Cycle 1
Health 2025-12-12 · Fire 2025-12-12
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lehighton, PA
Mahoning Operating LLC
2-star overall rating with 3-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
397 Hemlock Drive, Lehighton, PA
(570) 386-5522
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
142
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.20
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.17
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
0.58
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
0.96
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
0.37
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
0.75
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.12
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
0.23
CMS adjusted RN staffing hours
Adjusted total hours
1.08
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,584
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9841
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.54% · Performance 21.66% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.73
Baseline 6.73% · Performance 7.62% · Measure score 0.73 · Achievement 0.73 · Improvement 0
Total nurse turnover
6.80
Baseline 37.35% · Performance 35.90% · Measure score 6.80 · Achievement 6.80 · Improvement 0.66
Adjusted total nurse staffing
2.99
Baseline 3.32 hours · Performance 3.93 hours · Measure score 2.99 · Achievement 2.99 · Improvement 1.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 111 · Observed rate 12.61% · Lower 95% interval 7.83% |
| Discharge to community | 42.64% |
50.57%
7.9 pts worse
|
No Different than the National Rate · Eligible stays 120 · Observed rate 35% · Lower 95% interval 34.32% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 91 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 34.85% |
53.69%
18.8 pts worse
|
Numerator 23 · Denominator 66 |
| Discharge mobility score | 39.39% |
50.94%
11.5 pts worse
|
Numerator 26 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 91 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.62% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 8.24% · Lower 95% interval 4.56% |
| Staff COVID-19 vaccination coverage | 0.75% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 133 |
| Staff flu vaccination coverage | 17.76% |
42%
24.2 pts worse
|
Numerator 27 · Denominator 152 |
| Discharge function score | 48.48% |
56.45%
8 pts worse
|
Numerator 32 · Denominator 66 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 39.34% |
25.2%
14.1 pts better
|
Numerator 24 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.6 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
86.9%
11.1 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 98.0% |
| 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 | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 6.3% |
6.5%
0.2 pts better
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.3% · Q3 8.6% · Q4 10.7% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.0% |
19.9%
1.1 pts worse
|
19.6%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 19.7% · Q3 25.4% · Q4 15.4% · 4Q avg 21.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
18.7%
1.1 pts worse
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 21.3% · Q3 22.6% · Q4 17.6% · 4Q avg 19.8% · 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 | 22.0% |
19.6%
2.4 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 32.7% · Q3 30.9% · Q4 13.7% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.0% |
18.3%
3.7 pts worse
|
14.9%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 23.1% · Q3 30.8% · Q4 16.9% · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.7% |
0.9%
3.8 pts worse
|
1.0%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.1% · Q3 4.1% · Q4 2.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.4% |
26.4%
3 pts worse
|
19.8%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.0% · Q2 22.1% · Q3 28.4% · Q4 25.9% · 4Q avg 29.4% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
5.3%
2.7 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 0.0% · Q4 6.8% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
68.9%
18.9 pts better
|
81.7%
6.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.1% · Q2 85.2% · Q3 94.8% · Q4 94.5% · 4Q avg 87.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.7% |
9.8%
1.1 pts better
|
12.0%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.7% · Observed 7.7% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.5%
2 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.0% |
68.7%
10.3 pts better
|
79.7%
0.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
23.1%
4 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 24.2% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2025-02-21 · Fire 2025-02-21
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2024-03-22 · Fire 2024-03-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-12-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-16
E · Potential for more than minimal harm
2025-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-28
E · Potential for more than minimal harm
2025-02-21
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 2025-04-22
E · Potential for more than minimal harm
2025-02-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-02-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-22
E · Potential for more than minimal harm
2024-03-22
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 2024-05-07
E · Potential for more than minimal harm
2024-03-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-03-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-05-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2026-01-20
E · Potential for more than minimal harm
2025-12-12
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 2026-01-20
E · Potential for more than minimal harm
2025-12-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-12
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-12
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-12-12
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2026-01-20
D · Potential for more than minimal harm
2025-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-07
E · Potential for more than minimal harm
2025-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-02-21
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-04-10
B · Minimal harm
2025-02-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-10
E · Potential for more than minimal harm
2024-03-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-03-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-03-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-05-13
D · Potential for more than minimal harm
2024-03-22
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-05-13
B · Minimal harm
2024-03-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-05-13
Penalties and ownership
What sits behind the stars
Ownership
Sapphire Unlimited Holdings Inc.
5% Or Greater Direct Ownership Interest · Organization
Mickey, Devon
5% Or Greater Indirect Ownership Interest · Individual
Mickey, Michael
5% Or Greater Indirect Ownership Interest · Individual
Mickey, Devon
Corporate Officer · Individual
Mickey, Michael
Corporate Officer · Individual
Sapphire Unlimited Holdings Inc.
5% Or Greater Security Interest · Organization
Sapphire Unlimited Holdings Inc.
5% Or Greater Mortgage Interest · Organization
Stoffa, Teresa
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
St Luke's Rehabilitation And Nursing Center
Coaldale, PA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Forest Hills Rehabilitation & Healthcare Center
Weatherly, PA
1-star overall rating with 2-star inspections with abuse icon flag with $69,160 in total fines with 10 recent health deficiencies
#3
Greenwood Center For Nursing And Rehab
Tamaqua, PA
1-star overall rating with 1-star inspections with $76,674 in total fines with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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