Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlisle Manor Health Care Inc during CMS and state inspections, most recent first.
A facility failed to maintain an exterior exit staircase that was identified as a resident egress. A State Fire Marshal citation noted the exit access and discharge were not maintained because the exterior staircase was breaking apart. Two residents reported the cinderblock and concrete stairs were crumbling and said they had raised the issue through resident council, but it had not been fixed. Staff later verified the staircase was crumbling, and the Administrator stated there were no scheduled repairs and no repairs had been made since the citation.
Inaccurate PASARR Missing Mental Health Diagnoses: A resident with severe dementia, anxiety disorder, and psychosis had a PASARR that did not list the anxiety or psychosis diagnoses. The MDS showed severe cognitive impairment, and the Administrator confirmed the PASARR was missing the mental health diagnoses and that no other PASARR on file included them.
A resident’s MAR remained inaccurate after PEG tube removal, with several meds still documented as being administered via PEG tube instead of by mouth. The resident had COPD, dementia, GERD, and other chronic conditions, and the ADON confirmed the physician orders and MAR did not match the resident’s actual medication route. Facility policy required comparing the medication source with the MAR to verify the resident name, medication, dose, route, and time.
Hospice communication and documentation were not maintained for a resident with COPD, GERD, cerebral infarction, and anxiety disorder who was receiving hospice services and was moderately cognitively impaired. The record lacked hospice visit notes and an updated hospice care plan, and an RN verified the hospice visit log was not current even though the resident was reportedly seen weekly by hospice.
Staff failed to use required PPE for two residents under infection control precautions. One resident on EBP for a suprapubic catheter received catheter care from an RN who wore gloves but no gown, and another resident ordered contact and droplet precautions for norovirus had the wrong door signage, with staff needing to be reminded to wear a mask after entering the room. The record and interviews confirmed the precautions and PPE requirements were not followed.
Activities Program Not Directed by a Qualified Professional: The facility hired an Activities Director who did not hold any licenses, certificates, or registrations and did not have the required 2 years of social or recreational programming experience. The AD confirmed she was not a qualified OT or OTA and had not completed a state-approved training course, despite the job description requiring one of those qualifications.
A resident with multiple medical conditions reported $1,000 in cash missing after giving it to a nurse, who then allegedly gave it to a visitor. The incident was reported to police and internally investigated, but the facility failed to report the allegation of misappropriation to the State Survey Agency as required by policy.
A resident with multiple health issues, including dementia, was not provided timely incontinence care as per their care plan, resulting in a saturated and soiled brief. Observations showed the resident was left unattended for nearly three hours, and staff interviews confirmed the lapse in care. The DON acknowledged the need for more staff education.
A resident in a wheelchair sustained multiple fractures after falling while being assisted off a facility bus. The incident occurred when the resident's wheelchair got stuck in a gap between the ramp platform and the bus, causing the resident to flip out of the chair. The resident, who had a history of falls and moderate cognitive impairment, was in pain and required emergency room evaluation. Staff interviews indicated that the resident pulled himself out of the wheelchair by grabbing the lift railing, contributing to the fall.
Failure to Maintain Exterior Exit Staircase
Penalty
Summary
The facility failed to maintain an exterior exit egress staircase that was breaking apart. A State Fire Marshal report dated 03/19/26 cited the facility for exit accesses, exits, and an exit discharge not being maintained, and stated that the exterior exit staircase was breaking apart. The facility’s undated exit egress map identified the crumbling exterior stairwell as an exit egress for residents. Resident #9 and Resident #13 both reported that the exterior cinderblock and concrete staircase was crumbling and said they had discussed the issue with the facility through resident council, but it had not been fixed. Observation of the staircase on 05/26/26 showed it was visibly crumbling. The Maintenance Director and Administrator later verified that the exterior cinderblock and concrete staircase or egress was crumbling, and the Administrator stated the facility had no scheduled repairs and no repairs had been made since the State Fire Marshal citation.
