Home / Pennsylvania / Carlisle
940 Walnut Bottom Road, Carlisle, PA 17013 · Cumberland County · (717) 249-0085
150 certified beds, about 135 residents a day · For profit - Corporation · Medicare and Medicaid since 1987
CMS Care Compare ratings, data as of September 1, 2026 · CCN 395746 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on July 23, 2026, inspectors cited 27 health deficiencies (the Pennsylvania average is 10, the national average 9.2).
Of 71 health citations since April 2024, 6 were rated as actual harm or immediate jeopardy to residents (2 immediate jeopardy).
CMS lists 3 fines totaling $90,205 in the last three years; the largest was $50,150, and the latest is dated March 20, 2026.
Nurses and nurse aides worked 3.19 hours per resident per day, against 3.89 across Pennsylvania and 3.86 nationally. Registered nurses accounted for 0.39 of those hours.
61.3% of nursing staff left within the year CMS measured (Pennsylvania average 44.5%).
CMS links it to Genesis Healthcare, an affiliated group of 184 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 71 health citations on file.
Inspectors wroteBased on facility policy review, nurse aide competency review, clinical record review, review of select facility documentation, hospital discharge summary, and staff interviews, it was determined that the facility failed to provide adequate supervision and assistance to prevent accidents for one of 29 residents reviewed (Resident 111), which resulted in actual harm for Resident 111 as evidenced by a femur fracture. Review of facility policy, titled Falls Management last reviewed January 15, 2026, read, in part, Patients will be assessed for risk of falling as part of the nursing assessment process. Interventions to reduce risk and minimize injury will be implemented as appropriate. Implement and document patient-centered interventions according to individual risk factors in the patient's plan of care. [...]
Inspectors wroteBased on review of facility policy, clinical record, observations, and resident and staff interviews, it was determined the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, which resulted in actual harm as evidence by weight loss for one of five Residents reviewed (Resident 1). Also, the facility failed to adequately monitor and document fluid restrictions for one of five residents reviewed (Resident 8), and failed to reweigh and notify the physician and dietician of significant weight loss for one of five residents reviewed (Resident 21).
Inspectors wroteBased on facility policy review, personnel file review, and staff interview, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to perform licensure or registry verifications prior to hire for three of four personnel files reviewed (Employees 7, 8, and 9).
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for three of 29 residents reviewed (Residents 7, 47, and 56).
Inspectors wroteBased on clinical record review, facility policy review, as well as resident, resident representative, and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 29 residents reviewed (Residents 1, 34, 85, and 130), and failed to ensure that care plan meetings were held, residents were invited, and that the required interdisciplinary team members attended care plan meetings for three of 29 residents reviewed (Residents 6, 34, 106).
Inspectors wroteBased on facility policy review, clinical record reviews, observations, and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards during medication administration for four of six residents observed (Residents 1, 38, and 99) and failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one of two resident's reviewed for respiratory care (Resident 2).
Inspectors wroteBased on clinical record reviews, observation, and resident and staff interviews, it was determined that the facility failed to ensure that residents received proper treatment and assistive devices to maintain hearing abilities for two out of four residents reviewed for hearing (Residents 34 and 115).
Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility receive appropriate services, equipment, and assistance to maintain or improve mobility for four of four residents reviewed for limited range of motion (Residents 6, 7, 11, and 34).
Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to maintain complete and accurate records related to dialysis communication and failed to appropriately monitor a resident receiving dialysis services for one of one residents reviewed (Resident 4).
Inspectors wroteBased on policy review, grievance review, resident council meeting minute review, facility audit review, and resident and staff interviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for three out of three nursing units (East, West, and Arcadia).
Inspectors wroteBased on facility policy reviews, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that it was free from a medication error rate of five percent or greater based on four medication errors out of 25 opportunities.
Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interviews, it was determined that the facility failed to properly label medication vials, failed to dispose of medications upon a resident's discharge, and failed to monitor medication refrigerator temperatures to ensure refrigerated medications are stored at an acceptable temperature in two of two medication rooms observed (West Hall and Arcadia Unit); and failed to discard medications with illegible manufacturer expiration dates in one of three medication carts observed (East Wing D Hall).
