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CARLISLE SKILLED NURSING AND REHABILITATION CENTER Inspection Report, Violations & Safety Grade (CARLISLE, Pennsylvania)

940 WALNUT BOTTOM ROAD, CARLISLE, Pennsylvania 17013

Phone: 7172490085

CMS Overall:1/5

Overview & Bed Count

Certified Beds

150

Avg Residents/Day

135.5

Ownership

For profit - Corporation

Provider Type

Medicare and Medicaid

County

Cumberland

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing2/5

Quality2/5

Nurse Staffing Check

Metric	This Facility	Pennsylvania Avg	Difference
RN Hours per Resident per Day	0.42	0.78	-0.35
Total Nurse Hours per Resident per Day	3.41	3.90	-0.48
CMS Staffing Rating	2/5	3.1/5	-
Nursing Staff Turnover	63.0%	44.6%	-

Health Citation History

71 health citations on record

Date	Category	Description	Severity
2026-07-23	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2026-07-23	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	G – Actual Harm
2026-07-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	E – Moderate Harm Potential
2026-07-23	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	E – Moderate Harm Potential
2026-07-23	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2026-07-23	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Assist a resident in gaining access to vision and hearing services.	E – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	E – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	E – Moderate Harm Potential
2026-07-23	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	E – Moderate Harm Potential
2026-07-23	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2026-07-23	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2026-07-23	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	E – Moderate Harm Potential
2026-07-23	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.	E – Moderate Harm Potential
2026-07-23	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2026-07-23	Resident Rights Deficiencies	Allow residents to self-administer drugs if determined clinically appropriate.	D – Moderate Harm Potential
2026-07-23	Resident Rights Deficiencies	Ensure residents have reasonable access to and privacy in their use of communication methods.	D – Moderate Harm Potential
2026-07-23	Resident Rights Deficiencies	Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	D – Moderate Harm Potential
2026-07-23	Resident Assessment and Care Planning Deficiencies	Assure that each resident’s assessment is updated at least once every 3 months.	D – Moderate Harm Potential
2026-07-23	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	D – Moderate Harm Potential
2026-07-23	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	D – Moderate Harm Potential
2026-07-23	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2026-07-23	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	D – Moderate Harm Potential
2026-03-20	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	G – Actual Harm
2026-02-02	Quality of Life and Care Deficiencies	Provide routine and 24-hour emergency dental care for each resident.	E – Moderate Harm Potential
2025-12-15	Pharmacy Service Deficiencies	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	D – Moderate Harm Potential
2025-06-26	Nutrition and Dietary Deficiencies	Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.	K – Immediate Jeopardy
2025-06-26	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	J – Immediate Jeopardy
2025-06-26	Resident Rights Deficiencies	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.	E – Moderate Harm Potential
2025-06-26	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	E – Moderate Harm Potential
2025-06-26	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	E – Moderate Harm Potential
2025-06-26	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2025-06-26	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	E – Moderate Harm Potential
2025-06-26	Nursing and Physician Services Deficiencies	Observe each nurse aide's job performance and give regular training.	E – Moderate Harm Potential
2025-06-26	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2025-06-26	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-06-26	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2025-06-26	Quality of Life and Care Deficiencies	Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	D – Moderate Harm Potential
2025-06-26	Quality of Life and Care Deficiencies	Assist a resident in gaining access to vision and hearing services.	D – Moderate Harm Potential
2025-06-26	Quality of Life and Care Deficiencies	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	D – Moderate Harm Potential
2025-06-26	Quality of Life and Care Deficiencies	Provide safe, appropriate pain management for a resident who requires such services.	D – Moderate Harm Potential
2025-06-26	Nursing and Physician Services Deficiencies	Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.	D – Moderate Harm Potential
2025-06-26	Quality of Life and Care Deficiencies	Provide routine and 24-hour emergency dental care for each resident.	D – Moderate Harm Potential
2025-06-26	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2024-07-18	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	E – Moderate Harm Potential
2024-07-18	Resident Rights Deficiencies	Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	E – Moderate Harm Potential

Showing 50 of 71 citations.

Fire Safety Citation History

19 fire safety citations on record

Date	Category	Description	Severity
2025-06-26	Emergency Preparedness Deficiencies	Conduct risk assessment and an All-Hazards approach.	F – Moderate Harm Potential
2025-06-26	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	F – Moderate Harm Potential
2025-06-26	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2025-06-26	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	D – Moderate Harm Potential
2025-06-26	Emergency Preparedness Deficiencies	Develop and maintain an Emergency Preparedness Program (EP).	C – Minimal Harm Potential
2025-06-26	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	C – Minimal Harm Potential
2024-07-18	Egress Deficiencies	Have properly located and lighted "Exit" signs.	E – Moderate Harm Potential
2024-07-18	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2024-07-18	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2024-07-18	Miscellaneous Deficiencies	Provide properly sized and located linen or trash receptacles.	E – Moderate Harm Potential
2023-08-31	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	F – Moderate Harm Potential
2023-08-31	Egress Deficiencies	Install emergency lighting that can last at least 1 1/2 hours.	F – Moderate Harm Potential
2023-08-31	Construction Deficiencies	Use approved construction type or materials.	E – Moderate Harm Potential
2023-08-31	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	E – Moderate Harm Potential
2023-08-31	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2023-08-31	Miscellaneous Deficiencies	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	E – Moderate Harm Potential
2023-08-31	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	E – Moderate Harm Potential
2023-08-31	Construction Deficiencies	Meet other general requirements.	C – Minimal Harm Potential
2023-08-31	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	C – Minimal Harm Potential

Total Penalties & Fines

$90,205

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-03-20	Fine	$50,150	-
2025-06-26	Fine	$31,231	-
2024-04-11	Fine	$8,824	-

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Need Help Finding Safe Care?

Our family advisors can help you find vetted, top-rated facilities in the CARLISLE area at no cost.

Find Safe, Vetted Facilities Near CARLISLE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)

Advisor service is free for families. We may receive referral compensation.