LeTort Spring Nursing and Rehab: Medication Failures - PA
The resident, identified in inspection records only as Resident 3, had a physician's order for albuterol nebulization every four hours. He also had orders for geri-tussin, a cough syrup, on the same schedule, and Protonix, an acid-reducing medication, each morning. When inspectors reviewed his November 2025 medication administration record, the 4:00 AM entries for the albuterol and geri-tussin were blank. So was the 6:00 AM entry for the Protonix. His clinical record contained no progress notes, no nurse's explanation, nothing to account for the missed doses.
The Director of Nursing told inspectors she had placed a call to the nurse who worked that shift to find out whether the resident had actually received his medications. The inspection was conducted on January 29, 2026, nearly three months after the missed doses.
The problems with medication documentation at LeTort Spring were not limited to one resident or one morning.
Inspectors also reviewed the records of Resident 2, a separate patient whose medication history raised a different set of concerns. That resident had been prescribed Xanax, and the documentation surrounding a January 17, 2026, dose at 2:00 PM was contradictory. Inspectors found conflicting records and no explanation resolving them. Nobody at the facility provided clarifying information during the inspection interview.
There were also gaps in the weeks before that. Resident 2 had been prescribed Tylenol and buspirone, an anti-anxiety medication. The medication administration records for January 11 and January 21, 2026, showed those doses had not been documented as given. When the nursing home administrator audited the medication packets in response to the inspection, he found no pill pouches remaining in the cart for those dates, which he took to mean the pills had been administered. His conclusion: the nurses gave the medications but failed to document them.
That explanation left open a question the records could not answer. Whether the medications were given or simply missing from the packaging, the documentation did not show it either way.
The Xanax situation carried an additional problem. Inspectors found no information about when nursing staff had reordered Resident 2's Xanax from the pharmacy. The Director of Nursing confirmed she would expect staff to reorder a controlled substance when the supply dropped to a five-day threshold. She also confirmed she would expect staff to complete the Receipt Verification on the Controlled Substance Record. Whether that had happened for Resident 2's Xanax was not established during the inspection.
The Director of Nursing, the nursing home administrator, and a third staff member identified only as Employee 9 sat for an interview with inspectors on January 29 between 3:48 PM and 4:00 PM. The Director of Nursing said she would expect nurses to administer medications as ordered and to document them completely. She said the same thing twice, once about Resident 2 and once about Resident 3. The interview produced no new information about the January 17 Xanax discrepancy and no explanation for the blank entries in Resident 3's November record.
Inspectors classified the violations as causing actual harm.
Resident 3 had dementia. He could not have recognized that his breathing treatment had been skipped at 4:00 in the morning, could not have asked for it, could not have flagged the blank line in his own chart. His albuterol order had been in place since October 31, 2025. His cough syrup order dated to the same day. Both were prescribed every four hours. On the first morning of November, neither was given, or if they were, no one recorded it, and three months later the nurse who worked that shift still had not been reached.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Letort Spring Nursing and Rehab LLC from 2026-01-29 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 15, 2026 · Our methodology
LeTort Spring Nursing and Rehab LLC in CARLISLE, PA was cited for violations during a health inspection on January 29, 2026.
The resident, identified in inspection records only as Resident 3, had a physician's order for albuterol nebulization every four hours.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.