Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Lehigh Llc during CMS and state inspections, most recent first.
A resident with a history of fractured femur, CVA, and osteoarthritis had a physician order for diclofenac sodium gel to be applied to the lower extremities four times daily for pain, but multiple scheduled doses were not given because the medication was not available from the pharmacy. Documentation on the TAR indicated missed applications with references to nursing notes, which stated the gel was unavailable, and the DON confirmed that the ordered medication was not applied as prescribed due to pharmacy non-availability.
Two residents with intact cognitive abilities were found self-administering medications, including Fluticasone nasal spray, multivitamin gummies, Tylenol, and CBD gummies, without documented interdisciplinary assessment or secured storage, contrary to facility policy.
A resident with multiple sclerosis and diabetes was inaccurately coded as being on dialysis in the MDS assessment, despite no supporting documentation in the clinical record. The DON confirmed the error during staff interview.
A resident who was dependent on staff for all ADLs, including grooming and personal hygiene, was repeatedly observed lying in bed with dirty fingernails and not dressed, indicating that staff did not provide the necessary assistance as required by the care plan and clinical assessment.
A resident with hypertension and heart failure received Propranolol HCI on multiple occasions when their systolic blood pressure was below the physician-ordered threshold. The DON confirmed that staff administered the medication outside of the prescribed parameters.
A resident at risk for pressure ulcers and with a current heel wound was observed multiple times without prescribed Medix boots in place, despite physician orders and care plan interventions requiring their use at all times. The boots were found on the floor, and the resident's heels were directly on the bed, indicating staff did not follow necessary pressure ulcer prevention measures.
A resident with cognitive impairment and multiple diagnoses fell while returning to bed. Although x-rays were ordered following the incident, the responsible party was not informed until the next day, contrary to the facility's protocol requiring immediate notification.
The facility failed to maintain sanitary conditions in the kitchen, with the dish machine not achieving the correct sanitizer concentration and black substance on surrounding walls. A dietary employee did not check the sanitizer concentration, and the Director of Dietary confirmed this was against protocol.
The facility failed to maintain a clean and safe environment in two shower rooms. Observations revealed dirty and damaged shower chairs, a leaking shower head, and dirty lift wheels in both the first-floor and second-floor central baths.
A facility failed to accurately complete the MDS assessment for a resident receiving hospice services. Despite a physician's order for hospice care, the MDS did not reflect this status. The DON confirmed the oversight during an interview.
A resident with congestive heart failure had a physician's order for daily weight monitoring and provider notification for significant weight gain. The facility failed to obtain the resident's weight on multiple occasions and did not notify the physician of a 3.7-pound weight gain in 24 hours. The DON confirmed these deficiencies.
The facility failed to implement interventions for two residents to prevent decline in range of motion. A resident with muscle weakness did not receive a recommended daily restorative nursing program for arm movement. Another resident with dementia and hemiplegia was observed without a required carrot splint on her right hand, despite physician orders and care plan instructions.
Failure to Obtain and Administer Ordered Pain Medication
Penalty
Summary
The facility failed to ensure that a physician-ordered medication was available and administered as prescribed for one resident. The resident had diagnoses including a fractured femur, a stroke, and osteoarthritis, and on February 7, 2026, a physician ordered diclofenac sodium external gel to be applied to the resident’s lower extremities four times daily for pain related to osteoarthritis. Review of the February 2026 Treatment Administration Record showed that on February 8, 2026, all four scheduled applications, and on the morning of February 9, 2026, were marked as “other see notes.” Nursing notes for those dates documented that the diclofenac sodium gel was not applied because it was not available from the pharmacy. In an interview on February 11, 2026, the Director of Nursing confirmed that the medication had not been applied as ordered due to its unavailability from the pharmacy on the identified dates. This deficiency reflects a failure to provide pharmaceutical services to meet the resident’s needs and to ensure that ordered medications were obtained and available for use as prescribed.
Failure to Assess and Document Residents' Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess two residents for their ability to self-administer medications, as required by facility policy. For one resident with diagnoses including heart failure, diabetes, depression, and mild cognitive impairment, observations revealed multiple medications, including a bottle of Fluticasone nasal spray and multivitamin gummies, left unsecured on the bedside table. The resident reported self-administering these medications, but there was no documentation of an interdisciplinary team assessment or approval for self-administration, nor was there evidence of secured storage to prevent access by others. Another resident, diagnosed with high blood pressure and high cholesterol, was found to have a bottle of Tylenol and CBD gummies unsecured in a dresser drawer. This resident also reported self-administering Tylenol daily, with no documentation of an assessment for self-administration or secured storage of the medications. Interviews with staff and the administrator confirmed that neither resident had been assessed for self-administration of medications as required by facility policy.
Inaccurate MDS Assessment Coding for Resident
Penalty
Summary
The facility failed to complete an accurate Minimum Data Set (MDS) assessment for one resident. Clinical record review showed that the resident had diagnoses of multiple sclerosis and diabetes. However, the MDS assessment incorrectly indicated that the resident was on dialysis, despite there being no documentation in the clinical record to support this. During an interview, the Director of Nursing confirmed that the MDS assessment was inaccurately coded and that the resident was not on dialysis at the time.