Inspectors wroteBased on facility policy reviews, clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure staff implemented appropriate infection control guidelines during medication administration for two of six residents observed (Residents 1 and 79), during wound care for one of one resident observed (Resident 1), and failed to implement appropriate infection control precautions per facility policy and physician orders for one of 29 residents reviewed (Resident 65).
Inspectors wroteBased on facility policy review, review of personnel files, and staff interviews, it was determined the facility failed to ensure abuse training upon hire was completed for two of five employees reviewed (Employees 7 and 13).
Inspectors wroteBased on facility policy review, clinical record reviews, observations, and staff interview, it was determined that the facility failed to promote an environment that enhances each resident's dignity by storing incontinent briefs in open view for two of 29 residents reviewed (Residents 30 and 34).
Inspectors wroteBased on facility policy review, clinical record review, observation, and resident and staff interviews, it was determined that the facility failed to determine a resident's right to self-administer medications was clinically appropriate for one of one resident reviewed (Resident 1).
Inspectors wroteBased on policy review and resident and staff interviews, it was determined that the facility failed to ensure the resident has the right to privacy when receiving mail and packages for two of 29 residents reviewed (Residents 4 and 110).
Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to ensure the residents' right to a clean, comfortable, and homelike environment, including housekeeping and maintenance services, to maintain a sanitary, orderly and comfortable interior for three of 29 residents reviewed (Residents 6, 34, and 67).
Inspectors wroteBased on clinical record review and staff interviews, it was determined the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for one of 29 residents reviewed (Resident 6).
Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 29 residents reviewed (Resident 1). Findings Include: Facility policy, titled OPS416 Person-Centered Care Plan, revision date September 15, 2025, read, in part, 1. Baseline Care Plan . 1.1.7. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the patient and patient representative, if applicable.1.1. 7.2. Interventions shall be initiated that address the patient's current needs including: [...]
Inspectors wroteBased on policy review, clinical record review, resident council interviews, and resident and staff interviews, it was determined that the facility failed to provide necessary services to a resident who is unable to carry out activities of daily living (ADLs) to maintain personal hygiene for three out of five residents reviewed for ADL care (Residents 2, 3, and 28).
Inspectors wroteBased on clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that treatments were provided as ordered for two of 29 residents reviewed (Residents 99 and 106); failed to ensure catheter orders were complete for one of two residents reviewed for catheters (Resident 1); and failed to ensure consultation appointments were scheduled in a timely manner to meet each resident's physical, mental, and psychosocial needs for one of 29 residents reviewed (Resident 99).
Inspectors wroteBased on facility policy review, observations, resident and staff interviews, and clinical record reviews, it was determined that the facility failed to ensure that a resident receiving wound care was consistent with infection control standards of practice regarding aseptic field at the bedside and hand hygiene for one of four residents reviewed (Resident 1); and failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent of a pressure ulcers for one of four residents reviewed (Resident 122). Findings Include: Review of the facility policy, titled Procedure: Wound Dressings, Aseptic last reviewed February 24, 2025, revealed, in part, the following steps: 3. Prepare a clean, uncluttered, disinfected surface. 4. Create an aseptic field at bedside and place clean barrier on over-bed table. [...]
Inspectors wroteBased on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that a resident admitted with an indwelling foley catheter was accurately assessed for the removal of the catheter for one of one resident reviewed (Resident 1).
Inspectors wroteBased on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two of five residents reviewed for pain management (Residents 47 and 122).
Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide the licensed pharmacist's report of a medication irregularity for two of five residents reviewed (Residents 3 and 112).
Inspectors wroteBased on nurse aide job description review, employee file reviews, and staff interview, it was determined that the facility failed to ensure required in-service training for nurse aides sufficient to ensure the continuing competence of nurse aides no less than 12 hours per year and/or include resident abuse prevention training for two of five nurse aide files reviewed for annual education requirements (Employees 10 and 11).
