CARLISLE SKILLED NURSING AND REHABILITATION CENTER
940 WALNUT BOTTOM ROAD
CARLISLE, PA, 17013
7172490085
CCN: 395746
1
Overall1
Health1
Staffing1
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| GENESIS PM PA OPERATIONS LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| FC-GEN OPERATIONS INVESTMENT LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| GEN OPERATIONS I LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| GEN OPERATIONS II LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| GENESIS HEALTHCARE INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| GENESIS HEALTHCARE LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| GENESIS HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| GHC HOLDINGS LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| HCCF MANAGEMENT GROUP XI LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| SUN HEALTHCARE GROUP INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| SUNDANCE REHABILITATION HOLDCO INC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| ZAC PROPERTIES XI LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| WELLTOWER OP LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| BRIDGEFORD, LAURA | CORPORATE OFFICER | NOT APPLICABLE |
| MENDELSON, AVI | CORPORATE OFFICER | NOT APPLICABLE |
| MURRAY, LAUREN | CORPORATE OFFICER | NOT APPLICABLE |
| BERG, MICHAEL | CORPORATE OFFICER | NOT APPLICABLE |
| KIRSCHNER, JONATHAN | CORPORATE OFFICER | NOT APPLICABLE |
| MITRZYK, SUSAN | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| ANJUM, RASHID | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
Penalties (2)
| Date | Type | Amount |
|---|---|---|
| 2025-06-26 | Fine | $11K |
| 2024-04-11 | Fine | $9K |
Health Deficiencies (61)
2025-12-15 · Health
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
2025-06-26 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
K
F805 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
D
F790 · Quality of Life and Care Deficiencies
Provide routine and 24-hour emergency dental care for each resident.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
E
F730 · Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
D
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F697 · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
J
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F688 · Quality of Life and Care Deficiencies
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.
E
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F676 · Quality of Life and Care Deficiencies
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
E
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
E
F628 · Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
2024-07-18 · Health
E
F887 · Infection Control Deficiencies
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.
E
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
E
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
E
F761 · Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
E
F758 · Pharmacy Service Deficiencies
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.
E
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
E
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
E
F688 · Quality of Life and Care Deficiencies
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.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
E
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
E
F625 · Resident Rights Deficiencies
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.
E
F623 · Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
D
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
D
F584 · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
E
F550 · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
2024-05-08 · Health
D
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
2024-04-11 · Health
G
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2023-08-31 · Health
D
F887 · Infection Control Deficiencies
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.
E
F883 · Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
D
F868 · Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
D
F804 · Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
E
F803 · Nutrition and Dietary Deficiencies
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.
D
F755 · Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
D
F730 · Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
E
F725 · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
D
F698 · Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
D
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
E
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
E
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
D
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
E
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
E
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
D
F585 · Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.22
RN Hrs/Resident/Day0.54
0.36
LPN Hrs/Resident/Day0.81
1.01
CNA Hrs/Resident/Day2.33
1.85
PT Hrs/Resident/Day0.12
0.07
Data as of 2026-03-01