Carlisle, PA

LeTort Spring Nursing and Rehab LLC

1-star overall rating with 1-star inspections with $63,892 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

801 N. Hanover Street, Carlisle, PA

(717) 249-5322

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

0 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

109

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1989-04-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.00

Registered nurse staffing

LPN hours / resident day

0.00

Licensed practical nurse staffing

Aide hours / resident day

0.00

Nurse aide staffing

Total nurse hours

0.00

All reported nurse hours

Licensed hours

0.00

RN + LPN hours

Weekend hours

0.00

Weekend nurse staffing

Weekend RN hours

0.00

Weekend registered nurse coverage

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.00

CMS adjusted RN staffing hours

Adjusted total hours

0.00

CMS adjusted total nurse staffing hours

Case-mix index

0.00

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

Annual nurse turnover

SNF VBP

Value-based purchasing

Program rank

2,839

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

47.44

Composite VBP score used to determine payment impact.

Payment multiplier

1.0010

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.10

Baseline 18.82% · Performance 19.07% · Measure score 5.10 · Achievement 5.10 · Improvement 0

Healthcare-associated infections

6.32

Baseline 6.08% · Performance 5.95% · Measure score 6.32 · Achievement 6.32 · Improvement 0.71

Total nurse turnover

3.51

Baseline 49.25% · Performance 49.31% · Measure score 3.51 · Achievement 3.51 · Improvement 0

Adjusted total nurse staffing

4.04

Baseline 3.61 hours · Performance 4.23 hours · Measure score 4.04 · Achievement 4.04 · Improvement 2.35

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.39%	10.72% 0.3 pts better	No Different than the National Rate · Eligible stays 62 · Observed rate 8.06% · Lower 95% interval 7.2%
Discharge to community	50.26%	50.57% 0.3 pts worse	No Different than the National Rate · Eligible stays 54 · Observed rate 42.59% · Lower 95% interval 38.99%
Medicare spending per beneficiary	0.7	1.02 0.3 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 33 · Denominator 33
Falls with major injury	3.03%	0.77% 2.3 pts worse	Numerator 1 · Denominator 33
Discharge self-care score	46.88%	53.69% 6.8 pts worse	Numerator 15 · Denominator 32
Discharge mobility score	62.5%	50.94% 11.6 pts better	Numerator 20 · Denominator 32
Pressure ulcers or injuries, new or worsened	3.03%	2.29% 0.7 pts worse	Numerator 1 · Denominator 33 · Adjusted rate 3.16%
Healthcare-associated infections requiring hospitalization	5.95%	7.12% 1.2 pts better	No Different than the National Rate · Eligible stays 37 · Observed rate 0% · Lower 95% interval 2.74%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 94
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	65.63%	56.45% 9.2 pts better	Numerator 21 · Denominator 32
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 14 · 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	1.0	1.7 0.7 pts better	1.9 0.9 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	1.2 0.6 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	64.6%	86.9% 22.3 pts worse	93.4% 28.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 79.5% · Q2 70.6% · Q3 56.2% · Q4 50.7% · 4Q avg 64.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	93.5%	93.5% About the same	95.5% 2 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5%
Percentage of long-stay residents experiencing one or more falls with major injury	4.2%	3.2% 1 pts worse	3.3% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.4% · Q3 4.7% · Q4 4.0% · 4Q avg 4.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	2.3%	6.5% 4.2 pts better	11.4% 9.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3%
Percentage of long-stay residents who lose too much weight	6.2%	6.5% 0.3 pts better	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.7% · Q3 3.6% · Q4 6.0% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	28.8%	19.9% 8.9 pts worse	19.6% 9.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 31.2% · Q3 28.6% · Q4 23.2% · 4Q avg 28.8%
Percentage of long-stay residents who received an antipsychotic medication	25.3%	18.7% 6.6 pts worse	16.7% 8.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 25.0% · Q3 20.8% · Q4 28.1% · 4Q avg 25.3% · 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	17.0%	19.6% 2.6 pts better	16.3% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 10.6% · Q3 15.0% · Q4 11.9% · 4Q avg 17.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	24.8%	18.3% 6.5 pts worse	14.9% 9.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 20.0% · Q3 11.1% · Q4 31.0% · 4Q avg 24.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.9%	0.9% 1 pts worse	1.0% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 2.4% · Q4 2.5% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	3.2%	1.7% 1.5 pts worse	1.7% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 4.4% · Q3 1.6% · Q4 4.0% · 4Q avg 3.2% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	35.6%	26.4% 9.2 pts worse	19.8% 15.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 32.0% · Q3 36.2% · Q4 43.5% · 4Q avg 35.6%
Percentage of long-stay residents with pressure ulcers	2.8%	5.3% 2.5 pts better	5.1% 2.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.1% · Q3 1.8% · Q4 1.4% · 4Q avg 2.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	16.6%	68.9% 52.3 pts worse	81.7% 65.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 16.0% · Q3 12.5% · Q4 18.6% · 4Q avg 16.6%
Percentage of short-stay residents who had an outpatient emergency department visit	15.8%	9.8% 6 pts worse	12.0% 3.8 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.8% · Observed 14.3% · Expected 10.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.5% 0.8 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	32.7%	68.7% 36 pts worse	79.7% 47 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 32.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	24.9%	23.1% 1.8 pts worse	23.9% 1 pts worse	Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 20.0% · Expected 19.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-06 · Fire 2025-02-06

