Forest Park Nursing And Rehabilitation
FOREST PARK NURSING AND REHABILITATION in CARLISLE, PA — inspection on February 24, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation conducted of Resident 6 on February 18, 2026, revealed the Resident was residing in the locked dementia unit.
Interview conducted with Resident 6 on February 18, 2026, at approximately 1:00 PM, revealed the Resident did not give consent to move rooms and was not provided with a written notice of the room change.
Interview conducted with Employee 4 (Social Worker) on February18, 2026, at 1:25 PM, revealed that staff reported to him Resident 6 was going to get his money and car, and was going to leave the facility, so Employee 4 met with Resident 6, and Resident 6's POA (Power of Attorney) and decided to have Resident 6 move to the locked unit due to being an elopement risk.
Employee 4 confirmed that Resident 6 had a wander guard on, however, the facility had issues in the past where residents walked out of the facility wearing a wander guard and, at the end of the day, did not want to put anything to chance.
Employee 4 revealed that prior to the room change, Resident 6 was not having any issues in the room he was previously in.
Review of Resident 6's admission MDS (Minimum Data Set is part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes), revealed that Resident 6 has a BIMS (Brief interview of Mental Status) of 15, indicating normal thinking and memory.
Review of Resident 6's clinical record revealed a progress note written on February 13, 2026, at 4:03 PM, that the Resident changed rooms.
Review of Resident 6's clinical record revealed a progress note written on February 14, 2026, at 8:26 AM, that Resident 6 was upset and did not agree with the room change.
During an interview conducted with the Nursing Home Administrator (NHA) on February 18, 2026, at approximately 1:45 PM, it was revealed that it was a late Friday afternoon and Resident 6 was upset and wanted to leave, so they decided to put Resident 6 in a locked unit, so he was not able to do so. NHA confirmed Resident 6 was wearing a wander guard.
The facility was unable to provide a room change notification document that was provided to Resident 6 prior to changing rooms on February 13, 2026. Pa. code 211.12(d)(1) 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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
395270 02/24/2026
Forest Park Nursing and Rehabilitation 700 Walnut Bottom Road Carlisle, PA 17013
The facility failed to implement interventions to assure Resident safety, resulting in actual harm as evidenced by a laceration to a Resident's scalp, requiring sutures. 28 Pa.
Code 201.18(b)(1)(e)(1) Management28 Pa.
Code 211.10(c)(d) Resident care policies28 Pa.
Code 211.12(d)(1)(3)(5) Nursing services