Cycle 1
Health 2025-11-20 · Fire 2025-11-20
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Doylestown, PA
Heritage Pointe Rehabilitation And Healthcare Ctr
4-star overall rating with 4-star inspections with 4 recent health deficiencies
400 South Main Street, Doylestown, PA
(215) 348-2980
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
130
Certified beds
Average residents
111
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 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
0.52
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,433
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.35
Composite VBP score used to determine payment impact.
Payment multiplier
0.9974
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.36
Baseline 20.42% · Performance 18.95% · Measure score 5.36 · Achievement 5.36 · Improvement 3.84
Healthcare-associated infections
7.02
Baseline 5.41% · Performance 5.74% · Measure score 7.02 · Achievement 7.02 · Improvement 0
Total nurse turnover
2.63
Baseline 20.83% · Performance 52.94% · Measure score 2.63 · Achievement 2.63 · Improvement 0
Adjusted total nurse staffing
2.74
Baseline 2.55 hours · Performance 3.60 hours · Measure score 2.74 · Achievement 1.83 · Improvement 2.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.33% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 154 · Observed rate 15.58% · Lower 95% interval 8.7% |
| Discharge to community | 33.79% |
50.57%
16.8 pts worse
|
Worse than the National Rate · Eligible stays 109 · Observed rate 25.69% · Lower 95% interval 24.9% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 132 · Denominator 136 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 136 |
| Discharge self-care score | 42.35% |
53.69%
11.3 pts worse
|
Numerator 36 · Denominator 85 |
| Discharge mobility score | 49.41% |
50.94%
1.5 pts worse
|
Numerator 42 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 136 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.74% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 3.3% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 92.19% |
42%
50.2 pts better
|
Numerator 118 · Denominator 128 |
| Discharge function score | 61.18% |
56.45%
4.7 pts better
|
Numerator 52 · Denominator 85 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 98% |
96.28%
1.7 pts better
|
Numerator 49 · Denominator 50 |
| Resident COVID-19 vaccinations up to date | 12.66% |
25.2%
12.5 pts worse
|
Numerator 10 · Denominator 79 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.7
0.8 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
86.9%
1.7 pts better
|
93.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 69.3% · Q2 89.9% · Q3 99.0% · Q4 96.0% · 4Q avg 88.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
93.5%
3.7 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.2%
0.8 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.0% · Q3 4.9% · Q4 3.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 55.8% |
6.5%
49.3 pts worse
|
11.4%
44.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.2% · Q2 50.0% · Q3 54.1% · Q4 57.6% · 4Q avg 55.8% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.5%
0.3 pts better
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.9% · Q3 7.4% · Q4 5.9% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.0% |
19.9%
13.1 pts worse
|
19.6%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.3% · Q2 32.2% · Q3 31.5% · Q4 31.9% · 4Q avg 33.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
18.7%
3.4 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 24.0% · Q3 23.7% · Q4 19.4% · 4Q avg 22.1% · 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 | 7.2% |
19.6%
12.4 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 0.0% · Q3 7.0% · Q4 14.9% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.7% |
18.3%
5.6 pts better
|
14.9%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 11.1% · Q3 4.8% · Q4 19.3% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · 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 | 19.0% |
26.4%
7.4 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 16.9% · Q3 15.6% · Q4 22.7% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
5.3%
4.6 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.6% |
68.9%
10.3 pts worse
|
81.7%
23.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 51.5% · Q2 62.6% · Q3 63.3% · Q4 54.0% · 4Q avg 58.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.7% |
9.8%
2.1 pts better
|
12.0%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.7% · Observed 8.2% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.1% · Q4 4.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 41.8% |
68.7%
26.9 pts worse
|
79.7%
37.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 41.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
23.1%
7.1 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 27.9% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-12-05 · Fire 2024-12-05
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-12-21 · Fire 2023-12-21
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
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 2025-12-22
D · Potential for more than minimal harm
2025-11-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-20
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-22
F · Potential for more than minimal harm
2024-12-05
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 2025-01-07
D · Potential for more than minimal harm
2024-12-05
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 2025-01-07
C · Minimal harm
2024-12-05
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-01-07
Penalties and ownership
What sits behind the stars
Ownership
Heritage Pointe LLC
5% Or Greater Direct Ownership Interest · Organization
Kuchinski, Deanna
Operational/Managerial Control · Individual
Kuchinski, Deanna
Corporate Officer · Individual
Pa Noble Parentco LLC
5% Or Greater Indirect Ownership Interest · Organization
Star Pa I Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Stern, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Stern, Moshe
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Liberty Pointe Rehabilitation And Healthcare Ctr
Doylestown, PA
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Harborview Rehabilitation Care Center at Doylestow
Doylestown, PA
1-star overall rating with 2-star inspections with $92,859 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Wesley Enhanced Living - Doylestown
Doylestown, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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