Cycle 1
Health 2025-04-10 · Fire 2025-04-10
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Doylestown, PA
Pine Run Health Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
777 Ferry Road, Doylestown, PA
(215) 340-5200
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
82
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Presbyterian Senior Living
Operator or chain grouping
Approved since
1977-04-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 4 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
0.94
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.20
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.97
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,953
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.93
Baseline 20.01% · Performance 21.00% · Measure score 0.93 · Achievement 0.93 · Improvement 0
Healthcare-associated infections
3.53
Baseline 4.33% · Performance 6.78% · Measure score 3.53 · Achievement 3.53 · Improvement 0
Total nurse turnover
5.41
Baseline 31.00% · Performance 41.56% · Measure score 5.41 · Achievement 5.41 · Improvement 0
Adjusted total nurse staffing
2.61
Baseline 4.25 hours · Performance 3.82 hours · Measure score 2.61 · Achievement 2.61 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.87% |
10.72%
3.1 pts worse
|
Worse than the National Rate · Eligible stays 628 · Observed rate 14.49% · Lower 95% interval 11.18% |
| Discharge to community | 61.2% |
50.57%
10.6 pts better
|
Better than the National Rate · Eligible stays 599 · Observed rate 56.59% · Lower 95% interval 57.39% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.38% |
95.27%
4.1 pts better
|
Numerator 323 · Denominator 325 |
| Falls with major injury | 0.62% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 325 |
| Discharge self-care score | 60.89% |
53.69%
7.2 pts better
|
Numerator 165 · Denominator 271 |
| Discharge mobility score | 47.97% |
50.94%
3 pts worse
|
Numerator 130 · Denominator 271 |
| Pressure ulcers or injuries, new or worsened | 6.46% |
2.29%
4.2 pts worse
|
Numerator 21 · Denominator 325 · Adjusted rate 7.58% |
| Healthcare-associated infections requiring hospitalization | 6.78% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 355 · Observed rate 5.92% · Lower 95% interval 5.01% |
| Staff COVID-19 vaccination coverage | 3.9% |
8.2%
4.3 pts worse
|
Numerator 11 · Denominator 282 |
| Staff flu vaccination coverage | 51.98% |
42%
10 pts better
|
Numerator 118 · Denominator 227 |
| Discharge function score | 56.83% |
56.45%
0.4 pts better
|
Numerator 154 · Denominator 271 |
| Transfer of health information to provider | 98% |
95.95%
2 pts better
|
Numerator 49 · Denominator 50 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 247 · Denominator 247 |
| Resident COVID-19 vaccinations up to date | 28.39% |
25.2%
3.2 pts better
|
Numerator 44 · Denominator 155 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.7
1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.4 · Expected 1.2 · 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 1.6 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
86.9%
9.8 pts better
|
93.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 98.2% · Q3 98.1% · Q4 97.9% · 4Q avg 96.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
93.5%
4.7 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.2%
0.6 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 5.4% · Q3 5.8% · Q4 2.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
6.5%
4.5 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.9% · Q4 4.2% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.5%
1.8 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 5.4% · Q3 5.3% · Q4 0.0% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
19.9%
5.4 pts worse
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.1% · Q3 23.7% · Q4 35.1% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.0% |
18.7%
3.7 pts better
|
16.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 19.5% · Q3 13.2% · Q4 12.8% · 4Q avg 15.0% · 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 | 30.6% |
19.6%
11 pts worse
|
16.3%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 27.3% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.1% |
18.3%
9.8 pts worse
|
14.9%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 19.4% · Q3 27.8% · Q4 21.6% · 4Q avg 28.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.7%
0.2 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.9% |
26.4%
9.5 pts worse
|
19.8%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 35.0% · Q3 39.5% · Q4 33.6% · 4Q avg 35.9% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.3%
2.4 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 5.9% · Q3 5.9% · Q4 7.1% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
68.9%
16.8 pts better
|
81.7%
4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 81.4% · Q3 83.7% · Q4 88.7% · 4Q avg 85.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
9.8%
3.2 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 11.8% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 1.1% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.9% |
68.7%
20.2 pts better
|
79.7%
9.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
23.1%
2.2 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 23.0% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-22 · Fire 2024-03-22
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-04-06 · Fire 2023-04-06
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-06
F · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-04-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-04-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-06
F · Potential for more than minimal harm
2024-03-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-03-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-27
E · Potential for more than minimal harm
2024-03-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-27
E · Potential for more than minimal harm
2023-04-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-04-06
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-04-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-04-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-04-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-05
E · Potential for more than minimal harm
2023-04-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-05
C · Minimal harm
2023-04-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-12-02
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 2025-12-15
D · Potential for more than minimal harm
2025-12-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-15
F · Potential for more than minimal harm
2024-03-22
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 2024-04-29
D · Potential for more than minimal harm
2024-03-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-04-29
D · Potential for more than minimal harm
2024-03-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-29
B · Minimal harm
2024-03-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-04-29
Penalties and ownership
What sits behind the stars
Ownership
Phi
5% Or Greater Direct Ownership Interest · Organization
Birdsall, James
Corporate Director · Individual
Bowser, Nicole
W-2 Managing Employee · Individual
Chottiner, Lawrence
Corporate Director · Individual
Davis, Danny
Corporate Director · Individual
Davis, Danny
Corporate Officer · Individual
Denison, Barbara
Corporate Director · Individual
Elliott, Brenda
Corporate Director · Individual
Gergits, Charles
Operational/Managerial Control · Individual
Gergits, Charles
Corporate Director · Individual
Goldstein, Terry
Corporate Director · Individual
Kelly, Sharon
Corporate Director · Individual
Kinard, Joseph
Corporate Director · Individual
Kinard, Joseph
Corporate Officer · Individual
Krieger, Daniel
Corporate Officer · Individual
Mcalister, Dyan
Corporate Director · Individual
Mcalister, Dyan
Corporate Officer · Individual
Paxton, Stuart
Corporate Director · Individual
Reimann, Susan
Corporate Director · Individual
Reimann, Susan
Corporate Officer · Individual
Rhodes, Cheryl
Corporate Director · Individual
Scott, William
Corporate Director · Individual
Seibert, Joseph
Corporate Director · Individual
Shropshire, Jennifer
Corporate Director · Individual
Stone, Robyn
Corporate Director · Individual
Vinette-Clay, Melissa
W-2 Managing Employee · Individual
Wickline, Beverly
Corporate Officer · Individual
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#3
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4-star overall rating with 4-star inspections with 4 recent health deficiencies
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