Inspectors wroteBased on clinical record review select document review and staff interviews, it was determined that the facility failed to complete routine and weekly skin checks for one of five residents reviewed (Resident 1). In addition, the facility failed to provide timely and comprehensive care and services after a change in condition including a respiratory assessment on a resident in respiratory distress, which resulted in harm as evidenced by hospital admission for respiratory failure that required intubation and abnormal labs for one of five residents reviewed (Resident 2). Findings Include: [...]
Inspectors wroteBased on clinical record reviews and staff interviews, it was determined that the facility failed to ensure dental services were provided to meet resident needs for three of three residents reviewed (Residents 1, 2, and 3).
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide pharmaceutical services to meet the needs of each resident for one of three residents reviewed (Resident 2).
Inspectors wroteBased on facility policy reviews, observations, clinical record reviews, review of facility master menu diet guide sheets, and staff interviews, it was determined that the facility failed to provide an altered texture diet, as prescribed by the physician, for six residents (Residents 2, 9, 12, 14, 60, and 101) observed. This failure placed 14 additional residents that had similar diet needs at a high risk for death and resulted in an Immediate Jeopardy situation (Residents 12, 13, 39, 50, 51, 62, 68, 73, 74, 78, 98, 108, 110, and 289).
Inspectors wroteBased on clinical record review, facility document review, policy review and staff interviews, it was determined that the facility failed to conduct thorough fall investigations for one of six residents reviewed for falls (Resident 81) and failed to ensure that residents who expressed suicidal ideations were provided supervision and safety interventions were put into place to prevent serious bodily injury and/or death. This failure resulted in Resident 59 cutting himself and an immediate jeapordy situation.
Inspectors wroteBased on clinical record reviews, review of facility provided documentation, and staff interviews, it was determined that the facility failed to provide notice of a resident's transfer to the Office of the State Long-Term Care Ombudsman for five of 11 residents reviewed for hospital transfers (Residents 27, 48, 79, 81, and 86).
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for four of 33 residents reviewed (Residents 48, 79, 86 and 105).
Inspectors wroteBased on review of facility policy, clinical record reviews, as well as staff, resident representative, and resident interviews, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for four of 28 residents reviewed (Residents 48, 77, 94, and 102), and that residents were given the opportunity to participate in the care planning process and failed to ensure care plan meetings were being completed for five of 28 residents reviewed (Residents 25, 26, 47, 59, and 79). Findings Include: Facility policy, titled OPS416 Person-Centered Care Plan, last reviewed May 7, 2025, read in part, 7. Care plans will be: [...]
Inspectors wroteBased on observations, review of the clinical record, and staff interviews, it was determined that the facility failed to ensure care and services are provided in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for five of 28 residents (Residents 13, 27, 38, 79, and 102).
Inspectors wroteBased on review of facility policy, record review, observations, and resident and staff interviews, it was determined that the facility failed ensure the resident received care, consistent with professional standards, to treat and prevent pressure ulcers for two of three residents reviewed (Residents 77 and 106). Findings Include: Review of facility policy, titled NSG236, Revised October 15, 2024, revealed in 6.10. Determine the need for heel off-loading, 6.13 Implement special wound care treatments/techniques, as indicated and ordered, and step 11. Review care plan and revise as indicated. Review of Resident 77's clinical record revealed diagnoses that included osteomyelitis of left ankle and foot (infectious inflammation of bone marrow) and diabetes (a disease that effects how the body utilizes and regulates blood sugar). [...]
Inspectors wroteBased on facility document review and staff interview, it was determined that the facility failed to ensure employee performance reviews were completed yearly (at least every 12 months) for five of five employees reviewed (Employees 9, 12, 13, 14, and 15).
Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to discard expired medications in one of three medication carts observed (B Hall) and in one of two medication rooms observed (West Wing).
Inspectors wroteBased on review of manufacturer guidelines, observation, review of select facility temperature logs, and staff interviews, it was determined that the facility failed to utilize equipment in accordance with professional standards for food service safety in the main kitchen.
Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of one residents reviewed (Resident 287); and failed to provide the resident and their representative with a summary of the baseline care plan that includes, but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary for one of one resident's reviewed (Resident 287).