18 health deficiencies

Top issue: Quality of Life and Care (7 deficiencies)

1 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2024-03-21 · Fire 2024-03-21

22 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

1 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2023-04-05 · Fire 2023-04-05

9 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

3 fire-safety deficiencies

Top issue: Construction (2 deficiencies)

Fire safety

Fire-safety citations

C · Minimal harm 2025-02-06

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2025-03-06

C · Minimal harm 2024-03-21

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-03-31

E · Potential for more than minimal harm 2023-04-05

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2023-06-17

E · Potential for more than minimal harm 2023-04-05

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 2023-06-17

C · Minimal harm 2023-04-05

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2023-06-17

Inspection history

Recent health citations

G · Actual harm 2026-01-29

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2026-02-05

G · Actual harm 2026-01-29

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2026-02-05

D · Potential for more than minimal harm 2025-12-26

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 2026-01-27

D · Potential for more than minimal harm 2025-12-26

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 2026-01-27

K · Immediate jeopardy 2025-04-24

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 2025-04-22

G · Actual harm 2025-02-06

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-02-06

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 2025-03-14

E · Potential for more than minimal harm 2025-02-06

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 2025-03-14

E · Potential for more than minimal harm 2025-02-06

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 2025-03-14

E · Potential for more than minimal harm 2025-02-06

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-02-06

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 2025-03-14

D · Potential for more than minimal harm 2025-02-06

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-06

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-06

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 2025-03-14

D · Potential for more than minimal harm 2025-02-06

F790 · Quality of Life and Care Deficiencies

Health

Provide routine and 24-hour emergency dental care for each resident.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-06

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-06

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-06

F887 · Infection Control Deficiencies

Health

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Corrected 2025-03-14

E · Potential for more than minimal harm 2024-11-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-16

D · Potential for more than minimal harm 2024-11-25

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-12-16

D · Potential for more than minimal harm 2024-11-25

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-12-16

D · Potential for more than minimal harm 2024-07-30

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-08-23

G · Actual harm 2024-03-21

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-04-18

F · Potential for more than minimal harm 2024-03-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-04-18

E · Potential for more than minimal harm 2024-03-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-04-18

E · Potential for more than minimal harm 2024-03-21

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-04-18

E · Potential for more than minimal harm 2024-03-21

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 2024-04-18

E · Potential for more than minimal harm 2024-03-21

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-04-18

E · Potential for more than minimal harm 2024-03-21

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-04-18

E · Potential for more than minimal harm 2024-03-21

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 2024-04-18

E · Potential for more than minimal harm 2024-03-21

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 2024-04-18