Inaccurate PASARR Missing Mental Health Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was inaccurate for one resident. The resident was admitted with diagnoses including severe dementia with other behavioral disturbance, anxiety disorder, and psychosis not due to a substance or known physiological condition. The annual MDS showed the resident was severely cognitively impaired. Review of the PASARR dated 04/26/24 showed no mental health diagnoses were listed, and the resident’s anxiety disorder and psychosis were not included. The Administrator verified that the PASARR did not list those diagnoses and that the facility did not have any additional PASARRs on file that included them. The facility policy stated that assessments were coordinated with the PASARR program to ensure individuals with a mental disorder, intellectual disability, or related condition received care and services in the most integrated setting appropriate to their needs.
Inaccurate MAR documented PEG tube medication route after tube removal
Penalty
Summary
Resident #25’s medical record was inaccurate because medication routes were documented as being administered through a PEG tube after the PEG tube had been removed. The resident was admitted with COPD, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, shortness of breath, dementia without behavioral disturbance, anxiety, GERD, and hyperlipidemia. The quarterly MDS showed the resident was moderately cognitively impaired and did not have a feeding tube, and a progress note stated the resident went out of the facility for PEG tube removal. Review of the MAR showed several medications were still ordered and documented as given via PEG tube, including Lexapro, omeprazole, metoprolol tartrate, venlafaxine, gabapentin, and meclizine, even though the PEG tube had been discontinued. The ADON confirmed the PEG tube had been removed and acknowledged that the physician orders and MAR were inaccurate because the route of administration should have been by mouth. The facility policy stated the medication source was to be compared with the MAR to verify the resident name, medication, dose, route, and time.
Hospice communication and documentation were not maintained
Penalty
Summary
The facility failed to maintain updated communication with a resident's hospice provider and failed to keep updated hospice documentation in the resident's medical record. Resident #25 was admitted with COPD, GERD with esophagitis, cerebral infarction, and an anxiety disorder, and the quarterly MDS indicated the resident was moderately cognitively impaired and receiving hospice services. The facility hospice care plan dated 01/12/24 stated the resident was on hospice related to COPD and included interventions to coordinate the plan of care with the resident, family, and hospice, and to communicate changes in condition to hospice. The hospice face sheet showed the resident was admitted to hospice on 01/12/24 with COPD, cerebral infarction, anxiety disorder, and GERD. The hospice care plan from the hospice company dated 01/15/24 stated the facility would notify hospice of changes and would have ongoing health needs met. However, the medical record from 01/16/26 to 05/28/26 contained no hospice notes or documentation of hospice visits, and there was no updated hospice care plan from the hospice company after 01/15/24. The hospice visit sign-in log from 03/09/26 to 05/28/26 listed hospice visits on 03/09/36, 04/03/26, 04/07/26, and 05/07/26, and RN #86 verified the log was not up to date, that the resident was seen by hospice weekly, and that no hospice notes or updated care plan were present in the record.
Failure to Use Required PPE and Precaution Signage
Penalty
Summary
The facility failed to provide and implement its infection prevention and control program when staff did not use the required PPE during resident care. Resident #5 was admitted with diagnoses including osteomyelitis of the vertebra and sacral region and had moderate cognitive impairment. The care plan identified enhanced barrier precautions (EBP) for the resident because of a suprapubic catheter, with gloves and gowns required for high-contact care activities. During observation, an RN performed suprapubic catheter care after hand hygiene and gloves were donned, but no gown was worn. The RN later confirmed that a gown was not used during the catheter care. The facility also failed to use the correct transmission-based precautions for Resident #11, who had severe cognitive impairment and was ordered contact and droplet precautions for norovirus. The resident’s room door displayed only an EBP sign before entry, and a CNA had to instruct staff to put on a mask after entering the room. An LPN confirmed the resident was supposed to be on droplet and contact precautions, and the ADON/infection preventionist verified the resident returned from the hospital after testing positive for norovirus but did not have the correct signage on the door. The facility policy and CDC guidance reviewed in the report stated that norovirus requires contact precautions with gowns and gloves upon entry.
