F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review, observation, and staff interview, it was determined that the facility failed to ensure
that physician's orders were implemented for one of 33 sampled residents. (Resident 2)
Residents Affected - Few
Findings include:
Clinical record review revealed that Resident 2 had diagnoses that included dementia, hypertension, and
chronic obstructive pulmonary disease. Review of the Minimum Data Set assessment dated [DATE],
indicated that the resident had memory impairment and was dependent on staff for dressing. On November
10, 2024, a physician ordered for staff to apply compression stockings (Tubigrips) on bilateral legs for
swelling.
On December 10, 2024, at 11:45 a.m. and 12:44 p.m., and again on December 11, 2024, at 10:00 a.m. and
10:25 a.m., the resident was observed dressed and seated in her wheelchair in the dining room on the
nursing unit without the Tubigrips in place. On December 11, 2024, at 10:30 a.m., the licensed practical
nurse stated that staff was to put the Tubigrips on with morning care.
In an interview on December 12, 2024, at 10:30 a.m., the Director of Nursing stated that staff was to apply
the Tubigrips every day with morning care as ordered by the physician.
CFR(s) 483.25 Quality of Care
Previously cited 4/13/24
28 Pa.Code 211.22(d)(1)(5)Nursing services.
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 3
Event ID:
395409
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
395409
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Pointe Rehabilitation and Healthcare Ctr
252 Belmont Avenue
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, it was determined that the facility failed to maintain sanitary conditions and store
food properly in the dietary department.
Residents Affected - Many
Findings include:
During an environmental tour of the dietary department on December 10, 2024, at 9:30 a.m., observations
revealed the following:
There was a large hole in the paneling on the back wall of the recycling area located in the dietary
department.
The convection ovens were soiled. The insides of the top and bottom oven doors were coated with grease.
The bottom of the top oven was covered heavily with burnt debris and burnt food crumbs.
There was a large metal scoop stored on the inside of the large bin that contained flour.
There was debris on the floor alongside the wall near the steamer and dry goods bins.
On the inside of the ice machine, there was a brown substance on parts of the lid. The brown substance
was also on the left inside wall of the ice machine.
There were five cracked floor tiles near the entrance way of the utility hallway that was located inside the
dietary department.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 207.2(a) Administrator's responsibility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395409
If continuation sheet
Page 2 of 3
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
395409
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/12/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Liberty Pointe Rehabilitation and Healthcare Ctr
252 Belmont Avenue
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)
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Minimal harm
or potential for actual harm
Based on resident interview and observation, it was determined that the facility failed to provide a working
call bell for two of 33 sampled residents. (Residents 4, 142)
Residents Affected - Few
Findings include:
During a resident group meeting conducted on December 11, 2024, at 10:00 a.m., Resident 4 stated that
when she activated the call bell from her bed, the light outside the door did not activate. Resident 142
stated that when he activated the call bell from his bed, there was no sound or light, and that he must yell
for assistance.
Observations on December 11, 2024, at 11:15 a.m., revealed that when Resident 4 activated the call bell
from her bed, no light was observed outside of her door. At 11:35 a.m., Resident 142 activated the call bell
from his bed; no sound or light was observed.
28 Pa. Code 201.18(b)(3) Management.
28 Pa. Code 211.12(d) Nursing services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395409
If continuation sheet
Page 3 of 3
