Cycle 1
Health 2025-08-21 · Fire 2025-08-21
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Macungie, PA
Complete Care At Lehigh LLC
4-star overall rating with 4-star inspections with 5 recent health deficiencies
1718 Spring Creek Road, Macungie, PA
(610) 366-0500
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
123
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1994-11-18
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
0.69
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,009
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
41.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9947
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.13% · Performance 22.47% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.78
Baseline 4.94% · Performance 5.51% · Measure score 7.78 · Achievement 7.78 · Improvement 0
Total nurse turnover
6.49
Baseline 66.91% · Performance 37.50% · Measure score 6.49 · Achievement 6.41 · Improvement 6.49
Adjusted total nurse staffing
2.42
Baseline 3.84 hours · Performance 3.77 hours · Measure score 2.42 · Achievement 2.42 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.29% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 269 · Observed rate 11.52% · Lower 95% interval 8.35% |
| Discharge to community | 54.9% |
50.57%
4.3 pts better
|
No Different than the National Rate · Eligible stays 260 · Observed rate 48.08% · Lower 95% interval 49.13% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 149 · Denominator 149 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 149 |
| Discharge self-care score | 26.42% |
53.69%
27.3 pts worse
|
Numerator 28 · Denominator 106 |
| Discharge mobility score | 44.34% |
50.94%
6.6 pts worse
|
Numerator 47 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 2.01% |
2.29%
0.3 pts better
|
Numerator 3 · Denominator 149 · Adjusted rate 1.88% |
| Healthcare-associated infections requiring hospitalization | 5.51% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 3.42% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 5 · Denominator 85 |
| Staff flu vaccination coverage | 68.49% |
42%
26.5 pts better
|
Numerator 100 · Denominator 146 |
| Discharge function score | 48.11% |
56.45%
8.3 pts worse
|
Numerator 51 · Denominator 106 |
| Transfer of health information to provider | 95.65% |
95.95%
0.3 pts worse
|
Numerator 22 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 86 · Denominator 86 |
| Resident COVID-19 vaccinations up to date | 36.78% |
25.2%
11.6 pts better
|
Numerator 32 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.7
0.4 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.4 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.8% |
86.9%
8.9 pts better
|
93.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 96.1% · Q3 94.9% · Q4 96.2% · 4Q avg 95.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.2%
0.7 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.9% · Q3 4.0% · Q4 4.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.7% |
6.5%
2.2 pts worse
|
11.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 10.0% · Q3 8.7% · Q4 9.5% · 4Q avg 8.7% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
6.5%
4.8 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.1% · Q3 1.1% · Q4 3.4% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
19.9%
1.6 pts better
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 19.6% · Q3 15.1% · Q4 19.1% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
18.7%
7.2 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.6% · Q3 12.0% · Q4 15.7% · 4Q avg 11.5% · 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 | 24.0% |
19.6%
4.4 pts worse
|
16.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 33.2% · Q3 22.4% · Q4 21.6% · 4Q avg 24.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.4% |
18.3%
1.9 pts better
|
14.9%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 20.2% · Q3 25.6% · Q4 13.3% · 4Q avg 16.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.7%
1.1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.1% · Q3 1.1% · Q4 4.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
26.4%
3.8 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 32.4% · Q3 24.1% · Q4 32.8% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.3%
1.7 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.0% · Q3 4.2% · Q4 5.1% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
68.9%
12.7 pts better
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 90.6% · Q3 75.0% · Q4 61.5% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
9.8%
About the same
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.0% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.5%
0.3 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.0% · Q3 1.8% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
68.7%
18.4 pts better
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
23.1%
2.6 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 19.3% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-12 · Fire 2024-07-12
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-08-10 · Fire 2023-08-10
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-21
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 2025-10-10
D · Potential for more than minimal harm
2025-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-10
D · Potential for more than minimal harm
2024-10-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-12-03
F · Potential for more than minimal harm
2024-07-12
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 2024-09-10
D · Potential for more than minimal harm
2024-07-12
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 2024-09-10
D · Potential for more than minimal harm
2024-07-12
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-07-12
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-10
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
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#2
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2-star overall rating with 1-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Cedarbrook Senior Care And Rehabilitation
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5-star overall rating with 4-star inspections with 5 recent health deficiencies
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