Inspectors wroteBased on facility policy review, clinical record review, observations, and resident and staff interviews, it was determined that the facility failed to provide care and services regarding hygiene and bathing for one of 28 residents reviewed (Resident 48).
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined the facility failed to ensure each resident receives proper treatment and services to maintain hearing abilities for one of three residents reviewed for vision and hearing (Resident 42).
Inspectors wroteBased on review of clinical records, policy review, observation, and staff interviews, it was determined that the facility failed to provide restorative nursing care for range of motion exercises for two of four residents reviewed for limited range of motion (Residents 5 and 88).
Inspectors wroteBased on review of facility policy, clinical record reviews, and resident and staff interviews, it was determined that the facility failed to manage or prevent pain consistent with professional standards of practice and the residents' goals and preferences for three of 28 residents reviewed (Residents 13, 27, and 287).
Inspectors wroteBased on observations, review of grievances, and resident and staff interviews it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one out of three nursing units (West wing). Findings Include: During the initial pool process on June 23, 2025, and June 24, 2025, there were 10 residents who expressed concern to the survey team about call bell response time and/or staffing. Review of facility grievances from April, May, and June of 2025 revealed three grievances related to extended wait time for call bells to be answered. Review of Resident Council Meeting minutes for April, May, and June of 2025 revealed that residents present at the meetings complained about extended call bell wait times in April and May of 2025. [...]
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure dental services were provided to meet resident need for one of one resident reviewed for dental (Resident 14).
Inspectors wroteBased on review of facility policy, review of medication package insert, observations, and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the preparation and administration of medications to four of four residents observed (Residents 19, 52, 87, and 109).
Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for four of four Residents reviewed (Residents 5, 25, 40, and 54).
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to provide a notice of transfer to residents and/or resident representatives, or to the Office of the State Long-Term Care Ombudsman for eight of 11 residents reviewed for hospital transfers (Residents 5, 7, 22, 25, 27, 39, 54, and 103).
Inspectors wroteBased on policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide residents and/or resident representatives with the facility's bed hold policy upon transfer for seven of 11 residents reviewed for hospitalization (Residents 5, 7, 25, 27, 39, 54, and 103).
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for six of 30 residents reviewed (Residents 7, 25, 38, 39, 123, and 124).
Inspectors wroteBased on clinical record review, facility policy review, observation, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for four of 27 residents reviewed (Resident's 5, 40, 41, and 113).
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed for limited range of motion (Resident 115).
Inspectors wroteBased on observations, clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure respiratory care was provided in a manner consistent with professional standards of practice for three of five residents reviewed for respiratory care (Residents 41, 54, and 84).
Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure pharmacy recommendations were appropriately acted upon for four of five residents reviewed for unnecessary medications (Resident 7, 25, 54, and 56), and one of one resident reviewed for insulin use (Resident 51).
Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, it was determined that the facility failed to ensure the resident medication regimen was free of unnecessary psychotropic medications for two of five residents reviewed for unnecessary medications (Residents 25 and 56).
Inspectors wroteBased on observations, facility policy review, and staff interview, it was determined that the facility failed to place opened dates on medications in two of three medication carts observed (100 Hall and 200 Hall). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medication, Biologicals, last reviewed April 24, 2024, read, in part, This Policy 5.3 sets forth the procedures relating to the storage and expiration dates of medication, biologicals, syringes, and needles. Procedure 5. Once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dated for opened medication. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. [...]
Inspectors wroteBased on facility policy reviews, observations, and staff interview, it was determined that the facility failed to store food and utilize equipment in accordance with professional standards for food service safety in the main kitchen and three of three nourishment areas
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that each resident's medical record includes documentation that indicates the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal and influenza immunizations for four of five residents reviewed for immunizations (Residents 17, 25, 47, and 107). Findings Include: Review of facility policy, titled IC600 Influenza Immunization Program, revised September 1, 2023, revealed, Obtain consent for influenza vaccination; patient immunization consent is documented in PointClickCare (PCC) [electronic health record] --Patient Informed Consent or Declination; document influenza vaccination refusals. [...]
