Cycle 1
Health 2025-12-11 · Fire 2025-12-11
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Carlisle, PA
Thornwald Home
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
442 Walnut Bottom Road, Carlisle, PA
(717) 249-4118
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
83
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-09-01
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
0.90
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
2.38
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.74
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
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.96
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,589
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.29% · Performance 22.31% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.91% · Performance 8.55% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.95
Baseline 37.80% · Performance 47.52% · Measure score 3.95 · Achievement 3.95 · Improvement 0
Adjusted total nurse staffing
3.98
Baseline 4.52 hours · Performance 4.21 hours · Measure score 3.98 · Achievement 3.98 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.87% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 15.53% · Lower 95% interval 8.87% |
| Discharge to community | 39.45% |
50.57%
11.1 pts worse
|
Worse than the National Rate · Eligible stays 80 · Observed rate 32.5% · Lower 95% interval 31.39% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.92% |
95.27%
2.7 pts better
|
Numerator 47 · Denominator 48 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 2 · Denominator 48 |
| Discharge self-care score | 29.73% |
53.69%
24 pts worse
|
Numerator 11 · Denominator 37 |
| Discharge mobility score | 24.32% |
50.94%
26.6 pts worse
|
Numerator 9 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 2 · Denominator 48 · Adjusted rate 3.14% |
| Healthcare-associated infections requiring hospitalization | 8.55% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 4.5% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 147 |
| Staff flu vaccination coverage | 36.15% |
42%
5.9 pts worse
|
Numerator 77 · Denominator 213 |
| Discharge function score | 40.54% |
56.45%
15.9 pts worse
|
Numerator 15 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 44.44% |
25.2%
19.2 pts better
|
Numerator 12 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.7
0.5 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.2
0.7 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.8% |
86.9%
6.9 pts better
|
93.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 100.0% · Q3 91.4% · Q4 88.7% · 4Q avg 93.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.9% |
93.5%
1.4 pts better
|
95.5%
0.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.2%
1.6 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.1% · Q3 4.3% · Q4 7.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
6.5%
4.6 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 1.5% · Q4 1.4% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 14.1% |
6.5%
7.6 pts worse
|
5.4%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 25.4% · Q3 7.8% · Q4 4.8% · 4Q avg 14.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.7% |
19.9%
3.8 pts worse
|
19.6%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 25.7% · Q3 28.8% · Q4 22.2% · 4Q avg 23.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
18.7%
5.3 pts better
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.7% · Q3 13.6% · Q4 12.9% · 4Q avg 13.4% · 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 | 22.0% |
19.6%
2.4 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 18.4% · Q3 33.9% · Q4 17.6% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.3% |
18.3%
10 pts worse
|
14.9%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 41.7% · Q3 20.4% · Q4 26.8% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.8% |
26.4%
7.4 pts worse
|
19.8%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 42.2% · Q3 32.3% · Q4 26.8% · 4Q avg 33.8% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.3%
1.8 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.6% · Q3 1.6% · Q4 2.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.8% |
68.9%
5.1 pts worse
|
81.7%
17.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.2% · Q2 50.0% · Q3 71.0% · Q4 61.8% · 4Q avg 63.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.5% |
9.8%
7.3 pts better
|
12.0%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.5% · Observed 2.3% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.4% |
68.7%
3.7 pts better
|
79.7%
7.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.0% |
23.1%
5.9 pts worse
|
23.9%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 27.3% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-12 · Fire 2024-12-12
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2024-01-18 · Fire 2024-01-18
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-16
E · Potential for more than minimal harm
2024-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-03
E · Potential for more than minimal harm
2024-01-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-11
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-01-15
D · Potential for more than minimal harm
2025-12-11
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 2026-01-15
G · Actual harm
2025-07-21
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 2025-08-21
D · Potential for more than minimal harm
2025-01-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-04
D · Potential for more than minimal harm
2025-01-30
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 2025-03-04
D · Potential for more than minimal harm
2025-01-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-04
E · Potential for more than minimal harm
2024-12-12
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 2025-01-21
D · Potential for more than minimal harm
2024-12-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-01-18
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 2024-03-05
D · Potential for more than minimal harm
2024-01-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-18
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 2024-03-05
D · Potential for more than minimal harm
2024-01-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-05
D · Potential for more than minimal harm
2024-01-18
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 2024-03-05
Penalties and ownership
What sits behind the stars
$9,110
2025-07-21
Fine
Fine · fine $9,110
Fine
Ownership
Barnhart, Ida
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
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
Keene, Brian
Operational/Managerial Control · Individual
Raisig, Heather
Operational/Managerial Control · Individual
Sheller, Cathy
Operational/Managerial Control · Individual
Shelly, Craig
Operational/Managerial Control · Individual
Souder, Adele
Operational/Managerial Control · Individual
United Church Of Christ Homes
Operational/Managerial Control · Organization
Velez, Victoria
Operational/Managerial Control · Individual
Weiser, Neil
Operational/Managerial Control · Individual
Weller, Sunday
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
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
#3
Chapel Pointe At Carlisle
Carlisle, PA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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