Doylestown Health Care Center
DOYLESTOWN HEALTH CARE CENTER in DOYLESTOWN, OH — inspection on August 11, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the witness statement within the SRI investigation authored by CNA #86 dated
her, so we did it in the bed! She didn't get up at all that night. It took two people to change her, and I reported to the nurse about her crying about pain.
Review of the health status note dated [DATE] timed 12:00 P.M. authored by the DON revealed Physician #84 in and was updated that this resident was observed on the floor by staff on [DATE] around 11:00 P.M. as walking [rounds] were completed.
The nurse and two nurse aides assisted the resident back into bed.
Review of the health status note dated [DATE] timed 12:24 P.M. authored by the DON revealed this nurse and the social worker updated Resident #68's daughter that the resident was observed by staff on [DATE] during walking around on the floor beside her bed.
The resident was assisted back into bed by three staff.
Review of the corrective discipline record dated [DATE] revealed LPN #74 received a verbal warning for an incident on [DATE] at 11:00 P.M. that any change in plane was considered a fall.
The record included CNA reported Resident #68 on [DATE] was on the floor at the foot of the bed. No incident report, progress note, or notification was made to the primary care physician or the family.
With any incident, report and document an incident report, progress note, and notify physician and resident representative. LPN #74 signed the form on [DATE].
Interview on [DATE] at 7:25 A.M. with LPN #74 revealed on [DATE] at 11:00 P.M., Resident #68 was observed sitting on the floor next to her bed.
LPN #74 stated she did not consider that a fall because the resident had only fallen a couple of inches. LPN #74 and CNA #78 put Resident #68 back to bed. LPN #74 verified she did not obtain vital signs after the fall, did not assess range of motion after the fall, and did not notify the physician, hospice or the resident's family of the fall. LPN #74 was unsure if she notified the [DATE] oncoming nurse of Resident #68 falling and being found on the floor.
Interviews were attempted via telephone with CNA #78 on [DATE] at 8:40 A.M. and on [DATE] at 9:35 A.M., however the interviews were unsuccessful.
Interview on [DATE] at 10:10 A.M. with the Director of Nursing (DON) revealed Physician #84 did not actually assess Resident #68 on [DATE] because the resident was sleeping so Physician #84 only observed the resident.
The DON verified Physician #84 was not notified on [DATE] of Resident #68's fall that occurred on [DATE] at 11:00 P.M. because at that time, the facility was unaware the resident had fallen.
The DON also verified the SRI investigation concluded Resident #68's right hip fracture was a result of the fall on [DATE] at 11:00 P.M.
Review of the facility's Accident and Incident policy dated 2008 revealed if the incident was a fall, check for limited range of motion, bruises, pain, lacerations, swelling and vital signs. If the fall involved a possible head injury, check the pupils and level of consciousness, obtain a statement of what occurred from anyone who witnessed the incident and/or resident if capable, notify the attending physician if the resident has sustained any serious injury, notify the family or responsible party, write an incident report, notify your supervisor, and notify the oncoming nurse.
This deficiency represents non-compliance investigated under Complaint Number 2576943 and Self-Reported Incident Control Number 1281390.
365695 08/11/2025
Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230
Review of the facility policy, Fall Prevention and Fall Management, revised November 2024 revealed fall management included to develop a care plan with interviews based on risk review and follow care plan for transfer status and staff assistance required.
When a fall occurs, the following protocol will be followed by the nurse: assess the resident's vital signs, level of consciousness and orientation to the environment, assess the resident's body of any injury and will assess range of motion as able.
The assessment will include neurological assessment if resident hit their head or displays a change in level of awareness/consciousness of if fall unwitnessed and unable to determine if resident hit their head, will not move the resident from the floor until the basic physical assessment is complete, complete a Risk Management/quality assurance (QA) incident report, implement a plan of care intervention to reduce the risk of another fall based on the initial evaluation and investigation, notify the physician of the fall and assessment., notify the resident/resident's representative of the incident and intervention, document the assessment of the resident and any orders/interventions in the medical record, and the QA incident report and fall incident investigation are forwarded to the DON and are reviewed by the interdisciplinary team to discuss the need for further evaluation, investigation or intervention implementation.
This deficiency represents non-compliance investigated under Complaint Number 2576943 and Self-Reported Incident Control Number 1281390.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.