Cycle 1
Health 2024-12-12 · Fire 2024-12-12
3 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Doylestown, PA
Liberty Pointe Rehabilitation And Healthcare Ctr
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
252 Belmont Avenue, Doylestown, PA
(215) 348-2983
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
178
Certified beds
Average residents
153
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Prestige Healthcare Administrative Services
Operator or chain grouping
Approved since
1980-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing
LPN hours / resident day
1.00
Licensed practical nurse staffing
Aide hours / resident day
2.02
Nurse aide staffing
Weekend hours
3.48
Weekend nurse staffing
RN turnover
55%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.7
0.5 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.2
1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 49.1% |
86.9%
37.8 pts worse
|
93.4%
44.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.4% |
93.5%
11.1 pts worse
|
95.5%
13.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.2%
1 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 33.0% |
6.5%
26.5 pts worse
|
11.4%
21.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.4% |
6.5%
1.9 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.5% |
19.9%
6.6 pts worse
|
19.6%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 26.5% |
18.7%
7.8 pts worse
|
16.7%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.5% |
19.6%
13.1 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
18.3%
9 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.9%
0.6 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.7%
0.4 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.6% |
26.4%
5.8 pts better
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.3%
0.4 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 24.1% |
68.9%
44.8 pts worse
|
81.7%
57.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.3% |
9.8%
3.5 pts better
|
12.0%
5.7 pts better
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 12.9% |
68.7%
55.8 pts worse
|
79.7%
66.8 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
23.1%
3.3 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2023-01-27 · Fire 2023-01-27
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-12-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-12-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-12-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-21
E · Potential for more than minimal harm
2024-12-12
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-01-21
E · Potential for more than minimal harm
2023-12-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-06
E · Potential for more than minimal harm
2023-12-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-02-06
E · Potential for more than minimal harm
2023-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-06
E · Potential for more than minimal harm
2023-12-21
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-01-17
F · Potential for more than minimal harm
2023-01-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-27
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-03-21
E · Potential for more than minimal harm
2023-01-27
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-27
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-27
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 2023-02-28
E · Potential for more than minimal harm
2023-01-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-28
E · Potential for more than minimal harm
2023-01-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-21
D · Potential for more than minimal harm
2023-01-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-28
C · Minimal harm
2023-01-27
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-02-28
C · Minimal harm
2023-01-27
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-02-28
C · Minimal harm
2023-01-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-12
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 2025-01-14
D · Potential for more than minimal harm
2024-12-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-12
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-07-08
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 2024-07-31
D · Potential for more than minimal harm
2024-07-08
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-07-31
D · Potential for more than minimal harm
2024-04-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-17
B · Minimal harm
2024-02-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-14
F · Potential for more than minimal harm
2023-12-21
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 2024-01-23
E · Potential for more than minimal harm
2023-12-21
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 2024-01-23
D · Potential for more than minimal harm
2023-12-21
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 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-01-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-28
D · Potential for more than minimal harm
2023-01-27
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 2023-02-28
Penalties and ownership
What sits behind the stars
Ownership
Liberty Pointe LLC
5% Or Greater Direct Ownership Interest · Organization
Clyde Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
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
Operational/Managerial Control · Individual
Nearby options
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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
#2
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Doylestown, PA
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Heritage Pointe Rehabilitation And Healthcare Ctr
Doylestown, PA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
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