Doylestown Health Care Center: Fall Cover-Up Fractures Hip - OH
That is what federal inspectors concluded after investigating Doylestown Health Care Center following a complaint and a self-reported incident. The inspection, completed August 11, 2025, focused on a single resident identified in records as Resident #68 and a single nurse identified as LPN #74. The consequences for the resident were not minor.
The nursing assistant who was present that night, CNA #86, described what she found in a written statement included in the facility's own investigation. At 11 p.m., she wrote, Resident #68 complained about pain. It was hard to change her, so they did it in the bed. She didn't get up at all that night. It took two people to change her, and the aide reported to the nurse that the resident was crying about pain.
LPN #74, interviewed by inspectors, confirmed she had found Resident #68 sitting on the floor next to her bed. Her explanation for why she filed no report and made no calls was direct: she did not consider it a fall because the resident had only fallen a couple of inches.
She verified, when pressed, that she did not obtain vital signs. Did not assess range of motion. Did not notify the physician. Did not notify hospice. Did not notify the family. She was not even sure whether she had told the nurse coming on for the next shift that the woman had been found on the floor.
The facility's own accident and incident policy, written in 2008, lists exactly what a nurse is supposed to do when a resident falls: check for limited range of motion, bruises, pain, lacerations, and swelling; take vital signs; notify the attending physician if there is any serious injury; notify the family; write an incident report; tell the supervisor; tell the oncoming nurse. LPN #74 did none of it.
The physician, identified as Physician #84, came to the facility the following day. The Director of Nursing told inspectors that Physician #84 did not actually assess the resident because the resident was sleeping, so the physician only observed her. The DON confirmed that Physician #84 was not notified of the fall at all on that day, because at that point the facility believed no fall had occurred.
The corrective discipline record the facility eventually created told a different story than the health status notes circulating in the days after the incident. The discipline record stated plainly that a CNA had reported Resident #68 on the floor at the foot of the bed, that no incident report was written, no progress note was documented, and no notification was made to the primary care physician or the family. LPN #74 signed that form.
The health status notes, meanwhile, described the event in softer terms. A note authored by the DON said the resident was "observed on the floor by staff" during walking rounds and was "assisted back into bed by three staff." Another note the same day recorded that the DON and the social worker had updated the resident's daughter, telling her that her mother had been "observed by staff during walking around on the floor beside her bed."
The facility's own subsequent investigation concluded that Resident #68's right hip fracture was the result of the fall that night.
A second nursing assistant, CNA #78, who helped LPN #74 return the resident to bed, did not speak with inspectors. Two phone interviews were attempted on separate days. Both were unsuccessful.
Resident #68 had been groaning when a staff member helped her prepare for bed that night. When asked if she was in pain, she said her knees were hurting. By 11 p.m. she was on the floor. By the time anyone understood what had happened, she had a broken hip, and the physician who was supposed to have been called immediately had spent the night unaware.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Doylestown Health Care Center from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 25, 2026 · Our methodology
DOYLESTOWN HEALTH CARE CENTER in DOYLESTOWN, OH was cited for violations during a health inspection on August 11, 2025.
That is what federal inspectors concluded after investigating Doylestown Health Care Center following a complaint and a self-reported incident.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.