Cycle 1
Health 2025-02-21 · Fire 2025-02-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Doylestown, PA
Wesley Enhanced Living - Doylestown
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
200 Veterans Lane, Doylestown, PA
(215) 345-4300
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-02-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.58
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
4.17
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
1.32
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.55
CMS adjusted RN staffing hours
Adjusted total hours
4.35
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,427
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9975
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.21
Baseline 21.12% · Performance 19.48% · Measure score 4.21 · Achievement 4.21 · Improvement 3.51
Healthcare-associated infections
3.01
Baseline 5.19% · Performance 6.93% · Measure score 3.01 · Achievement 3.01 · Improvement 0
Total nurse turnover
6.20
Baseline 50.00% · Performance 38.33% · Measure score 6.20 · Achievement 6.20 · Improvement 4.14
Adjusted total nurse staffing
4.33
Baseline 3.58 hours · Performance 4.31 hours · Measure score 4.33 · Achievement 4.33 · Improvement 2.81
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.39% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 13.19% · Lower 95% interval 9.02% |
| Discharge to community | 58.34% |
50.57%
7.8 pts better
|
Better than the National Rate · Eligible stays 134 · Observed rate 55.22% · Lower 95% interval 50.72% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 68 · Denominator 70 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 70 |
| Discharge self-care score | 66% |
53.69%
12.3 pts better
|
Numerator 33 · Denominator 50 |
| Discharge mobility score | 72% |
50.94%
21.1 pts better
|
Numerator 36 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 2 · Denominator 70 · Adjusted rate 3.43% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 4.37% |
| Staff COVID-19 vaccination coverage | 1.25% |
8.2%
6.9 pts worse
|
Numerator 3 · Denominator 240 |
| Staff flu vaccination coverage | 98.84% |
42%
56.8 pts better
|
Numerator 256 · Denominator 259 |
| Discharge function score | 70% |
56.45%
13.5 pts better
|
Numerator 35 · Denominator 50 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 15.91% |
25.2%
9.3 pts worse
|
Numerator 7 · Denominator 44 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.7 · 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 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
86.9%
1.9 pts better
|
93.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 95.7% · Q4 59.1% · 4Q avg 88.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.5%
6.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.2%
2.1 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
6.5%
6.5 pts better
|
11.4%
11.4 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 who lose too much weight | 2.2% |
6.5%
4.3 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
19.9%
4.9 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 15.2% · Q3 11.1% · Q4 24.3% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
18.7%
9.1 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 8.1% · Q3 11.1% · Q4 12.1% · 4Q avg 9.6% · 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 | 16.0% |
19.6%
3.6 pts better
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 17.1% · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.6% |
18.3%
4.3 pts worse
|
14.9%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 31.2% · Q3 17.1% · Q4 20.0% · 4Q avg 22.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.5% · Q3 1.5% · Q4 1.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 2.1% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.7% |
26.4%
6.3 pts worse
|
19.8%
12.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 43.6% · Q3 29.8% · Q4 41.4% · 4Q avg 32.7% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
5.3%
1.6 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 7.3% · Q3 10.1% · Q4 5.8% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.8% |
68.9%
15.9 pts better
|
81.7%
3.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 95.6% · Q3 88.5% · Q4 54.3% · 4Q avg 84.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
9.8%
10 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 18.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
68.7%
19.3 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.3% |
23.1%
12.2 pts worse
|
23.9%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.3% · Observed 31.9% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-28 · Fire 2024-03-28
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-21
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 2025-04-27
E · Potential for more than minimal harm
2025-02-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-27
E · Potential for more than minimal harm
2025-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-27
E · Potential for more than minimal harm
2024-03-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-06-21
E · Potential for more than minimal harm
2024-03-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-03-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-03-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-03-28
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-31
D · Potential for more than minimal harm
2023-04-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-04-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-04-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-04
D · Potential for more than minimal harm
2023-04-20
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-04-25
Penalties and ownership
What sits behind the stars
Ownership
New Heritage Towers
5% Or Greater Direct Ownership Interest · Organization
Conner, Ronnie
Corporate Director · Individual
Dukert, Lynne
Operational/Managerial Control · Individual
Nearby options
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#2
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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
#3
Heritage Pointe Rehabilitation And Healthcare Ctr
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4-star overall rating with 4-star inspections with 4 recent health deficiencies
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