Doylestown Health Care Center

In the surveyor’s words

From the most serious findings on record at Doylestown Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 11, 2025

  Based on closed record review, interview, review of a facility Self-Reported Incident (SRI) and associated investigation, review of a corrective discipline record and policy review, the facility failed to ensure Resident #68 received timely comprehensive assessment and intervention following a fall with injury. Actual Harm occurred on [DATE] when Resident #68, who was assessed as severely cognitive impaired and at high risk of falls, sustained a fall and was not properly assessed after the fall. Following the fall, the resident experienced pain rated a 10 on a pain scale of 1 to 10 with 10 being the most severe pain and was assessed to have non-verbal indicator of pain including screaming, crying, agitation, combativeness and groaning. […]

• Actual harm, isolatedF689Apr 16, 2024

  Based on staff interview, medical record review, emergency department encounter report review, and facility policy and procedure review, the facility failed to ensure adequate supervision to prevent Resident #168, who was a high-risk for elopement, from exiting a fifteen second delayed and alarmed egress door resulting in a fall with injury. This affected one resident (Resident #168) of three residents reviewed for elopement. The facility census was 68. Actual harm occurred on 03/23/24 around 4:20 P.M. when Resident #168, who was severely cognitively impaired, exited the facility through a fifteen second delayed and alarmed egress door in a wheelchair. […]

• No harm, potential for more than minimal, widespreadF727Sep 12, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, and the facility submitted Payroll Based Journal (PBJ) tracking information, the facility failed to ensure service of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 68 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report form submitted from 01/01/24 through 03/31/24 revealed the following dates submitted for the second quarter, the facility was low on registered nurse (RN) hours in the building on the following dates: 01/01/24 Monday (MO); 01/06/24 Saturday (SA); 01/14/24 Sunday (SU); 01/21/24 (SU);… […]

• No harm, potential for more than minimal, widespreadF812Sep 12, 2024

  Based on observations, interview and policy review, the facility failed to ensure food was stored properly and the kitchen and food service areas were clean and sanitary. This had the potential to affect all 68 residents in the facility receiving meals from the kitchen. Findings include: 1. Initial tour of the kitchen on 09/09/24 from 7:37 A.M. through 8:05 A.M. revealed the dry storeroom had food residue and a dried black liquid on the floor, the bottom of the reach-in freezer had frozen liquid on the bottom, and in the walk-in refrigerator there was sliced cheese and sliced turkey that was not labeled or dated. This was verified by [NAME] # 257 on 09/09/24 at 8:06 A.M. 2. Observation of memory care unit's serving area on 09/09/24 at 12:06 P.M. […]

• No harm, potential for more than minimal, widespreadF812Oct 26, 2023

  Based on observations, interview, and facility policy review the facility failed to the kitchen was clean and sanitary. This had the potential to affect 71 residents that received meals from the facility. The facility identified one resident (#25) received nothing by mouth. The facility census was 72. Findings include: Observation of the kitchen on 10/25/23 from 11:19 A.M. through 11:30 A.M. with Registered Dietitian (RD) #374 revealed there was food splatter on the back of the mixer, there were food spills and residue on the bottom of the reach-in refrigerator, and the microwave had food splatter in it. Behind the equipment there was a juice container, popsicle sticks, paper, and food crumbs. […]