Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sarah A Todd Memorial Home during CMS and state inspections, most recent first.
A resident with hemiplegia and protein calorie malnutrition was enrolled in hospice care, representing a significant change in condition, but the facility did not complete a required Significant Change MDS assessment within the appropriate timeframe. Review of the clinical record and hospice plan of care confirmed the hospice start, and review of the MDS showed no significant change assessment had been done since hospice enrollment. The NHA acknowledged in interview that a Significant Change MDS should have been completed within 14 days of the change in status.
Two residents with dementia had inaccurately coded MDS assessments that did not match their clinical records. One resident, identified as at risk for elopement with documented exit-seeking and wandering behaviors and an active elopement bracelet order, was coded on the MDS as having no wandering behavior. Another resident with multiple documented falls, including two with injuries (skin tears and a large hand bruise) and one without injury, was coded on the MDS as having two or more falls without injury and only one fall with injury. The NHA confirmed both assessments were coded inaccurately, resulting in resident assessments that did not accurately reflect their clinical status.
The facility failed to monitor dishwashing equipment temperatures in the main kitchen and a dining area, with multiple instances of unrecorded and below-standard temperatures over several months. No corrective actions were documented, indicating a systemic issue in maintaining food service safety standards.
The facility failed to respect the dignity of two residents during medication administration. A resident with dementia and diabetes received insulin injections in a common area, contrary to facility policy. Another resident with similar conditions also received an injection in a public setting. The facility's expectation is for injections to be administered in private rooms.
The facility failed to follow infection control procedures during insulin administration for three residents. Employees did not cleanse the rubber tips of insulin pens before attaching needles, contrary to manufacturer instructions. The Nursing Home Administrator confirmed that the facility expected staff to perform this step to prevent infection.
The facility failed to maintain proper egress door signage for special locking arrangements, affecting multiple smoke compartments. Observations revealed that exit discharge doors lacked delayed egress signage in several areas, including the Service Corridor and various halls on the 1st floor. This deficiency was confirmed by the DON and Director of Maintenance.
The facility failed to maintain sprinkler heads in one of four smoke zones, as observed during an inspection. Three sprinkler heads outside on the Kitchen Loading Dock were covered with debris. This was confirmed in an interview with the DON and Director of Maintenance, acknowledging the sprinkler heads were subject to load.
The facility did not ensure that power receptacles within six feet of a water source were GFI protected in one of four smoke zones. Observations revealed that outlets in the kitchen, near the pot and pan sink and behind the ice machine, lacked GFI protection. This was confirmed by the DON and Director of Maintenance during an exit conference.
Failure to Complete Significant Change MDS After Hospice Enrollment
Penalty
Summary
The facility failed to complete a comprehensive assessment following a significant change in condition for one resident. The resident’s clinical record showed diagnoses including hemiplegia and protein calorie malnutrition. The record further showed that hospice care was initiated on October 3, 2025, as documented on the Hospice Certification and Plan of Care. Review of the resident’s Minimum Data Set (MDS) revealed that no Significant Change MDS assessment had been completed since the resident entered hospice care, despite this representing a significant change in condition. In an interview on January 8, 2026, at 11:30 AM, the Nursing Home Administrator confirmed that a Significant Change MDS should have been completed within 14 days after the change in the resident’s status. This deficiency was cited under 28 Pa Code 211.12(d)(1)(5) related to nursing services.
