Cycle 1
Health 2025-04-03 · Fire 2025-04-03
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Nazareth, PA
Moravian Hall Square Health And Wellness Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies
175 West North Street, Nazareth, PA
(610) 746-1000
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
56
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-04-11
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
0.66
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.97
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.38
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
5.02
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,653
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9963
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.89% · Performance 23.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.3
Baseline 5.29% · Performance 5.95% · Measure score 6.3 · Achievement 6.3 · Improvement 0
Total nurse turnover
4.31
Baseline 40.48% · Performance 46.07% · Measure score 4.31 · Achievement 4.31 · Improvement 0
Adjusted total nurse staffing
6.70
Baseline 4.77 hours · Performance 4.99 hours · Measure score 6.70 · Achievement 6.70 · Improvement 1.63
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.34% |
10.72%
3.6 pts worse
|
Worse than the National Rate · Eligible stays 321 · Observed rate 15.26% · Lower 95% interval 11.33% |
| Discharge to community | 54.74% |
50.57%
4.2 pts better
|
No Different than the National Rate · Eligible stays 285 · Observed rate 50.88% · Lower 95% interval 49.54% |
| Medicare spending per beneficiary | 0.64 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 142 · Denominator 144 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 144 |
| Discharge self-care score | 22.61% |
53.69%
31.1 pts worse
|
Numerator 26 · Denominator 115 |
| Discharge mobility score | 21.74% |
50.94%
29.2 pts worse
|
Numerator 25 · Denominator 115 |
| Pressure ulcers or injuries, new or worsened | 4.86% |
2.29%
2.6 pts worse
|
Numerator 7 · Denominator 144 · Adjusted rate 5.23% |
| Healthcare-associated infections requiring hospitalization | 5.95% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 159 · Observed rate 3.77% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 164 |
| Staff flu vaccination coverage | 95.26% |
42%
53.3 pts better
|
Numerator 201 · Denominator 211 |
| Discharge function score | 28.7% |
56.45%
27.8 pts worse
|
Numerator 33 · Denominator 115 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 60 · Denominator 62 |
| Resident COVID-19 vaccinations up to date | 29.69% |
25.2%
4.5 pts better
|
Numerator 19 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.7
0.6 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
86.9%
7 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 97.7% · Q3 100.0% · Q4 80.9% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
93.5%
2.4 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.2%
2.6 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · 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 | 4.8% |
6.5%
1.7 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.3% · Q3 0.0% · Q4 8.1% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
19.9%
1.3 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 22.5% · Q3 19.0% · Q4 17.1% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.6% |
18.7%
1.1 pts better
|
16.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 28.0% · Q3 19.4% · Q4 10.3% · 4Q avg 17.6% · 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 | 25.0% |
19.6%
5.4 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.9% |
18.3%
7.6 pts worse
|
14.9%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 33.3% · Q3 18.4% · Q4 23.7% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 1.4% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.0% |
26.4%
4.6 pts worse
|
19.8%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 40.7% · Q3 29.1% · Q4 37.8% · 4Q avg 31.0% |
| Percentage of long-stay residents with pressure ulcers | 5.1% |
5.3%
0.2 pts better
|
5.1%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 10.8% · Q3 5.1% · Q4 0.0% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
68.9%
19.8 pts better
|
81.7%
7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.1% · Q2 90.1% · Q3 93.3% · Q4 83.7% · 4Q avg 88.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
9.8%
2.7 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.2% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.7% · Q3 2.5% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.0% |
68.7%
9.3 pts better
|
79.7%
1.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
23.1%
4.3 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 23.2% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-04-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-20
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-06-01
E · Potential for more than minimal harm
2023-04-20
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-06-01
Inspection history
Recent health citations
G · Actual harm
2025-06-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-04-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-04-03
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 2025-04-14
D · Potential for more than minimal harm
2025-02-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-01-17
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-03-21
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 2024-04-15
D · Potential for more than minimal harm
2023-04-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-05-01
D · Potential for more than minimal harm
2023-04-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-05-01
Penalties and ownership
What sits behind the stars
Ownership
Capobianco, Susan
Operational/Managerial Control · Individual
Capobianco, Susan
Corporate Officer · Individual
Donlan, Alice
Operational/Managerial Control · Individual
Hunt, Christopher
Operational/Managerial Control · Individual
Hunt, Christopher
Corporate Officer · Individual
Swartley, James
Corporate Officer · Individual
Unitas Communities
Operational/Managerial Control · Organization
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#3
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