Doylestown Health Care Center

Inspectors wroteBased on observations, staff interviews, policy review, and record review, the facility failed to ensure all residents were free from physical restraints. This affected one (#7) of three residents reviewed for abuse. The facility identified 18 residents resided on the memory care unit. The facility census was 48.

Inspectors wroteBased 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. On [DATE] (five days after the fall) an x-ray revealed a right hip fracture which the facility correlated to the fall on [DATE]. [...]

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to implement fall interventions, as determined necessary by the comprehensive care plan for Resident #13. This affected one resident (#13) of three residents revealed for falls. The census was 66. Findings Include: Review of the medical record for Resident #13 revealed an admission date of 09/24/24 with diagnoses of history of falling, atrial fibrillation, anxiety disorder, moderate dementia with agitation, difficulty walking, lack of coordination, cognitive communication deficit, multiple fractures of ribs, intracapsular fracture of right femur, and fracture of facial bones. Resident #13 resided on the secured, memory care unit. Review of a health status note dated 06/23/25 timed 10:44 A.M. [...]

Inspectors wroteTHE 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure Resident #20 was knowledgeable of the facility smoking policies and safe vaping procedures and care planned interventions were implemented. This affected one resident (#20) of one resident reviewed for smoking hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu and give residents the alternate menu items of choice. This affected three residents (Residents #10, #20, and #37) of three residents who had their meals and tickets reviewed. The facility census was 68.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain acceptable infection control practices during medication administration. This affected two residents (#16 and #120) of two residents reviewed for medication administration.

Inspectors wroteBased 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. Resident #168 fell forward on a ramp leading to the parking lot and was found face down leaning to her left side with obvious facial injuries that were bleeding. [...]

Inspectors wroteBased on record reviews, review of facility internal investigations, and interviews with staff, the facility failed to protect Resident #44 from verbal abuse. This affected one resident (Resident #44) of three reviewed for abuse. The census was 66.

Inspectors wroteBased on record reviews, review of of facility Self-Reported Incident (SRI) history, review of facility internal investigation and staff interview, the facility failed to report an allegation of verbal abuse towards Resident #44 to the State agency. This affected one resident (Resident #44)of three reviewed for abuse. The census was 66.

Inspectors wroteBased on record reviews, review of investigations and interviews with staff the facility failed to thoroughly investigate an allegation of abuse involving Resident #44. This affected one resident (Resident #44) of three residents reviewed for abuse. The census was 66.

Inspectors wroteBased 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.

Inspectors wroteBased on record review, interview, and policy review the facility failed to timely notify the physician of a change in resident status for one resident (#22) of three residents reviewed for change in condition. The facility census was 72.

Inspectors wroteBased on record review and interviews the facility failed to ensure Resident #52's medical record had accurate documentation. This affected one resident (#52) of one resident reviewed for smoking. The facility census was 72.

Inspectors wroteBased on observation, interview, and policy review the facility failed to maintain a clean and sanitary kitchen and properly store food and food utensils. This had the potential to affect all residents except Resident #1 who received nothing by mouth. The facility census was 55.

Inspectors wroteBased on interview, observation, record review, review of guidance from the Centers for Disease Control and Prevention(CDC) the facility failed to ensure infection control procedures were followed to prevent the potential spread of Covid-19 and Legionella. This affected Residents #5, #50, #403, #452 and had the potential to affect all 55 residents residing at the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a fall care plan for Resident #35. This affected one resident (#35) of three residents (#19, #34, and #35) reviewed for falls. The facility census was 55.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure orthotics and adaptive equipment was implemented per orders including knee braces, Ankle Foot Orthosis (AFO), and slings for Residents #34 and #44. This affected two of two residents (Resident #34 and #44) reviewed for orthotics and adaptive equipment. The facility identified seven residents (Resident #12, #29, #31, #34, #41, #44, and #52) that had adaptive equipment including orthotics, splints, braces and slings.

Inspectors wroteBased on interview, observation and record review the facility failed to ensure Resident #16's and Resident #30's respiratory equipment was dated when it was changed last. This affected two of two residents (Resident #16 and #30) reviewed for respiratory care. The facility identified 11 residents (Resident #1, #2, #4, #5, #12, #16, #19, #30, #34, #42, #49) that utilized respiratory equipment.

Inspectors wroteBased on record review, interview and observation the facility failed to complete pre and post dialysis assessments and failed to update the care plan regarding fistula site. This affected one resident (Resident #26) of one resident reviewed for dialysis.

Inspectors wroteBased on medical record review and staff interview the facility failed to provide restorative services as directed for Resident #12. This affected one ( Resident #12) of three reviewed for restorative and range of motion services.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure new fall interventions were implemented following a resident fall. This affected one (Resident #63) of six residents reviewed for falls. The facility census was 71.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure supplement administration and intake amount was accurately documented. This affected one (Resident #50) of four residents reviewed for weight loss. The facility census was 71.

Inspectors wroteBased on observation of posted staffing information, facility policy review and staff interview the facility failed to update the required posted staffing information. This had the potential to affect ass 71 residents currently residing in the facility. An observation on 05/20/19 at 8:40 A.M. of the staffing information posted on the bulletin board revealed it was dated 05/17/19. An interview on 05/20/19 at 8:40 A.M. Secretary #300 verified the posted staffing information was dated 05/17/19. An interview on 05/21/19 at 8:00 A.M. with the Administrator revealed indicated the State Tested Nursing Assistant (STNA) coordinator had taken the weekend staffing down to update them. She verified they had not been updated over the weekend. She verified there was a manager in the building on the weekends who could have updated the required nurse hours posting but had not done so. [...]