Letort Spring Nursing And Rehab Llc
LeTort Spring Nursing and Rehab LLC in CARLISLE, PA — inspection on January 29, 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
During a staff interview with the
that she would expect nursing staff to administer a resident's medications as ordered by their
medication packets were audited and that there were no pill pouches still in the cart dated for January 11 and 21, 2026, and, therefore, the Tylenol and buspirone medications must have been administered and that the nurses must have failed to complete all the administration documentation of Resident 2's medications on those dates.
The DON indicated that she would expect nursing staff to reorder a medication when they are down to a five-day supply.
The DON confirmed that she would expect the pharmacy to dispense and deliver medications timely or to notify the facility immediately if there was an issue with filling a medication order.
The DON confirmed that she would expect staff to complete the Receipt Verification on a resident's Controlled Substance Record. At the interview, no additional information was provided regarding the conflicting documentation of Resident 2's January 17, 2026, 2:00 PM, dose of Xanax or information as to when nursing staff reordered Resident 2's Xanax from the pharmacy.
Review of Resident 3's clinical record revealed diagnoses that included dementia, hypertension (high blood pressure), and unspecified cough.
Review of Resident 3' s physician orders revealed orders for albuterol sulfate nebulization solution 2.5 milligrams/ 3 milliliters 0.083% administer 3 milliliters orally via nebulizer every four hours, dated October 31, 2025; geri-tussin oral syrup 100 milligrams/5 milliliters give 10 milliliters every four hours, dated October 31, 2025; and Protonix delayed release 40 milligrams in the morning, dated October 30, 2025.
Review of Resident 3's November 2025 MAR revealed that on November 1, 2025, his 4:00 AM doses of albuterol and geri-tussin as well as his 6:00 AM dose of Protonix were blank.
Review of Resident 3's clinical record progress notes failed to reveal any documentation as to why these medications were not administered as ordered.
During a staff interview with the NHA, DON, and Employee 9 on January 29, 2026, between 3:48 PM and 4:00 PM, the DON indicated that she would expect nursing staff to administer a resident's medications as ordered by their physicians and to complete all documentation appropriately.
She indicated that she had a call out to the nurse to determine if Resident 3 received his medications. 28 Pa.
Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1) Management28 Pa.
Code 211.9(a)(1) Pharmacy services28 Pa.
Code 211.10(c) Resident care policies28 Pa.
Code 211.12(d)(1)(2)(3)(5) Nursing services
395784 01/29/2026
Letort Spring Nursing and Rehab LLC 801 N.
Hanover Street Carlisle, PA 17013
During a staff interview with the Nursing Home Administrator
PM, the DON confirmed that facility nursing staff reordered Resident 1's lacosamide on January 12,
staff to follow-up with the pharmacy when the medication was not delivered when ordered.
She confirmed that there was no documentation of any notifications to or from pharmacy between January 12 and 17, 2026, at 1:26 PM regarding Resident 1's lacosamide supply.
The DON indicated that she would expect nursing staff to reorder a medication when they are down to a five-day supply.
The DON further indicated that the facility does have lacosamide in their locked electronic emergency medication supply, but nursing staff were unable to utilize this for Resident 1 between January 16 and 18, 2026, because the pharmacy said that they did not have a current script for the lacosamide and, therefore, would not supply an authorization code to retrieve the medication from the locked emergency supply.
The DON further confirmed that the pharmacy indicated on January 18, 2026, after a new prescription was provided by Resident 1's physician, that the pharmacy already had a current prescription for Resident 1's lacosamide and that it was overlooked by pharmacy staff and, therefore, the medication was not refilled when initially ordered on January 12, 2026.
The DON confirmed that she would expect the pharmacy to dispense and deliver medications timely or to notify the facility immediately if there was an issue with filling a medication order.
Review of Resident 2's clinical record revealed diagnoses that included dementia and anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
Review of Resident 2's physician orders revealed an order for Xanax (medication used to treat anxiety) 0.5 milligrams give one tablet every 8 hours, dated December 22, 2025.
Review of Resident 2's clinical record progress notes revealed a Medication Administration Note written by Employee 8 (LPN) dated January 26, 2026, at 8:45 AM, that indicated Resident 2's Xanax was not administered and awaiting pharmacy delivery.
Review of Resident 2's clinical record progress notes revealed a nurses note written by Employee 4 (RN) dated January 26, 2026, at 3:34 PM, that indicated Employee 4 contacted the pharmacy about retrieving Resident 2's Xanax from the emergency medication supply.
Employee 4 questioned why they could not administer Xanax 0.25 milligrams two tablets to equal Resident 4's ordered dose of 5 milligrams, but that the pharmacy indicated that medications must be dispensed as written.
The note further indicated that Employee 4 contacted Resident 2's physician for further orders and that the pharmacy indicated that the medication would be on the next pharmacy delivery to the facility.
Review of Resident 2's clinical record progress notes revealed a nurses note written by Employee 4 dated January 26, 2026, at 4:27 PM, that indicated Resident 2's physician gave a one-time order for Xanax 0.25 milligrams give two tablets now.
Review of Resident 2's current Controlled Substance Record revealed that the pharmacy filled the Xanax prescription on January 25, 2026, but the Receipt Verification section of the form was blank.
According to the record, the first dose was administered from the package on January 26, 2026, at 6:30 PM.
During a staff interview with the NHA, DON, and Employee 9 on January 29, 2026, between 3:48 PM and 4:00 PM, the DON indicated that she would expect nursing staff to reorder a medication when they are down to a five-day supply.
The DON confirmed that she would expect the pharmacy to dispense and deliver medications timely or to notify the facility immediately if there was an issue with filling a medication order.
The DON confirmed that she would expect staff to complete the Receipt Verification on a resident's Controlled Substance Record. At time of interview, no additional information was provided regarding when nursing staff reordered Resident 2's Xanax from the pharmacy or why there was a delay in delivery from the pharmacy. 28 Pa.
Code 201.14(a) Responsibility of licensee28 Pa.
Code 201.18(b)(1) Management28 Pa.
Code 211.9(a)(1) Pharmacy services28 Pa.
Code 211.10(c) Resident care policies28 Pa.
Code 211.12(d)(1)(2)(3)(5) Nursing services