Cycle 1
Health 2026-01-08 · Fire 2024-12-19
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Carlisle, PA
Sarah A Todd Memorial Home
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1000 West South Street, Carlisle, PA
(717) 245-2187
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
110
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-07-01
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
0.79
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.61
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,641
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0023
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.36
Performance 19.88% · Measure score 3.36 · Achievement 3.36 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.25
Performance 7.16% · Measure score 2.25 · Achievement 2.25 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
8.32
Baseline 42.67% · Performance 29.65% · Measure score 8.32 · Achievement 8.32 · Improvement 6.80
Adjusted total nurse staffing
5.50
Baseline 4.61 hours · Performance 4.64 hours · Measure score 5.50 · Achievement 5.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.33% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 4.11% · Lower 95% interval 5.93% |
| Discharge to community | 37.45% |
50.57%
13.1 pts worse
|
Worse than the National Rate · Eligible stays 50 · Observed rate 30% · Lower 95% interval 26.26% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 51 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 22.73% |
53.69%
31 pts worse
|
Numerator 10 · Denominator 44 |
| Discharge mobility score | 34.09% |
50.94%
16.8 pts worse
|
Numerator 15 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 5.88% |
2.29%
3.6 pts worse
|
Numerator 3 · Denominator 51 · Adjusted rate 4.26% |
| Healthcare-associated infections requiring hospitalization | 7.16% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 1.09% |
8.2%
7.1 pts worse
|
Numerator 2 · Denominator 184 |
| Staff flu vaccination coverage | 36.92% |
42%
5.1 pts worse
|
Numerator 96 · Denominator 260 |
| Discharge function score | 25% |
56.45%
31.5 pts worse
|
Numerator 11 · Denominator 44 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 9 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.1 · Expected 1.4 · 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 0.4 · Expected 1.4 · 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 99.1% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
93.5%
5.6 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.2%
1.3 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 2.8% · Q4 2.8% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
6.5%
3.7 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.5% · Q3 2.2% · Q4 3.1% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.5%
1.3 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.1% · Q3 4.0% · Q4 6.9% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
19.9%
2.6 pts worse
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 22.2% · Q3 22.5% · Q4 24.3% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
18.7%
4.7 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 24.7% · Q3 22.0% · Q4 19.8% · 4Q avg 23.4% · 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 | 18.8% |
19.6%
0.8 pts better
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 28.8% · Q3 11.9% · Q4 12.1% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.0% |
18.3%
0.3 pts better
|
14.9%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 17.7% · Q3 16.3% · Q4 16.1% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.2% |
0.9%
3.3 pts worse
|
1.0%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.7% · Q3 3.8% · Q4 2.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.7%
0.2 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 3.8% · Q4 1.9% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.7% |
26.4%
5.3 pts worse
|
19.8%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 24.7% · Q3 35.6% · Q4 32.2% · 4Q avg 31.7% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.3%
2.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 4.1% · Q3 3.5% · Q4 2.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
68.9%
12.1 pts better
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.8% · Q2 80.0% · Q3 80.0% · Q4 78.3% · 4Q avg 81.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
9.8%
2.1 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 6.4% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.4% |
68.7%
16.7 pts better
|
79.7%
5.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
23.1%
5.2 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 14.9% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-19 · Fire 2024-02-01
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2024-02-01 · Fire 2023-03-02
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-19
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-12-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-01-13
F · Potential for more than minimal harm
2024-02-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-20
E · Potential for more than minimal harm
2023-03-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-02-13
E · Potential for more than minimal harm
2024-12-19
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 2025-01-31
D · Potential for more than minimal harm
2024-12-19
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-02-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-20
Penalties and ownership
What sits behind the stars
Ownership
United Church Of Christ Homes
5% Or Greater Direct Ownership Interest · Organization
Adams, Kimberly
Operational/Managerial Control · Individual
Arnold, Erica
Operational/Managerial Control · Individual
Cliftonlarsonallen Llp
Operational/Managerial Control · Organization
Conrad Siegel Investment Advisors, Inc
Operational/Managerial Control · Organization
Dierolf, Lori
Operational/Managerial Control · Individual
Duncan, Ronald
Operational/Managerial Control · Individual
Eyster, Sharon
Operational/Managerial Control · Individual
Eyster, Sharon
Corporate Officer · Individual
Fields, Meredith
Operational/Managerial Control · Individual
Fields, Meredith
Corporate Officer · Individual
Gagnon, Tempest
Operational/Managerial Control · Individual
Gourley, Ronald
Operational/Managerial Control · Individual
Gourley, Ronald
Corporate Officer · Individual
Gramm, Luanne
Operational/Managerial Control · Individual
Jayman, Erin
Operational/Managerial Control · Individual
Marsh And Mclennan Companies, Inc
Operational/Managerial Control · Organization
Newland, Jasmine
Operational/Managerial Control · Individual
Shelly, Craig
Operational/Managerial Control · Individual
Starner, Jeffrey
Operational/Managerial Control · Individual
Velez, Victoria
Operational/Managerial Control · Individual
Weiser, Neil
Operational/Managerial Control · 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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