Inspection·November 20, 2025

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, clinical record review, and staff interview, it was determined that the facility failed to maintain a medication error rate of less than five percent (%) for one of two nursing units observed during medication administration. (North unit)Findings include: Observation of medication administration on November 19, 2025, from 8:10 a.m. to 8:50 a.m., revealed 32 medication opportunities with two medication errors that resulted in a medication administration error rate of 6.25%. Clinical record review revealed that Resident 52 had diagnoses that included atrial fibrillation (fast heart rate), chronic kidney disease, and hypothyroidism. A review of the physician's order dated February 5, 2025, revealed that staff was to administer one 600 milligram (mg) tablet of a calcium supplement (calcium carbonate) two times a day. Observation of the medication pass on November 19, 2025, at 8:20 a.m., revealed that Licensed Practical Nurse (LPN) 1 administered one tablet of calcium carbonate 500 mg which was 100 mg less than the physician's order. Clinical record review revealed that Resident 63 had diagnoses that included dementia and cerebral infarction. A review of the physician's order dated September 16, 2025, revealed that staff were to administer memantine, a medication to treat the symptoms of dementia, twice a day. Observation of the medication pass on November 19, 2025, at 8:30 a.m., revealed that LPN 1 did not administer the medication. In an interview on November 19, 2025, at 12:15 p.m., the Director of Nursing confirmed that LPN 1 administered the incorrect dose of calcium carbonate. In an interview on November 20, 2025, at 1:12 p.m., the Director of Nursing confirmed that LPN 1 did not administer the memantine on the morning of November 19, 2025. 28 Pa. Code 211.12(d)(1)(5) Nursing services. Residents Affected - Few Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 395047 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395047 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Pointe Rehabilitation and Healthcare Ctr 400 South Main Street Doylestown, PA 18901 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)