Health inspection·January 16, 2026

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on facility policy review, observation, clinical record review, and resident and staff interviews, it was determined that the facility failed to assess a resident's capability to self-administer medications for one of 36 sampled residents. (Resident 121)Findings include: Residents Affected - Few Review of facility policy entitled, Resident Self-Administration of Medication, last reviewed February 13, 2025, revealed that a resident was only to self-administer medications after the facility's interdisciplinary team had determined which medications may be self-administered safely. The resident's preference would be documented on the appropriate form and placed in the medical record. The results of the interdisciplinary team assessment were recorded on the Medication Self-Administration Assessment Form which was placed in the resident's medical record. When the interdisciplinary team determined that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer would be stored in the medication cart or medication room. Clinical record review revealed that Resident 121 had diagnoses that included metabolic encephalopathy (brain dysfunction) and diabetes. Review of the Minimum Data Set assessment, dated December 22, 2025, revealed that Resident 121's cognitive ability was intact and the resident required extensive assistance from staff for activities of daily living. Observations on January 13, 2026, at 10:15 a.m., January 14, 2026, at 10:00 a.m. and 1:00 p.m., and January 15, 2026, at 9:30 a.m., revealed a 16-ounce jar of zinc oxide ointment and an antifungal cream unsecured on the bedside table in Resident 121's room. In an interview on January 14, 2026, at 10:15 a.m., Resident 121 stated that she self-administered the antifungal cream daily and that staff applied the zinc oxide to her sacral area after incontinence care. There was no documentation to support that the facility had assessed Resident 121 for the ability to self-administer the antifungal cream. The medications were not secured in her room. In an interview on January 16, 2026, at 9:31 a.m., the Director of Nursing confirmed that Resident 121 was not assessed to self-administer medications, and the medications should not have been in the room. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. Page 1 of 7 395409 395409 01/16/2026 Liberty Pointe Rehabilitation and Healthcare Ctr 252 Belmont Avenue Doylestown, PA 18901

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to ensure the call bell was accessible for one of 36 sampled residents. (Resident 14)Findings include: Clinical record review revealed that Resident 14 had diagnoses that included hemiplegia and hemiparesis (paralysis on one side of the body), history of stroke, limited range of motion, and chronic pain. Review of the Minimum Data Set assessment, dated January 12, 2026, revealed Resident 14 was alert and oriented, able to communicate needs to staff, and had limited range of motion to the left arm and leg. Review of the care plan revealed Resident 14 was at risk for falls related to a history of falls and required a two person assist with transfers, mobility, and activities of daily living. The interventions included that staff were to keep the call bell within reach. Observations on January 14, 2026, at 10:15 a.m., and 1:00 p.m., and January 15, 2026, at 9:49 a.m., revealed that the call bell was not within Resident 14's reach. The call bell was observed tied to the left side rail, on the resident's side with paralysis. In an interview on January 15, 2026, at 9:50 a.m., Resident 14 stated he would like to use his call button, but he did not know where it was. In an interview on January 16, 2026, at 9:20 a.m., the Director of Nursing confirmed that the call bell was not in reach for Resident 14 and it should have been. 28 PA Code 211.12 (d)(1)(5) Nursing services. Residents Affected - Few 395409 Page 2 of 7 395409 01/16/2026 Liberty Pointe Rehabilitation and Healthcare Ctr 252 Belmont Avenue Doylestown, PA 18901

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide a safe, clean, and comfortable environment on three of five nursing units. (Station 1, Station 2, Station 3) Findings include: Observations on January 13, 2026, from 9:45 a.m. through 1:00 p.m. and on January 14, 2026, from 8:00 a.m. through 12:00 p.m., revealed the following: The Station 1 dining room had dust and a black substance on ceiling tiles. The Station 1 activities room door didn't latch. The Station 1 central bathroom toilet ran continuously. The bathroom of room [ROOM NUMBER] had a loose doorknob. The half wall by the nurses' station in Station 2 had chipped paint along the length of the top of the wall. The ceiling in room [ROOM NUMBER] had dark stains and chipped paint There was a hole in the ceiling in room [ROOM NUMBER]. The window blind in room [ROOM NUMBER] did not close and there was no curtain on the window. The ceiling in room [ROOM NUMBER] over wardrobes had cracks and stains. In room [ROOM NUMBER], there was peeling paint and wallboard damage over the bed and a black stain on the ceiling. 28 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(1)(e)(2.1) Management. 395409 Page 3 of 7 395409 01/16/2026 Liberty Pointe Rehabilitation and Healthcare Ctr 252 Belmont Avenue Doylestown, PA 18901

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop a comprehensive care plan that addressed individual resident needs as identified in the comprehensive assessment for three of 36 sampled residents. (Residents 20, 24, 147)Findings include: Clinical record review revealed that Resident 20 was admitted to the facility on [DATE], and had diagnoses that included end stage renal disease (kidney failure), diabetic retinopathy (damage to blood vessels in the eye), and diabetes. The Minimum Data Set (MDS) completed on December 11, 2025, indicated that the resident was alert and had a diagnosis of diabetic retinopathy. The Care Area Assessment (CAA) summary dated December 11, 2025, noted that the resident's vision problem was to be addressed in the care plan. There was no evidence that interventions to address Resident's 20's vision problem were included in the current care plan. Clinical record review revealed that Resident 24 was admitted to the facility on [DATE], and had diagnoses that included chronic obstructive pulmonary disease. The MDS completed on December 3, 2025, indicated that the resident was alert and had likely carious teeth and was occasionally incontinent of urine. The CAA summary dated December 3, 2025, noted that the resident's dental needs and urinary incontinence were to be addressed in the care plan. There was no evidence that interventions to address Resident's 24's dental needs and urinary incontinence were included in the current care plan. Clinical record review revealed that Resident 147 was admitted to the facility on [DATE], and had diagnoses that included hemiplegia (paralysis on one side) and muscle weakness. The MDS completed on September 16, 2025, indicated that the resident was alert and had no teeth. The CAA summary dated September 18, 2025, noted that the resident's dental needs were to be addressed in the care plan. There was no evidence that interventions to address Resident's 147's dental needs were included in the current care plan. In an interview on January 16, 2026, at 9:28 a.m., the Director of Nursing confirmed there was no documented evidence that the identified care areas were addressed in the identified care plans. 28 Pa. Code 211.12(d)(1)(5) Nursing services. 395409 Page 4 of 7 395409 01/16/2026 Liberty Pointe Rehabilitation and Healthcare Ctr 252 Belmont Avenue Doylestown, PA 18901

