LeTort Spring Nursing and Rehab LLC Inspection Report, Violations & Safety Grade (CARLISLE, Pennsylvania)

801 N. HANOVER STREET, CARLISLE, Pennsylvania 17013

Phone: 7172495322

CMS Overall:1/5

Overview & Bed Count

Certified Beds

109

Avg Residents/Day

102.6

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Cumberland

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing2/5

Quality2/5

Nurse Staffing Check

Metric	This Facility	Pennsylvania Avg	Difference
RN Hours per Resident per Day	0.51	0.78	-0.26
Total Nurse Hours per Resident per Day	3.51	3.90	-0.39
CMS Staffing Rating	2/5	3.1/5	-
Nursing Staff Turnover	65.2%	44.6%	-

Health Citation History

59 health citations on record

Date	Category	Description	Severity
2026-03-23	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	D – Moderate Harm Potential
2026-02-11	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2026-02-11	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	E – Moderate Harm Potential
2026-02-11	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2026-02-11	Nutrition and Dietary Deficiencies	Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.	E – Moderate Harm Potential
2026-02-11	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-02-11	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	D – Moderate Harm Potential
2026-02-11	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2026-02-11	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2026-02-11	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2026-02-11	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2026-02-11	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2026-02-11	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2026-02-11	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2026-02-11	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2026-02-11	Quality of Life and Care Deficiencies	Provide care or services that was trauma informed and/or culturally competent.	D – Moderate Harm Potential
2026-02-11	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2026-02-11	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	D – Moderate Harm Potential
2026-02-11	Administration Deficiencies	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	D – Moderate Harm Potential
2026-01-29	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	G – Actual Harm
2026-01-29	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	G – Actual Harm
2025-12-26	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-12-26	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	D – Moderate Harm Potential
2025-04-24	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	K – Immediate Jeopardy
2025-02-06	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	G – Actual Harm
2025-02-06	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	E – Moderate Harm Potential
2025-02-06	Resident Rights Deficiencies	Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	E – Moderate Harm Potential
2025-02-06	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2025-02-06	Pharmacy Service Deficiencies	Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	E – Moderate Harm Potential
2025-02-06	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-02-06	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2025-02-06	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2025-02-06	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	D – Moderate Harm Potential
2025-02-06	Quality of Life and Care Deficiencies	Provide routine and 24-hour emergency dental care for each resident.	D – Moderate Harm Potential
2025-02-06	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2025-02-06	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	D – Moderate Harm Potential
2025-02-06	Infection Control Deficiencies	Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	D – Moderate Harm Potential
2024-11-25	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2024-11-25	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2024-11-25	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2024-07-30	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	D – Moderate Harm Potential
2024-03-21	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	G – Actual Harm
2024-03-21	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2024-03-21	Resident Rights Deficiencies	Reasonably accommodate the needs and preferences of each resident.	E – Moderate Harm Potential
2024-03-21	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	E – Moderate Harm Potential
2024-03-21	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2024-03-21	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2024-03-21	Nutrition and Dietary Deficiencies	Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.	E – Moderate Harm Potential
2024-03-21	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2024-03-21	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	E – Moderate Harm Potential

Showing 50 of 59 citations.

Fire Safety Citation History

5 fire safety citations on record

Date	Category	Description	Severity
2025-02-06	Construction Deficiencies	Meet other general requirements.	C – Minimal Harm Potential
2024-03-21	Construction Deficiencies	Meet other general requirements.	C – Minimal Harm Potential
2023-04-05	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2023-04-05	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-04-05	Construction Deficiencies	Meet other general requirements.	C – Minimal Harm Potential

Total Penalties & Fines

$63,892

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2025-04-24	Fine	$17,345	-
2025-02-06	Fine	$33,716	-
2024-03-21	Fine	$12,831	-

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