin (antibiotic) on January 4-7, for treatment of his UTI. Review of Resident 20's significant change MDS, dated [DATE], revealed in section I, it was not coded that Resident 20 had a UTI in the past 30 days. Further review of the MDS revealed in Section N, it was not coded that Resident 20 received an antibiotic in the past seven days. On March 13, 2025, at 10:32 AM, the NHA stated that the UTI was missed being coded on the MDS and one day of antibiotic should have been coded during the seven day lookback period. 395923 Page 2 of 3 395923 03/13/2025 Chapel Pointe at Carlisle 770 S. Hanover Street Carlisle, PA 17013

F 0641 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395923 Page 3 of 3