Inspectors wroteBased on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide evidence that education was provided to Residents on the risks and benefits of the COVID-19 vaccine for three of five residents reviewed for immunizations (Residents 17, 25, and 107). Findings Include: Review of facility policy, titled IC604 COVID-19 Vaccination, revised February 7, 2024, revealed, Based on the patient's COVID-19 vaccination history, offer the vaccination following the manufacturer's recommended schedule. Obtain consent. [...]
Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to maintain a safe, clean, and home-like environment on one of three units observed (East Lounge).
Inspectors wroteBased on review of clinical records, facility policy review, and staff interview, it was determined that the facility failed to ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of two residents reviewed (Resident 57).
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 27 residents reviewed (Residents 378).
Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident comprehensive plan of care accurately reflected the status of two of 27 residents reviewed (Residents 56 and 83).
Inspectors wroteBased on facility policy review, observations, clinical record review, and staff interview, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of 27 residents reviewed (Resident 5). Findings Include: Review of facility policy, titled 5.3 Storage and Expiration Dating of Medications, Biologicals, with a last revision date of August 7, 2023, and last review date of April 24, 2024, revealed 13. Bedside Medication Storage: 13.1 Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order and approval by the Interdisciplinary Care Team and Facility administration; and 13.2 Facility should store bedside medications or biologicals in a locked compartment within the resident's room. [...]
Inspectors wroteBased on clinical record review and resident and staff interviews, it was determined that the facility failed to ensure each resident received treatment in accordance with professional standards of practice for two of 27 residents reviewed (Residents 113 and 378). Findings Include: Review of Resident 113's clinical records revealed diagnoses that included acute renal failure (ARF - a sudden and often reversible decrease in kidney function), short bowel syndrome (condition that occurs when the small is damaged preventing absorption of nutrients from food), and protein-calorie malnutrition (nutritional state where the body doesn't get enough protein, calories, or other nutrients causing changes in body composition and function). Review of Resident 113's physician orders revealed an order for a left double lumen PICC (peripherally inserted central catheter): [...]
Inspectors wroteBased on observations, policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections and complications related to the use of a foley catheter (small, flexible tube that can be inserted through the urethra and into the bladder, allowing urine to drain) for two of two residents reviewed for catheter use (Residents 12 and 40). Findings Include: Review of facility policy, titled Catheter: Indwelling Urinary - Care Of, revised February 1, 2023, revealed, Secure the catheter tubing to keep the drainage bag below the level of the resident's bladder and off the floor. Review of Resident 12's clinical record revealed diagnoses that included malignant neoplasm of bladder (bladder cancer) and retention of urine. [...]
Inspectors wroteBased on facility policy review, observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to monitor hydration status precisely and effectively for one of 27 residents reviewed (Resident 7).
Inspectors wroteBased on observation, review of facility policy and documents, and staff interviews, it was determined that the facility failed to provide foods and beverages that are palatable, and at a safe and appetizing temperature for one of one meal observed on the Arcadia unit.
Inspectors wroteBased on clinical record review, hospital records, staff interviews, and review of the facility incident report, it was determined that the facility failed to ensure that care and services were provided timely following a fall with fracture for one of three residents reviewed (Resident 1), which resulted in harm as evidenced by uncontrolled fracture-related pain and delayed corrective treatment.