Inaccurate MDS Coding for Wandering and Falls
Penalty
Summary
The deficiency involves inaccurate resident assessments documented in the MDS for two residents. For one resident with chronic kidney disease and dementia, the clinical record showed an elopement risk assessment completed on November 21, 2025, identifying the resident as at risk for elopement. The care plan documented the resident as at risk for elopement with an elopement monitor applied to the right ankle, and physician orders included an active order for an elopement bracelet starting the same date. A nursing progress note dated November 26, 2025, at 9:50 PM described exit-seeking behaviors, including attempts to get outdoors, looking for keys, and wandering. Despite these documented behaviors and interventions, the MDS dated November 27, 2025, coded Section E0900 (Wandering – Presence & Frequency) as 0, indicating that wandering behavior was not exhibited during the look-back period. In an interview, the Nursing Home Administrator acknowledged that this MDS was coded inaccurately and should have captured the resident’s wandering behavior. The second resident had diagnoses including dementia and anxiety and experienced multiple falls. The clinical record documented a fall on October 23, 2025, with no injury; a fall on November 3, 2025, resulting in skin tears to the right forearm and elbow; and a fall on December 9, 2025, resulting in a bruise on the top of the right hand measuring 6.5 cm by 6.5 cm. However, the MDS for this resident coded Section J1900 (Number of Falls Since Admission/Entry or Reentry or Prior Assessment) as two or more falls with no injury and one fall with injury. In an interview, the Nursing Home Administrator stated that this MDS was also coded inaccurately and should have reflected two falls with injury and one fall with no injury. These discrepancies between the clinical records and the MDS coding demonstrate that the facility failed to ensure that resident assessments accurately reflected the residents’ actual status, in violation of 28 Pa. Code 211.5(f) Clinical records and 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Failure to Monitor Dishwashing Equipment Temperatures
Penalty
Summary
The facility failed to properly utilize and monitor dishwashing equipment in accordance with professional standards for food service safety in the main kitchen and one of the dining areas. The Dish Machine Temperature Logs for the main kitchen and the [NAME] Unit revealed multiple instances where wash and rinse cycle temperatures were not recorded, and several occasions where the wash cycle temperature was below the minimum acceptable temperature. These deficiencies were noted across several months, including April, May, August, September, and October 2024, with no corrective actions documented. Interviews with facility staff, including the Dietary Manager and the Nursing Home Administrator, confirmed that there was an expectation for kitchen equipment to be utilized and monitored according to professional standards. However, the logs showed repeated failures to record temperatures and address low temperature readings, indicating a lack of adherence to the established action plan. This lack of documentation and corrective action suggests a systemic issue in maintaining food service safety standards within the facility.
Plan Of Correction
The dishwasher temps in both areas will be recorded and monitored for minimum acceptable temperatures. Dietary staff will notify their supervisor. The supervisor will investigate and make necessary adjustments or call maintenance, if necessary. The dietary staff, including the dietary manager, will be educated on the importance of monitoring the dishwasher temperatures and reporting discrepancies, per policy. Audits will be done by the Dietary Director or designee to ensure temperature logs are complete 3 meals a week for one quarter to ensure compliance. After that, audits will be completed for two meals a week for a month to ensure compliance. The results of these audits will be reported to the Quality Assurance and Performance Improvement Committee. If any temperatures are missing or are not in acceptable ranges, the dietary supervisor on duty or designee will investigate and make necessary adjustments or call maintenance. Supervisor or designee will document action taken. Corrective action will be completed on 1/31/25.
Failure to Respect Resident Dignity During Medication Administration
Penalty
Summary
The facility failed to administer medications in a manner that respected the residents' dignity for two residents observed during medication administration. Resident 23, who has diagnoses including dementia with Lewy bodies and diabetes mellitus type II, was observed receiving insulin injections in both upper arms while seated in the unit's common area, with multiple other residents present. This action was contrary to the facility's policy, which emphasizes treating residents with respect and dignity. Similarly, Resident 53, diagnosed with dementia and diabetes mellitus type II, was observed receiving an insulin injection in the left lower abdomen after their shirt was lifted, also in the common area with multiple residents present. The Nursing Home Administrator confirmed that the facility's expectation is for injections to be administered in the residents' rooms to ensure privacy and dignity, which was not adhered to in these instances.
Plan Of Correction
Employee 1 was educated on the importance of administering medication in a private area and not a common area. The residents were not negatively impacted by this deficient practice. Other residents were not noted to have had similar situations. All residents who are receiving medication are receiving them either in a private, non-common area or will be asked prior to receiving the medication/treatment if the location is satisfactory to the resident. All licensed nurses will be educated on the importance of dignity and respect and administering medications in a private area. Audits will be completed weekly on 2 residents by direct observation for one quarter to ensure compliance. After that, audits will be completed by direct observation bi-weekly on 2 residents for a month to ensure compliance. The results of these audits will be reported to the Quality Assurance and Performance Improvement Committee. Corrective action will be completed by 1/31/25.
Failure to Follow Infection Control Procedures During Insulin Administration
Penalty
Summary
The facility failed to adhere to infection control procedures during medication administration for three residents. Observations revealed that Employee 1 did not cleanse the rubber tip of the Basaglar Kwikpen before attaching the insulin needle for Resident 53. Similarly, Employee 1 neglected to swab the rubber tips of the Lantus Solostar and Novolog Flexpen before administering insulin to Resident 23. Employee 2 also failed to cleanse the rubber tip of the Insulin Aspart Flexpen before injecting insulin into Resident 18. The manufacturer's instructions for the insulin pens, including Basaglar Kwikpen, Lantus Solostar, Novolog Flexpen, and Insulin Aspart Flexpen, specify that the rubber tip should be swabbed with an alcohol swab before attaching the needle to prevent infection. During a staff interview, the Nursing Home Administrator confirmed that the facility's expectation was for employees to cleanse the rubber tips of insulin pens prior to needle attachment. This deficiency was identified under 28 Pa code 211.12(d)(1)(5) Nursing services.
