LeTort Spring Nursing and Rehab LLC
Open-data reference.
LeTort Spring Nursing and Rehab LLC is a non profit - church related facility in CARLISLE, PA with 109 certified beds and a 1-star overall CMS rating. The facility has 47 deficiency records on file. Total penalties: $64K.
801 N. HANOVER STREET, CARLISLE, PA 17013
Phone: 7172495322
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 395784
- Ownership
- Non profit - Church related
- Provider Type
- Medicare and Medicaid
- Beds
- 109
- Residents
- N/A
- In Hospital
- No
- County
- Cumberland
- Last Inspection
- Feb 6, 2025
Staffing Data
- RN Hours
- N/A (nat'l avg: 0.68)
- LPN Hours
- N/A
- CNA Hours
- N/A
- Total Nursing Hours
- N/A (nat'l avg: 3.89)
- PT Hours
- N/A
What the CMS Record Reveals About LeTort Spring Nursing and Rehab LLC
LeTort Spring Nursing and Rehab LLC operates 109 certified beds in CARLISLE, PA, and carries a CMS overall rating of 1 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (1★), staffing levels (N/A★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 47 deficiency records from recent surveys, of which 3 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 3 penalties totaling $64K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence.
Classified as "Non profit - Church related" ownership and operating as a "Medicare and Medicaid" provider, LeTort Spring Nursing and Rehab LLC falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (47 most recent)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 22, 2025
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.
Category: Infection Control Deficiencies
Corrected: Mar 14, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Mar 14, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Mar 14, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Mar 14, 2025
Provide routine and 24-hour emergency dental care for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 14, 2025
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.
Category: Pharmacy Service Deficiencies
Corrected: Mar 14, 2025
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 14, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 14, 2025
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 14, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 14, 2025
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Mar 14, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Mar 14, 2025
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Mar 14, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 16, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 16, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 16, 2024
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Aug 23, 2024
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 18, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Apr 18, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 18, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 18, 2024
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Category: Nutrition and Dietary Deficiencies
Corrected: Apr 18, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Apr 18, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Apr 18, 2024
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 18, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Category: Nursing and Physician Services Deficiencies
Corrected: Apr 18, 2024
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 18, 2024
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 18, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 18, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 18, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Apr 18, 2024
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 18, 2024
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 18, 2024
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Apr 18, 2024
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Apr 18, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jun 22, 2023
Observe each nurse aide's job performance and give regular training.
Category: Nursing and Physician Services Deficiencies
Corrected: May 23, 2023
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Jun 22, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: May 23, 2023
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jun 22, 2023
Ensure each resident receives an accurate assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 23, 2023
Assess the resident when there is a significant change in condition
Category: Resident Assessment and Care Planning Deficiencies
Corrected: May 23, 2023
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.
Category: Resident Rights Deficiencies
Corrected: May 23, 2023
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: May 23, 2023
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 24.8% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 6.3% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 1.9% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.2% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 2.3% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 4.2% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 64.6% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 16.6% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 17.0% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 28.8% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 93.5% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 32.7% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.8% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 35.6% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 25.3% | Yes |
Penalty History 3 penalties totaling $64K
| Date | Type | Amount |
|---|---|---|
| Apr 24, 2025 | Fine | $17K |
| Feb 6, 2025 | Fine | $34K |
| Mar 21, 2024 | Fine | $13K |
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Frequently Asked Questions
What is the overall CMS rating for LeTort Spring Nursing and Rehab LLC?
What are the staffing levels at LeTort Spring Nursing and Rehab LLC?
How many beds does LeTort Spring Nursing and Rehab LLC have?
Does LeTort Spring Nursing and Rehab LLC have any deficiencies on record?
Has LeTort Spring Nursing and Rehab LLC received any fines or penalties?
Who owns LeTort Spring Nursing and Rehab LLC?
When was LeTort Spring Nursing and Rehab LLC last inspected?
What quality measures are tracked for LeTort Spring Nursing and Rehab LLC?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.