19 fire safety citations on file: 6 on June 26, 2025, 4 on July 18, 2024, 9 on August 31, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| March 20, 2026 | Fine | $50,150 |
| June 26, 2025 | Fine | $31,231 |
| April 11, 2024 | Fine | $8,824 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Pennsylvania | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.19 | 3.89 | 3.86 |
| Registered nurses | 0.39 | 0.79 | 0.69 |
| All nursing staff on weekends | 2.89 | 3.53 | 3.42 |
| Nurse aides | 1.93 | ||
| Licensed practical nurses | 0.87 | ||
| Nursing staff turnover (share who left in a year) | 61.3% | 44.5% | 45.8% |
| Registered nurse turnover | 58.3% | 39.9% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.71 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.31 on weekdays and 2.89 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 9.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.30 in April to June 2025 to 3.19 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.19 | 0.39 | 3.31 | 2.89 | 9.9% | 0 of 90 | 135 |
| Oct to Dec 2025 | 3.00 | 0.37 | 3.14 | 2.65 | 3.5% | 0 of 92 | 134 |
| Jul to Sep 2025 | 3.22 | 0.36 | 3.37 | 2.84 | 7.4% | 0 of 92 | 134 |
| Apr to Jun 2025 | 3.30 | 0.38 | 3.46 | 2.89 | 24.7% | 0 of 91 | 137 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Pennsylvania, Jan to Mar 2026 | 3.69 | 0.65 | 3.82 | 3.34 | 11.3% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Pennsylvania, all employers | |||
| CNAs (nursing assistants) | $21.44 | $18.88 to $22.52 | 67,740 |
| LPNs and LVNs | $30.74 | $29.02 to $35.01 | 38,260 |
| Registered nurses | $46.36 | $38.75 to $50.35 | 146,520 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Pennsylvania | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 19.0 | 16.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.9 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 3.9 | 1.4 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 3.6 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 3.5 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 25.1 | 17.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.8 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 16.6 | 17.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 17.9 | 22.5 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 16.7 | 9.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.2 | 1.6 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.6 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Carlisle Skilled Nursing and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (46.3% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
46.3% this home
No different from the national rate
US median of homes 51.5% · Pennsylvania: 100 better, 108 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 97 eligible stays.
10.5% this home
No different from the national rate
US median of homes 10.7% · Pennsylvania: 3 better, 9 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 104 eligible stays.
9.8% this home
No different from the national rate
US median of homes 7.1% · Pennsylvania: 7 better, 5 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 68 eligible stays.
36.5% this home
Median of homes: Pennsylvania54.4% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 74 residents counted.
1.0% this home
Median of homes: Pennsylvania0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 99 residents counted.
7.3% this home
Median of homes: Pennsylvania2.0% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 99 residents counted.
86.2% this home
Median of homes: Pennsylvania100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 29 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: 940 WALNUT BOTTOM ROAD OPERATIONS LLC. CMS links this home to Genesis Healthcare, a group of 184 nursing homes averaging 2.3 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Genesis Pm Pa Operations LLC | 5% or greater direct ownership interest | Organization | 100% | 11/14/2022 |
| Fc-Gen Operations Investment LLC | 5% or greater indirect ownership interest | Organization | 11/14/2022 | |
| Gen Operations I LLC | 5% or greater indirect ownership interest | Organization | 11/14/2022 | |
| Gen Operations II LLC | 5% or greater indirect ownership interest | Organization | 11/14/2020 | |
| Genesis Healthcare Inc | 5% or greater indirect ownership interest | Organization | 11/14/2022 | |
| Genesis Healthcare LLC | 5% or greater indirect ownership interest | Organization | 11/14/2022 | |
| Genesis Holdings LLC | 5% or greater indirect ownership interest | Organization | 11/14/2022 | |
| Ghc Holdings LLC | 5% or greater indirect ownership interest | Organization | 11/14/2022 | |
| Sun Healthcare Group Inc | 5% or greater indirect ownership interest | Organization | 11/14/2022 | |
| Berg, Michael | Corporate officer | Individual | 11/14/2022 | |
| Bridgeford, Laura | Corporate officer | Individual | 06/01/2024 | |
| Kirschner, Jonathan | Corporate officer | Individual | 01/01/2019 | |
| Mendelson, Avi | Corporate officer | Individual | 06/01/2024 | |
| Murray, Lauren | Corporate officer | Individual | 01/01/2019 | |
| Anjum, Rashid | Operational/managerial control | Individual | 06/01/2022 | |
| Mitrzyk, Susan | Operational/managerial control | Individual | 05/01/2020 | |
| Anjum, Rashid | Adp of the SNF | Individual | 02/14/2025 | |
| Mitrzyk, Susan | Adp of the SNF | Individual | 02/14/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
Licensed assisted living residences and personal care homes in the same town or within 5 miles, each with its Pennsylvania licence record.
These are the official offices in Pennsylvania. NursingHomeClear cannot take or act on complaints.