Plan Of Correction
The residents suffered no ill effects from this deficient practice. The rubber tips of the insulin pens will be cleansed prior to Resident 53, Resident 23, and Resident 18's insulin injections. All residents who receive insulin injections will have the rubber tip cleansed prior to use. Licensed nurses will be educated on the insulin pen policy/procedure. Audits will be completed by direct observation on 3 residents per week for one quarter to ensure that the rubber tips are properly cleansed prior to the insulin injections. After that, the audits will be completed on one resident per week for a month to ensure compliance. Results of these audits will be reported to the Quality Assurance and Performance Improvement Committee. Corrective action will be completed by 1/31/25.
Failure to Maintain Egress Door Signage for Special Locking Arrangements
Penalty
Summary
The facility failed to maintain proper egress door signage for special locking arrangements, which affected multiple smoke compartments within the building. During an observation on December 3, 2024, it was noted that the exit discharge doors were equipped with special locking arrangements but lacked the required delayed egress signage. This deficiency was observed in one of four smoke compartments, specifically at the Service Corridor double doors. Further observations on the same day revealed similar issues in three additional smoke compartments. The exit discharge doors on the 1st floor, including the Therapy Hall by Therapy, Hall 3 by Resident Room 48, and Hall 4, were all found to be lacking the necessary signage for their special locking arrangements. These findings were confirmed during an interview with the Director of Nursing and the Director of Maintenance, who acknowledged the absence of the required signage.
Plan Of Correction
Signage will be purchased and installed on egress doors. Signs will be installed by 1/13/25. Signage will be inspected every month by the Director of Environmental Services or designee to ensure that they are in place and in good condition. This inspection will be added to our preventative maintenance program to ensure signage is in place and in good condition. The results of this will be reported by the Director of Environmental Services or designee to the Quality Assurance and Performance Improvement Committee. Signage will be purchased and installed on egress doors. Signs will be installed by 1/13/25. Signage will be inspected every month by the Director of Environmental Services or designee to ensure that they are in place and in good condition. This inspection will be added to our preventative maintenance program to ensure signage is in place and in good condition. The results of this will be reported by the Director of Environmental Services or designee to the Quality Assurance and Performance Improvement Committee.
Sprinkler Heads Covered with Debris
Penalty
Summary
The facility failed to maintain the sprinkler heads in one of four smoke zones, as evidenced by an observation on December 3, 2024. During the inspection at 11:23 AM, it was noted that three sprinkler heads located outside on the Kitchen Loading Dock were covered with debris. This deficiency was confirmed during an interview at the exit conference with the Director of Nursing and Director of Maintenance on the same day at 1:30 PM, where it was acknowledged that the sprinkler heads were subject to load.
Plan Of Correction
Sprinkler heads will be cleared of debris. This occurred on 12/12/24. The sprinkler heads will be inspected by the Director of Environmental Services or designee every month as part of our preventative maintenance program. Audits will be completed by the Director of Environmental Services or designee weekly for every quarter to ensure compliance, and the results will be reported to the Quality Assurance and Performance Improvement Committee.
Failure to Maintain GFI Protection Near Water Sources
Penalty
Summary
The facility failed to maintain power receptacles with Ground Fault Interruption (GFI) protection within six feet of a water source in one of four smoke zones. During an observation on December 3, 2024, between 11:15 AM and 11:20 AM, it was noted that outlets in the kitchen, specifically by the pot and pan sink and behind the ice machine, were not GFI protected. This deficiency was confirmed during an interview with the Director of Nursing and Director of Maintenance at the exit conference on the same day.
Plan Of Correction
Outlets within 6 feet of a water source will be GFI protected. The outlet by the pot and pan sink was moved more than 6 feet away from the water source on 12/9/24. The outlet by the ice machine was changed to a GFI on 12/10/24. Checking all outlets will be part of our monthly preventative maintenance program by the Director of Environmental Services or designee. The results of our preventative maintenance program findings will be reported by the Director of Environmental Services or designee to the Quality Assurance and Performance Improvement Committee.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Thornwald Home | 0.7 mi | ★★★★★ | 7 | 0 |
| Forest Park Nursing And Rehabilitation | 0.7 mi | ★★★★★ | 9 | 0 |
| Carlisle Skilled Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Chapel Pointe At Carlisle | 1.1 mi | ★★★★★ | 0 | 0 |
| Letort Spring Nursing And Rehab Llc | 1.6 mi | ★★★★★ | 23 | 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 July 2026) and official state health department websites.