Cycle 1
Health 2023-02-23 · Fire 2023-02-23
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Carlisle, OH
Carlisle Manor Health Care Inc
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
730 Hillcrest Drive, Carlisle, OH
(937) 746-2662
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1996-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.68
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.21
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
75%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,916
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.71
Baseline 2.64 hours · Performance 3.34 hours · Measure score 1.71 · Achievement 0.91 · Improvement 1.71
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 14.04% |
8.2%
5.8 pts better
|
Numerator 8 · Denominator 57 |
| Staff flu vaccination coverage | 55.88% |
42%
13.9 pts better
|
Numerator 38 · Denominator 68 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
92.4%
4.2 pts worse
|
93.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 89.5% · Q3 87.2% · Q4 83.3% · 4Q avg 88.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.9% |
94.5%
1.6 pts worse
|
95.5%
2.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.3%
3.2 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.9% · Q3 5.1% · Q4 5.6% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
26.1%
21.8 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.9% · Q3 0.0% · Q4 9.1% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
6.2%
3.7 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 0.0% · Q3 3.6% · Q4 3.6% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.5% |
25.4%
9.1 pts worse
|
19.6%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 33.3% · Q3 32.1% · Q4 42.9% · 4Q avg 34.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
11.5%
7.7 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 4.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.0% |
7.7%
2.7 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
6.2%
0.8 pts worse
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 13.3% · Q3 3.7% · Q4 3.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.2%
0.4 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.5% |
21.7%
5.2 pts better
|
19.8%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 24.0% · Q3 20.1% · Q4 12.0% · 4Q avg 16.5% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
3.7%
2.5 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 9.1% · Q3 6.4% · Q4 2.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 54.5% |
78.1%
23.6 pts worse
|
81.7%
27.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 82.9% · Q2 58.5% · Q3 35.9% · Q4 41.3% · 4Q avg 54.5% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.0% |
75.6%
14.6 pts worse
|
79.7%
18.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-24 · Fire 2019-10-24
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-09-13 · Fire 2018-09-13
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-02-23
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-02-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-02-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-02-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-02-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-13
F · Potential for more than minimal harm
2019-10-24
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-12-13
F · Potential for more than minimal harm
2019-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-12-13
F · Potential for more than minimal harm
2018-09-13
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-10-10
F · Potential for more than minimal harm
2018-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-10-10
E · Potential for more than minimal harm
2018-09-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-10-10
E · Potential for more than minimal harm
2018-09-13
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2018-10-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-05
D · Potential for more than minimal harm
2024-09-04
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-11
G · Actual harm
2024-07-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-06
E · Potential for more than minimal harm
2023-02-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-16
E · Potential for more than minimal harm
2023-02-23
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-03-16
D · Potential for more than minimal harm
2023-02-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-16
E · Potential for more than minimal harm
2018-09-13
F909 · Environmental Deficiencies
Health
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.
Corrected 2018-10-10
D · Potential for more than minimal harm
2018-09-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-10-10
D · Potential for more than minimal harm
2018-09-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2018-10-10
Penalties and ownership
What sits behind the stars
Ownership
Embassy Healthcare Holdings Inc
5% Or Greater Direct Ownership Interest · Organization
2020 Gsr Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Aaron Handler Family Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Ah Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Bishop, Robert
Operational/Managerial Control · Individual
George S. Repchick 2020 Family Dynasty Trust
5% Or Greater Indirect Ownership Interest · Organization
Handler, Aaron
Operational/Managerial Control · Individual
Handler, Aaron
Corporate Officer · Individual
Kuranga, Abraham
Operational/Managerial Control · Individual
Repchick, George
Operational/Managerial Control · Individual
Repchick, George
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Momentous Health At Franklin
Franklin, OH
1-star overall rating with 1-star inspections with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Willow Knoll Post-Acute And Senior Living
Middletown, OH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Kingston Of Miamisburg
Miamisburg, OH
4-star overall rating with 3-star inspections with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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