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
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
0.61
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.90
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,872
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.21
Baseline 24.84% · Performance 22.72% · Measure score 2.21 · Achievement 0 · Improvement 2.21
Healthcare-associated infections
6.30
Baseline 11.04% · Performance 6.93% · Measure score 6.30 · Achievement 3.02 · Improvement 6.30
Total nurse turnover
1.07
Baseline 43.59% · Performance 59.31% · Measure score 1.07 · Achievement 1.07 · Improvement 0
Adjusted total nurse staffing
4.33
Baseline 2.67 hours · Performance 4.17 hours · Measure score 4.33 · Achievement 3.85 · Improvement 4.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.76% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 15.57% · Lower 95% interval 9.68% |
| Discharge to community | 45.33% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 193 · Observed rate 30.05% · Lower 95% interval 36.75% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.91% |
95.27%
3.4 pts worse
|
Numerator 159 · Denominator 173 |
| Falls with major injury | 1.16% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 173 |
| Discharge self-care score | 37.62% |
53.69%
16.1 pts worse
|
Numerator 38 · Denominator 101 |
| Discharge mobility score | 36.63% |
50.94%
14.3 pts worse
|
Numerator 37 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 3.47% |
2.29%
1.2 pts worse
|
Numerator 6 · Denominator 173 · Adjusted rate 2.56% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 8.53% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 29.65% |
42%
12.4 pts worse
|
Numerator 51 · Denominator 172 |
| Discharge function score | 52.48% |
56.45%
4 pts worse
|
Numerator 53 · Denominator 101 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 68 · Denominator 68 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 38 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 92 |
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 · Adjusted 2.2 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| 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 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · Used in QM five-star |
| 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 · Q1 52.0% · Q2 46.9% · Q3 47.9% · Q4 49.7% · 4Q avg 49.1% |
| 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 · 4Q avg 82.4% |
| 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 · Q1 4.7% · Q2 3.5% · Q3 3.5% · Q4 4.9% · 4Q avg 4.2% · Used in QM five-star |
| 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 · Q1 26.6% · Q2 25.7% · Q3 37.8% · Q4 41.9% · 4Q avg 33.0% |
| 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 · Q1 11.9% · Q2 9.4% · Q3 6.6% · Q4 5.6% · 4Q avg 8.4% |
| 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 · Q1 28.5% · Q2 23.7% · Q3 26.3% · Q4 27.4% · 4Q avg 26.5% |
| 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 · Q1 24.8% · Q2 27.6% · Q3 25.9% · Q4 27.5% · 4Q avg 26.5% · 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 | 6.5% |
19.6%
13.1 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 12.5% · Q4 10.6% · 4Q avg 6.5% · Used in QM five-star |
| 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 · Q1 6.1% · Q2 10.1% · Q3 12.6% · Q4 8.5% · 4Q avg 9.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.7% · Q3 0.0% · Q4 0.7% · 4Q avg 0.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.5% · Q3 0.8% · Q4 3.0% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 17.8% · Q2 20.3% · Q3 20.9% · Q4 23.5% · 4Q avg 20.6% |
| 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 · Q1 7.1% · Q2 6.6% · Q3 4.9% · Q4 4.0% · 4Q avg 5.7% · Used in QM five-star |
| 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 · Q1 16.0% · Q2 17.2% · Q3 25.4% · Q4 39.4% · 4Q avg 24.1% |
| 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 · Adjusted 6.3% · Observed 7.0% · Expected 12.4% · 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 0.0% · Q2 2.9% · Q3 2.7% · 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 | 12.9% |
68.7%
55.8 pts worse
|
79.7%
66.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 12.9% |
| 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 · Adjusted 19.8% · Observed 25.4% · Expected 30.6% · Used in QM five-star |
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
Other facilities in reach
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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
#2
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
#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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