Cycle 1
Health 2025-04-10 · Fire 2025-04-10
4 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Carlisle, PA
Cumberland Crossings Retirement Community
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1 Longsdorf Way, Carlisle, PA
(717) 245-9941
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
47
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-05-08
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
1.03
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.27
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.31
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
3.89
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
4.62
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
89%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,082
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9862
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.10
Baseline 25.15% · Performance 21.41% · Measure score 4.10 · Achievement 0 · Improvement 4.10
Healthcare-associated infections
0
Baseline 5.87% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.85
Baseline 38.30% · Performance 43.86% · Measure score 4.85 · Achievement 4.85 · Improvement 0
Adjusted total nurse staffing
3.38
Baseline 3.46 hours · Performance 4.04 hours · Measure score 3.38 · Achievement 3.38 · Improvement 2
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.98% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 12.5% · Lower 95% interval 8.21% |
| Discharge to community | 55.62% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 107 · Observed rate 52.34% · Lower 95% interval 46.11% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 54.29% |
53.69%
0.6 pts better
|
Numerator 38 · Denominator 70 |
| Discharge mobility score | 52.86% |
50.94%
1.9 pts better
|
Numerator 37 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 1.15% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 87 · Adjusted rate 1.19% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 4.73% |
| Staff COVID-19 vaccination coverage | 2.63% |
8.2%
5.6 pts worse
|
Numerator 3 · Denominator 114 |
| Staff flu vaccination coverage | 88.28% |
42%
46.3 pts better
|
Numerator 113 · Denominator 128 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 42 · Denominator 70 |
| Transfer of health information to provider | 82.5% |
95.95%
13.5 pts worse
|
Numerator 33 · Denominator 40 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 30 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 32.56% |
25.2%
7.4 pts better
|
Numerator 14 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
86.9%
11.7 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 100.0% · Q3 100.0% · Q4 96.8% · 4Q avg 98.6% |
| 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 | 5.1% |
3.2%
1.9 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 7.7% · Q3 5.9% · Q4 3.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.3% |
6.5%
5.8 pts worse
|
11.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 15.4% · Q3 6.7% · Q4 7.4% · 4Q avg 12.3% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
6.5%
2.8 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.5% · Q3 3.6% · Q4 4.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.4% |
19.9%
3.5 pts better
|
19.6%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.1% · Q3 21.4% · Q4 11.5% · 4Q avg 16.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
18.7%
8.6 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.5% · Q3 8.7% · Q4 13.0% · 4Q avg 10.1% · 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 | 21.7% |
19.6%
2.1 pts worse
|
16.3%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
18.3%
10.8 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.7% · Q3 11.1% · Q4 4.0% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
1.7%
1.9 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 2.6% · Q3 2.9% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
26.4%
1.3 pts better
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 25.7% · Q3 27.9% · Q4 26.2% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.3%
2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.4% · Q3 4.4% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
68.9%
25.6 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.0% · Q2 94.7% · Q3 94.7% · Q4 95.4% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.6% |
9.8%
8.8 pts worse
|
12.0%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 16.4% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.3% |
68.7%
19.6 pts better
|
79.7%
8.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
23.1%
4.6 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 16.4% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-16 · Fire 2024-05-16
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
8 health deficiencies
Top issue: Nutrition and Dietary (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-10
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 2025-06-10
E · Potential for more than minimal harm
2025-04-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-10
F · Potential for more than minimal harm
2024-05-16
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-10
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-10
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 2025-05-21
D · Potential for more than minimal harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
D · Potential for more than minimal harm
2024-05-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-05-16
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 2024-07-09
D · Potential for more than minimal harm
2024-05-16
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 2024-07-09
D · Potential for more than minimal harm
2024-05-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-07-09
F · Potential for more than minimal harm
2023-05-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-05-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-05-25
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-05-25
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 2023-07-11
D · Potential for more than minimal harm
2023-05-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-05-25
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-05-25
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-07-11
D · Potential for more than minimal harm
2023-05-25
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-07-11
Penalties and ownership
What sits behind the stars
Ownership
Diakon
5% Or Greater Direct Ownership Interest · Organization
Diakon
Operational/Managerial Control · Organization
Feege, Barbara
Corporate Director · Individual
Goldstein, Jennifer
Corporate Director · Individual
Habecker, Scott
Corporate Officer · Individual
Habecker, Scott
W-2 Managing Employee · Individual
Hebrink, Chad
Corporate Director · Individual
Hendrickson, Nels
Corporate Director · Individual
Hough, Douglas
Corporate Director · Individual
Lehman, Michael
Corporate Director · Individual
Leo, Jarrod
W-2 Managing Employee · Individual
Lutheran Senior Services East
5% Or Greater Direct Ownership Interest · Organization
Lutheran Senior Services East
Operational/Managerial Control · Organization
Main, Don
Corporate Director · Individual
Main, Don
Corporate Officer · Individual
Schellenberg, Susan
Corporate Director · Individual
Schlegel, Jennifer
Corporate Director · Individual
Taylor, Carol
Corporate Director · Individual
Vandergast, Shari
Corporate Director · Individual
Weiser, Bradford
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
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
#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
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
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