Cycle 1
Health 2025-11-20 · Fire 2025-11-20
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Reading, PA
Complete Care At Berkshire LLC
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
5501 Perkiomen Avenue, Reading, PA
(610) 779-0600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1994-09-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.20
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,474
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0035
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.34
Baseline 16.39% · Performance 17.10% · Measure score 9.34 · Achievement 9.34 · Improvement 0
Healthcare-associated infections
4.65
Baseline 5.25% · Performance 6.44% · Measure score 4.65 · Achievement 4.65 · Improvement 0
Total nurse turnover
3.35
Baseline 45.00% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Adjusted total nurse staffing
2.48
Baseline 3.38 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 1.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.53% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 9.58% · Lower 95% interval 8.15% |
| Discharge to community | 46.99% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 177 · Observed rate 40.68% · Lower 95% interval 40.55% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 102 · Denominator 102 |
| Falls with major injury | 0.98% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 102 |
| Discharge self-care score | 53.25% |
53.69%
0.4 pts worse
|
Numerator 41 · Denominator 77 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 42 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 4 · Denominator 102 · Adjusted rate 4% |
| Healthcare-associated infections requiring hospitalization | 6.44% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 5.94% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 75.19% |
42%
33.2 pts better
|
Numerator 100 · Denominator 133 |
| Discharge function score | 58.44% |
56.45%
2 pts better
|
Numerator 45 · Denominator 77 |
| Transfer of health information to provider | 97.78% |
95.95%
1.8 pts better
|
Numerator 44 · Denominator 45 |
| Transfer of health information to patient | 96.67% |
96.28%
0.4 pts better
|
Numerator 29 · Denominator 30 |
| Resident COVID-19 vaccinations up to date | 8.06% |
25.2%
17.1 pts worse
|
Numerator 5 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.7
0.8 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
86.9%
4.5 pts better
|
93.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 93.0% · Q3 93.5% · Q4 87.9% · 4Q avg 91.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
93.5%
4.6 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.2%
0.3 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.0% · Q3 2.2% · Q4 1.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
6.5%
2.5 pts worse
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 11.7% · Q3 8.0% · Q4 12.5% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.5%
1.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 12.9% · Q3 2.8% · Q4 2.9% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.5% |
19.9%
2.4 pts better
|
19.6%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.3% · Q3 17.3% · Q4 20.0% · 4Q avg 17.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
18.7%
12.5 pts better
|
16.7%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 5.3% · Q3 6.6% · Q4 6.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.5% |
19.6%
1.1 pts better
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 23.3% · Q3 16.9% · Q4 7.3% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
18.3%
3.2 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 19.5% · Q3 12.5% · Q4 12.5% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.7%
0.1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 3.3% · Q4 2.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
26.4%
3.1 pts better
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 19.4% · Q3 27.4% · Q4 18.6% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.3%
2.3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.2% · Q3 4.1% · Q4 0.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.9% |
68.9%
4 pts worse
|
81.7%
16.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 63.2% · Q2 64.0% · Q3 67.2% · Q4 64.8% · 4Q avg 64.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.8%
3.8 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 5.7% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 3.1% · Q3 1.9% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.7% |
68.7%
5 pts worse
|
79.7%
16 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.9% |
23.1%
5.2 pts better
|
23.9%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 17.2% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-21 · Fire 2024-11-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-12-15 · Fire 2023-12-15
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-15
E · Potential for more than minimal harm
2025-11-20
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2026-02-15
C · Minimal harm
2025-11-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2026-02-15
E · Potential for more than minimal harm
2024-11-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-17
E · Potential for more than minimal harm
2024-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-17
B · Minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-17
E · Potential for more than minimal harm
2023-12-15
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-02-19
E · Potential for more than minimal harm
2023-12-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-04
E · Potential for more than minimal harm
2023-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-20
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-01-06
D · Potential for more than minimal harm
2025-11-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-06
D · Potential for more than minimal harm
2024-11-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-12-09
E · Potential for more than minimal harm
2023-12-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-02-13
D · Potential for more than minimal harm
2023-12-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-13
D · Potential for more than minimal harm
2023-12-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-13
D · Potential for more than minimal harm
2023-12-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-13
Penalties and ownership
What sits behind the stars
Ownership
Pc Pa Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Hershel
W-2 Managing Employee · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Reading, PA
3-star overall rating with 3-star inspections with 6 recent health deficiencies
#2
Wyomissing Health And Rehabilitation Center
Reading, PA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Spruce Manor Nursing & Rehabilitation Center
West Reading, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies
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