Cycle 1
Health 2025-03-13 · Fire 2025-03-13
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Carlisle, PA
Chapel Pointe At Carlisle
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
770 S. Hanover Street, Carlisle, PA
(717) 249-1363
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
58
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.14
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
3.18
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
5.22
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.04
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.81
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.85
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.21
CMS adjusted RN staffing hours
Adjusted total hours
5.53
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
7%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
20%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
313
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
73.54
Composite VBP score used to determine payment impact.
Payment multiplier
1.0239
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
5.19
Baseline 5.84% · Performance 6.28% · Measure score 5.19 · Achievement 5.19 · Improvement 0
Total nurse turnover
10
Baseline 25.64% · Performance 18.67% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
6.87
Baseline 4.42 hours · Performance 5.03 hours · Measure score 6.87 · Achievement 6.87 · Improvement 3.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 6.83% |
| Discharge to community | 58.8% |
50.57%
8.2 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 54.55% · Lower 95% interval 43.38% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 77.27% |
95.27%
18 pts worse
|
Numerator 17 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 1 · Denominator 22 · Adjusted rate 4.6% |
| Healthcare-associated infections requiring hospitalization | 6.28% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 0% · Lower 95% interval 2.76% |
| Staff COVID-19 vaccination coverage | 1.85% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 108 |
| Staff flu vaccination coverage | 39.37% |
42%
2.6 pts worse
|
Numerator 100 · Denominator 254 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.7
0.4 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.4 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
86.9%
12.6 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.2%
2.5 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.5% · Q3 5.9% · Q4 3.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 3.0% |
6.5%
3.5 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.0% · Q3 2.3% · Q4 2.4% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.9% |
19.9%
6 pts worse
|
19.6%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 22.0% · Q3 30.2% · Q4 30.2% · 4Q avg 25.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.8% |
18.7%
5.9 pts better
|
16.7%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 14.8% · Q3 16.7% · Q4 14.7% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 22.8% |
19.6%
3.2 pts worse
|
16.3%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 6.8% · Q4 19.8% · 4Q avg 22.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
18.3%
8.6 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 38.5% · Q3 15.0% · Q4 35.7% · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.2% · Q3 3.6% · Q4 1.7% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
1.7%
2.7 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 9.8% · Q4 2.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.3% |
26.4%
11.9 pts worse
|
19.8%
18.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 44.3% · Q3 34.8% · Q4 41.1% · 4Q avg 38.3% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
5.3%
0.7 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 8.2% · Q3 3.0% · Q4 1.4% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.6% |
68.9%
22.7 pts better
|
81.7%
9.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 89.7% · Q3 97.1% · Q4 93.9% · 4Q avg 91.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.7% |
9.8%
4.1 pts better
|
12.0%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.7% · Observed 4.8% · Expected 9.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 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 | 85.7% |
68.7%
17 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
23.1%
3.6 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 14.3% · Expected 17.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-04 · Fire 2024-04-04
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-11 · Fire 2023-05-11
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-05-14
C · Minimal harm
2025-03-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-13
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-14
E · Potential for more than minimal harm
2023-05-11
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-26
E · Potential for more than minimal harm
2023-05-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-26
D · Potential for more than minimal harm
2023-05-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-26
Penalties and ownership
What sits behind the stars
Ownership
Apa, Ruth
Corporate Director · Individual
Brown, Terry
Operational/Managerial Control · Individual
Peachey, Kent
Operational/Managerial Control · Individual
Peachey, Kent
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Thornwald Home
Carlisle, PA
4-star overall rating with 3-star inspections with $9,110 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Forest Park Nursing And Rehabilitation
Carlisle, PA
1-star overall rating with 1-star inspections with $170,109 in total fines with 25 recent health deficiencies
#3
Carlisle Skilled Nursing And Rehabilitation Center
Carlisle, PA
1-star overall rating with 1-star inspections with $20,004 in total fines with 19 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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