Failure to Provide Required ADL Assistance for Dependent Resident
Penalty
Summary
A resident with diagnoses including acute respiratory failure, chronic obstructive pulmonary disease, and a disorder of the brain was found to be dependent on staff for activities of daily living (ADLs) and had an ADL self-care deficit as documented in the clinical record and care plan. Observations conducted over two consecutive days revealed that the resident remained in bed with dirty fingernails, was not dressed, and had not received necessary assistance with grooming and personal hygiene from staff. Staff interviews confirmed that the resident was dependent on staff for all ADL care, yet appropriate assistance was not provided during the observed periods. These findings were based on clinical record review, direct observation, and staff interview, demonstrating a failure by the facility to ensure that required assistance with grooming and personal hygiene was provided to a resident who was unable to perform these tasks independently.
Failure to Follow Medication Administration Parameters
Penalty
Summary
Staff failed to follow physician's orders for a resident diagnosed with hypertension and heart failure. The physician had ordered Propranolol HCI to be administered twice daily, with specific parameters not to give the medication if the resident's systolic blood pressure was below 110 mm/Hg or if the heart rate was less than 55. Clinical record review showed that the medication was administered on three occasions in July and three occasions in August when the resident's systolic blood pressure was under 110 mm/Hg. The Director of Nursing confirmed that the medication was given outside of the established parameters.
Failure to Apply Pressure-Relieving Devices as Ordered
Penalty
Summary
A resident with diagnoses including acute respiratory failure, COPD, and a brain disorder was identified as being at risk for pressure sores and was dependent on staff for activities of daily living. The care plan included interventions to prevent skin impairment due to incontinence, such as elevating both heels off the bed with pillows and the application of Medix boots (pressure-relieving boots) at all times, as ordered by the physician. Clinical documentation indicated the presence of a pressure sore on the resident's right heel, with recommendations to float the heels using the prescribed boots. Despite these interventions and orders, multiple observations over two consecutive days revealed that the resident was lying in bed without the Medix boots in place, with both heels resting directly on the bed. The boots were seen on the floor in the resident's room during all observed periods. The DON confirmed that the boots were to be applied at all times as a pressure-relieving device. This failure to implement prescribed interventions resulted in the facility not providing necessary treatment and services to promote healing and prevent new pressure sores for the resident.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for one of the residents. The resident, who had diagnoses including diabetes, polyneuropathy, and muscle weakness, experienced a fall on October 10, 2024, at 7:25 a.m. while returning to bed after using the toilet. Following the fall, a nurse's note at 11:05 a.m. indicated new physician orders for x-rays of the right hip, pelvis, and thoracic and lumbar spine. However, the responsible party was not informed of the fall and the subsequent x-rays until the next day at 3:15 p.m. The Director of Nursing confirmed that staff are required to notify the responsible party immediately after such incidents.
Sanitation Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The dish machine did not achieve the appropriate concentration of sanitizer solution, which should be between 50-100 parts per million, for three full cycles. Additionally, there was a black substance on the walls surrounding the dish machine, indicating a lack of cleanliness. A backflow of water was observed from a drain on the dish room floor, and debris was found on a windowsill in the food preparation area. During an interview, a dietary employee admitted to not checking the concentration of the sanitizer solution during the morning operation. The Director of Dietary confirmed that staff are required to check and accurately record the concentration of the sanitizer solution while the dish machine is operating, as per the facility's protocol.
Facility Fails to Maintain Clean and Safe Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in two shower rooms, specifically the first-floor and second-floor central baths. Observations in the first-floor central bath revealed a shower chair with a black substance at the base, another chair with brown smudges on the seat and a black substance at the base, and a bariatric shower chair with hair on the seat and base. Additionally, the wheels on two lifts were dirty. In the second-floor central bath, a shower chair had a cracked seat, a leaking shower head was observed in the left shower stall, the wheels on three lifts were dirty, and a shower chair had a black substance under the seat.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the current status of a resident. Specifically, for one of the 24 sampled residents, the MDS assessment did not indicate that the resident was receiving hospice services, despite a physician's order for hospice care being in place since March 11, 2024. This discrepancy was confirmed during an interview with the Director of Nursing on July 12, 2024, who acknowledged that the MDS assessment did not accurately identify the resident's hospice status.
Failure to Implement Physician's Orders for Resident with CHF
Penalty
Summary
The facility failed to implement physician's orders for a resident diagnosed with congestive heart failure. The physician's order required staff to obtain a daily weight for the resident and notify the provider if there was a weight gain of two pounds or more in one day. However, there was no evidence that the resident's weight was obtained or that the resident refused to be weighed on several specified dates. Additionally, on one occasion, the resident experienced a 3.7-pound weight gain in 24 hours, but the staff did not notify the physician of this significant change. The Director of Nursing confirmed the lack of evidence regarding the weighing of the resident and the notification of the physician about the weight change.
Failure to Implement Range of Motion Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent further decline and improve range of motion for two residents. Resident 35, diagnosed with muscle weakness, was recommended a daily restorative nursing program (RNP) for active range of motion to both arms following an occupational therapy discharge assessment. However, there was no evidence that this program was implemented, as confirmed by the Director of Rehabilitation Services. Resident 54, who had diagnoses including dementia, hemiplegia, and a right hand contracture, was ordered by a physician to have a carrot splint applied to her right hand at all times. Despite this, multiple observations revealed that the splint was not in place while the resident was in her chair, indicating a failure to follow the care plan designed to prevent limitation in movement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Macungie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mosser Nursing Home | 2.2 mi | ★★★★★ | 1 | 0 |
| Lehigh Valley Hospital Tsu | 2.3 mi | ★★★★★ | 1 | 0 |
| Cedarbrook Senior Care And Rehabilitation | 2.5 mi | ★★★★★ | 8 | 0 |
| Cedar Crest Post Acute | 3 mi | ★★★★★ | 14 | 0 |
| Luther Crest Nursing Facility | 3.3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.