Activities Program Not Directed by a Qualified Professional
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. Review of the Activities Director's personnel file showed the individual was hired as the activities director but did not hold any licenses, certificates, or registrations in any professional capacity. The resume did not show two years of experience in social or recreational programming. During interview, the Activities Director confirmed she did not have any licenses, certificates, or registrations, did not have two years of experience in social or recreational programming, was not a qualified occupational therapist or occupational therapy assistant, and had not completed a state-approved training course. The facility's job description stated the activities director must meet one of several qualifications, including two years of college and either certification/licensure as a recreation or activities professional, two years of relevant experience, qualification as an occupational therapist or occupational therapy assistant, or completion of a state-approved training course.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the State Survey Agency as required by policy and regulation. A resident, who was cognitively intact and had diagnoses including left femur fracture, diabetes mellitus, depression, chronic ischemic heart disease, and anxiety, reported missing $1,000 in cash. The resident stated that he gave the money to a nurse to place in his nightstand, and later the nurse put the money in her medication cart. The following day, the nurse allegedly gave the money to one of the resident's visitors. The resident subsequently called the police and filed a report regarding the missing money. The police report indicated that the unit manager had not seen the cash since the resident refused to secure it in a locked box and noted that the resident had visitors on two consecutive days. The facility's social services staff confirmed that an internal investigation was initiated, including witness statements from the DON, a CNA, and the unit manager. However, the facility did not report the allegation of misappropriation to the State Survey Agency, as confirmed by the administrator. Facility policy required reporting such allegations within 24 hours, but this was not done.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #29, who was admitted with multiple diagnoses including dementia, depression, and chronic diastolic heart failure. The resident was cognitively impaired and dependent on staff for bathing and hygiene. The care plan required incontinence care every two hours and as needed, along with the application of a moisture barrier cream. However, observations revealed that the resident was left unattended in a Geri chair for nearly three hours without being offered incontinence care. Interviews with State Tested Nurse Aides (STNAs) confirmed that the resident was incontinent of bowel and bladder and should have been checked every two hours. Despite this, the resident's incontinence brief was found saturated with urine and smeared with feces, indicating a lapse in care. The Director of Nursing acknowledged the need for more education for the STNAs, as they were not timely in providing the necessary care. The facility's policy stated that all incontinent residents should receive appropriate care, which was not adhered to in this instance.
Resident Injury Due to Unsafe Transportation
Penalty
Summary
The facility failed to ensure the safe transportation of residents on and off the facility vehicle, resulting in actual harm to a resident. On the day of the incident, a resident in a wheelchair was being assisted off the facility bus when a gap between the ramp platform and the bus caused the wheelchair to turn and get stuck. This led to the resident flipping out of the wheelchair and sustaining multiple fractures, including a fracture to the left leg and ribs. The resident was in pain and was subsequently transported to the emergency room for evaluation and treatment. The resident involved had a history of altered mental status, type two diabetes mellitus, and chronic pain, and was at risk for falls due to frequent falls and low tolerance for activity. The resident required the use of a wheelchair for mobility and had moderate cognitive impairment. On the day of the incident, the resident was being assisted by a transporter who was helping unload residents from the bus. The transporter unlocked the resident's wheelchair and attempted to move it onto the lift, but the resident grabbed onto the lift railing, causing the wheelchair to get stuck in the gap and the resident to fall. Staff interviews revealed that the transporter was assisting the resident when the incident occurred, and the activity director was driving the bus. The transporter stated that the resident pulled himself out of the wheelchair by grabbing the lift railing, which contributed to the fall. The incident was witnessed by several staff members who provided statements about the resident's position and condition after the fall. The facility's Director of Nursing was not present during the incident but was informed of the events that transpired.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Carlisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Momentous Health At Franklin | 2.3 mi | ★★★★★ | 0 | 0 |
| Willow Knoll Post-acute And Senior Living | 3.3 mi | ★★★★★ | 11 | 0 |
| Kingston Of Miamisburg | 3.7 mi | ★★★★★ | 6 | 0 |
| Astoria Health & Rehab Center | 4.3 mi | ★★★★★ | 1 | 0 |
| Sycamore Trails Post Acute | 5.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.