Thornwald Home
442 Walnut Bottom Road, Carlisle, PA 17013 · Cumberland County · 83 certified beds · avg 77 residents/day · certified since Sep 1, 1989
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jul 21, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 21, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (16)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 11, 2025 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility hired someone with an official finding of abuse, neglect, exploitation, or theft against them. Facilities are not allowed to employ people with such findings. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Dec 11, 2025 | D · Potential for harm, one-off | The facility did not regularly inspect bed frames, mattresses, and bed rails for safety, or the rails and mattresses were not attached safely to the frames. |
| Jul 21, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 12, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Dec 12, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Jan 18, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 18, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jan 18, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jan 18, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 18, 2024 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 8 | 0 | E |
| 2025 | 8 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $9,110.
| Date | Type | Amount / length |
|---|---|---|
| Jul 21, 2025 | Fine | $9,110 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Pennsylvania avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.40 | 3.94 | 3.95 | top 25% in Pennsylvania; top 26% in the U.S. |
| Registered Nurse hours | 0.94 | 0.80 | 0.69 | top 24% in Pennsylvania; top 19% in the U.S. |
| Weekend total nurse staffing | 4.15 | 3.58 | 3.50 | top 21% in Pennsylvania; top 19% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.71 | 0.56 | 0.48 | top 22% in Pennsylvania; top 15% in the U.S. |
| Total nursing staff turnover (%) | 47.4 | 44.5 | 45.8 | bottom 41% in Pennsylvania; bottom 43% in the U.S. |
| RN turnover (%) | 45.0 | 39.9 | 42.9 | bottom 38% in Pennsylvania; bottom 44% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.37, RN 0.93, weekend 4.13. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Barnhart, Ida | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/11/2023 |
| Barnhart, Ida | Individual | ADP of the SNF | NOT APPLICABLE | 09/11/2023 |
| Bart, Justyna | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2026 |
| Bart, Justyna | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2026 |
| Blose, Leroy | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/26/2018 |
| Blose, Leroy | Individual | ADP of the SNF | NOT APPLICABLE | 04/28/2022 |
| Boone, Rebecca | Individual | Managing Control - Governing Body | NOT APPLICABLE | 04/28/2022 |
| Boone, Rebecca | Individual | ADP of the SNF | NOT APPLICABLE | 04/28/2022 |
| Cliftonlarsonallen LLP | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2012 |
| Cliftonlarsonallen LLP | Organization | ADP of the SNF | NOT APPLICABLE | 03/07/2025 |
| Conrad Siegel Investment Advisors, INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2009 |
| Conrad Siegel Investment Advisors, INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/07/2025 |
| Deaner, Kay | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/22/2024 |
| Deaner, Kay | Individual | ADP of the SNF | NOT APPLICABLE | 01/22/2024 |
| Dierolf, Lori | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/16/2022 |
| Dierolf, Lori | Individual | ADP of the SNF | NOT APPLICABLE | 06/16/2022 |
| Domingos, Tita | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/25/2024 |
| Domingos, Tita | Individual | ADP of the SNF | NOT APPLICABLE | 07/25/2022 |
| Eyster, Sharon | Individual | Corporate Officer | NOT APPLICABLE | 10/31/2022 |
| Eyster, Sharon | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/31/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you screen job applicants for past findings of abuse, neglect, or theft before hiring?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How often are beds and bed rails inspected, and who does those checks?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Forest Park Nursing and Rehabilitation | 0.1 mi | Carlisle, PA | ★☆☆☆☆ | 1/5 | |
| Carlisle Skilled Nursing and Rehabilitation Center | 0.3 mi | Carlisle, PA | ★☆☆☆☆ | 1/5 | SFF |
| Chapel Pointe at Carlisle | 0.6 mi | Carlisle, PA | ★★★★★ | 5/5 | |
| Sarah a Todd Memorial Home | 0.7 mi | Carlisle, PA | ★★★★★ | 4/5 | |
| Cumberland Crossings Retirement Community | 1.0 mi | Carlisle, PA | ★★★★★ | 5/5 | |
| Letort Spring Nursing and Rehab LLC | 1.7 mi | Carlisle, PA | ★☆☆☆☆ | 1/5 | |
| Claremont Nursing & Rehabilitation Center | 2.5 mi | Carlisle, PA | ★★★☆☆ | 2/5 | |
| Vibra Rehabilitation Center | 10.8 mi | Mechanicsburg, PA | ★★★☆☆ | 2/5 | |
| Fox Subacute at Mechanicsburg | 10.8 mi | Mechanicsburg, PA | ★★☆☆☆ | 3/5 | |
| Swaim Health Center | 10.9 mi | Newville, PA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 395802.