Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

CARLISLE MANOR HEALTH CARE INC

CARLISLE, OH · 48 certified beds · Last Life Safety survey February 23, 2023

CMS Certification Number 366043 · first certified March 1996

Ownership

Operated by EMBASSY HEALTHCARE · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within OH

14 citations — more than 40% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (October 2024 to October 2025), and past the point by which nine in ten OH facilities have been surveyed. This facility’s last Life Safety survey was February 2023. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

1 of the 14 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

E-0018

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0909 Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

How that compares

Citations on file over three years

Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	14
Median facility in OH	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
September 13, 2018	4
October 24, 2019	5
February 23, 2023	5

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2023-02-23
K-0341	Install a fire alarm system that can be heard throughout the facility.	2	2023-02-23
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2023-02-23
E-0018	Establish procedures for tracking staff and patients during an emergency.	1	2018-09-13
K-0363	Install corridor and hallway doors that block smoke.	1	2019-10-24
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	1	2018-09-13
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	1	2023-02-23
K-0271	Have exits that are accessible at all times.	1	2019-10-24

What the citations cover

Citations by CMS category

Smoke Deficiencies 8
Gas, Vacuum, and Electrical Systems Deficiencies 3
Egress Deficiencies 1
Emergency Preparedness Deficiencies 1
Other 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	8
Gas, Vacuum, and Electrical Systems Deficiencies	3
Egress Deficiencies	1
Emergency Preparedness Deficiencies	1
Miscellaneous Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

February 23, 2023 — 5 citations

Citations issued on February 23, 2023
Tag	What the surveyor checks	Status
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (June 13, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (June 13, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (June 13, 2023)
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	Deficient, Provider has date of correction (June 13, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (June 13, 2023)

October 24, 2019 — 5 citations

Citations issued on October 24, 2019
Tag	What the surveyor checks	Status
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (December 13, 2019)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (December 13, 2019)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (December 13, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (December 13, 2019)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (December 13, 2019)

September 13, 2018 — 4 citations

Citations issued on September 13, 2018
Tag	What the surveyor checks	Status
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (October 10, 2018)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (October 10, 2018)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 10, 2018)
K-0917	Ensure electrical receptacles or cover plates have distinctive color or marking.	Deficient, Provider has date of correction (October 10, 2018)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.