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 store food in a sanitary manner on two of five nursing units. (Stations 2 and 5)Findings include:Review of the facility policy entitled, Food: Safe Handling for Foods from Visitors, dated February 13, 2025, revealed that staff were to label foods that were intended for later consumption with the resident's name. Observation in the Station 2 resident nourishment room on January 14, 2026, at 12:25 p.m., revealed in the freezer there was one shrimp scampi meal and five popsicles that were not labeled with a name. In the refrigerator, there was a dish of pasta and meat sauce dated December 25, 2025. There was a store-bought container of chicken strips, an opened bottle of vegetable juice, and a container of beef and beans that were not labeled with a resident's name. Observation in the Station 5 resident nourishment room on January 14, 2026, at 8:40 a.m., revealed that there was an opened bottle of water, an opened container of ice cream cake, a bottle of green vegetable juice, and an opened package of frozen fruit bars in the freezer that were not labeled with a resident's name. There was an empty storage bag containing crumbs in the freezer door. In the refrigerator, there were three yogurts that had use-by dates of December 29, 2025, January 7, 2026, and January 11, 2026, and that were not labeled with a resident's name. There was one can of purchased coffee, an opened jar of jelly, an opened jar of eggplant ratatouille, a box of wafer cookies, and a box of snack cakes that were not labeled with a resident's name. There was a large Styrofoam cup of an unknown thick substance not labelled or dated. In an interview on January 15, 2026, at 2:15 p.m., the Administrator confirmed the resident nourishment rooms are for resident foods only and that staff should store their food elsewhere. CFR 483.60(i) Food Safety RequirementPreviously cited 12/12/2428 Pa. Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3)(e)(2.1) Management. 395409 Page 5 of 7 395409 01/16/2026 Liberty Pointe Rehabilitation and Healthcare Ctr 252 Belmont Avenue Doylestown, PA 18901

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent the spread of infection for two of 36 sampled residents. (Resident 7 and 20) Findings include: Residents Affected - Few Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed on February 13, 2025, revealed that staff were to implement Enhanced Barrier Precautions to prevent the spread of multidrug-resistant organisms for residents with specific diagnoses which included Extended-Spectrum Beta-Lactamase (ESBL) in urine, even if the resident has been colonized. Staff were to post clear signage on the door or wall outside of the resident's room indicating the type of precautions, the required personal protective equipment to wear, and the high-contact resident care activities that required the use of gown and gloves, such as bathing/showering, providing hygiene, changing briefs and linens, and assistance with toileting to prevent the spread of infections. Staff were to wear a gown and gloves during high contact resident care activities. Clinical record review revealed that Resident 7 was admitted to the facility on [DATE], with diagnoses that included abnormal findings in the urine, urinary tract infection, diabetes, and muscle weakness. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated the resident was alert and oriented, always incontinent of urine, required extensive assistance from staff for toileting, and was dependent on staff for bathing. Review of the care plan revealed that Resident 7 required Enhanced Barrier Precautions and was at risk for transmitting an infection due to ESBL in his urine. The intervention was for staff to wear gloves and gowns while assisting the resident with all high-contact activity. Observations on January 13, 2026, at 12:30 p.m., January 14, 2026, at 10:30a.m., and January 15, 2026, at 11:18 a.m., revealed that there was no sign posted on the resident's door indicating that Enhanced Barrier Precautions were in place for Resident 7 per the policy. Clinical record review revealed that Resident 20 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidney failure), diabetes, and muscle weakness. Review of the MDS assessment dated [DATE], indicated the resident was alert and required extensive assistance from staff for toileting. Review of the care plan revealed that Resident 20 required Enhanced Barrier precautions and had a hemodialysis catheter (hollow tube inserted into a large vein) on the right side of her chest. The intervention was for staff to wear gloves and gowns while assisting the resident with toileting. On January 13, 2026, at 10:52 a.m., a nurse aide (NA 1) was observed entering Resident 20's room and assisting him with toileting. NA 1 did not wear a gown to assist the resident. In an interview during the observation period, NA 1 stated that she should have worn a gown as she assisted Resident 20 with toileting. In an interview on January 16, 2026, at 9:30 a.m., the Director of Nursing confirmed that signage for Enhanced [NAME] Precautions should have been in place for Resident 7 and staff should have worn a gown to assist Resident 20 with toileting. 28 Pa. Code 211.10(d) Resident care policies. 395409 Page 6 of 7 395409 01/16/2026 Liberty Pointe Rehabilitation and Healthcare Ctr 252 Belmont Avenue Doylestown, PA 18901

F 0880 28 Pa. Code 211.12(d)(1)(5) Nursing services. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 395409 Page 7 of 7