Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Doylestown Health Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in increased risk for resident accidents.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified through a review of staffing data, revealing insufficient RN hours on multiple dates from January to April 2024. The DON confirmed the staffing challenges, which had the potential to affect all 68 residents in the facility.
The facility failed to maintain cleanliness and proper food storage in the kitchen and food service areas, affecting all residents receiving meals. Observations revealed food residue and dried liquid in the dry storeroom, frozen liquid in the freezer, and unlabeled and undated food in the refrigerator. Additionally, the memory care unit's microwave was dirty and rusted. The facility's policy lacked guidelines on labeling and dating food items.
A resident was found vaping in their room with supplies on the over-bed tray, violating the facility's smoking policy that requires vaping to occur in designated outdoor areas and supplies to be kept at the nurses' station. The resident's medical record lacked evidence of a signed acknowledgment of the facility's No Smoking Policy, and staff confirmed the resident had been allowed to vape in their room for years.
The facility failed to provide residents with their chosen menu items, affecting three residents. A resident did not receive the ordered sloppy joe melt and French fries, receiving a chicken breast and cheesy potato casserole instead. Another resident did not receive the ordered sausage on a bun and French fries, receiving cheesy potato casserole and macaroni salad instead. A third resident ordered a sloppy joe and French fries but received a chicken breast and cheesy potato casserole. The issue arose due to a shortage of key ingredients, and the staff did not notify residents or staff about the shortage.
The facility failed to maintain infection control during medication administration for two residents. An LPN used bare hands to pick up dropped pills for a resident with diabetes and heart failure, while another LPN used a spoon to retrieve a pill from a medication cart for a resident with dementia. Both actions were confirmed as improper by the DON.
A resident with severe cognitive impairment exited through a delayed and alarmed egress door, resulting in a fall and injuries. Despite documented exit-seeking behavior and a wanderguard, the facility failed to complete required elopement risk evaluations and care plan updates.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Deficiency in RN Staffing Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified through a review of the Payroll Based Journal (PBJ) Staffing Data Report, which revealed that the facility was low on RN hours on multiple dates from January to April 2024. The specific dates where RN coverage was insufficient included several weekends and weekdays, indicating a pattern of non-compliance with staffing requirements. Interviews with the Director of Nursing (DON) confirmed the difficulty in securing registered nurses during this period. The DON acknowledged the staffing challenges and verified the absence of RNs on the specified dates. This deficiency had the potential to affect all 68 residents residing in the facility, as the lack of adequate RN coverage could impact the quality of care and oversight provided to the residents.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to ensure proper storage and cleanliness in the kitchen and food service areas, potentially affecting all 68 residents receiving meals. During an initial tour of the kitchen, it was observed that the dry storeroom had food residue and a dried black liquid on the floor. The bottom of the reach-in freezer contained frozen liquid, and the walk-in refrigerator had unlabeled and undated sliced cheese and turkey. These observations were verified by a staff member. Additionally, the memory care unit's serving area had a dirty microwave with rust spots on the top inside, as verified by an LPN. A Registered Dietitian, who inspects the kitchen monthly, expressed shock at the microwave's condition. The facility's policy on Corporate Nutrition Services, revised in 02/23, outlines guidelines for food safety and sanitation but does not mention labeling or dating of food items.
Failure to Enforce Smoking Policy and Safe Vaping Procedures
Penalty
Summary
The facility failed to ensure that a resident was knowledgeable of the facility's smoking policies and safe vaping procedures, leading to a deficiency in maintaining a smoke-free environment. The resident, who had intact cognition, was observed vaping in his room with vaping supplies on his over-bed tray, contrary to the facility's policy that required all smoking, including vaping, to be done in designated outdoor areas. The facility's policy also mandated that all smoking materials be kept in a secured area at the nurses' station, which was not adhered to in this case. The resident's medical record did not contain evidence of a signed acknowledgment of the facility's No Smoking Policy, either from 2016 or the updated version from 2023. Interviews with the Director of Nursing and other staff confirmed that the resident had been permitted to vape in his room and keep his supplies with him, a practice that had been in place before the current staff's tenure. The facility was unable to locate a signed smoking form for the resident until after surveyor intervention, at which point the resident signed the outdated 2016 policy.
Failure to Provide Ordered Menu Items
Penalty
Summary
The facility failed to adhere to the prescribed menu and provide residents with their chosen alternative menu items, affecting three residents. Resident #10, who was moderately cognitively impaired, did not receive the ordered sloppy joe melt and French fries, instead receiving a chicken breast and cheesy potato casserole, which she did not prefer. Similarly, Resident #20, who was cognitively intact, did not receive the ordered sausage on a bun and French fries, receiving cheesy potato casserole and macaroni salad instead, leading to his dissatisfaction. Resident #37, also cognitively intact, ordered a sloppy joe and French fries but received a chicken breast and cheesy potato casserole, which she found unappealing. The issue arose because the facility ran out of key ingredients such as French fries, macaroni salad, and ground beef for sloppy joes. The dietary manager, who was responsible for food orders, was on vacation, and the staff member interviewed did not notify any staff or residents about the shortage. This lack of communication and failure to provide the selected alternatives led to the residents' dissatisfaction and the facility's non-compliance with dietary requirements.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration, affecting two residents. For Resident #120, who has a diagnosis of heart failure and type 2 diabetes mellitus with diabetic neuropathy, an LPN was observed administering medications without using gloves. The resident dropped six pills on the bed sheets, and the LPN picked them up with her bare hands and placed them back into the medicine cup before administering them to the resident. Both the LPN and the Director of Nursing confirmed that gloves should have been used in this situation. In another incident involving Resident #16, who has a cognitive communication deficit and dementia, an LPN was observed handling medication improperly. A pill fell out of the medicine cup onto the medication cart, and the LPN used a spoon to push the pill back into the cup before administering it to the resident. The LPN acknowledged that the pill should have been discarded and replaced. The Director of Nursing verified that the correct procedure would have been to dispose of the dropped medication and obtain a new pill.
Failure to Prevent Elopement and Injury
Penalty
Summary
The facility failed to ensure adequate supervision to prevent a high-risk elopement resident from exiting through a fifteen-second delayed and alarmed egress door, resulting in a fall with injury. Resident #168, who was severely cognitively impaired, exited the facility in a wheelchair and fell forward on a ramp leading to the parking lot. The resident sustained a six-centimeter laceration on the scalp and acute bilateral nasal bone fractures. The incident occurred despite the resident having a wanderguard, which had previously malfunctioned and was replaced, and multiple documented instances of exit-seeking behavior. Resident #168 had a history of severe cognitive impairment, hemiplegia, type one diabetes mellitus, and other significant medical conditions. The resident's elopement risk evaluation initially indicated no risk, but subsequent behaviors showed persistent exit-seeking. Despite these behaviors, the facility did not complete additional elopement risk evaluations after each attempt to elope, as required by their policy. The care plan was also not updated following multiple exit-seeking incidents. On the day of the incident, staff were aware of Resident #168's exit-seeking behavior and had placed the resident at the nurse's station for supervision. However, the resident managed to reach and exit through Exit door 12, which was not wanderguard armed but had a fifteen-second delayed alarm. The door alarmed, but the resident had already exited and fallen by the time staff responded. Interviews with staff and the Director of Nursing confirmed that the facility did not follow its policy for elopement assessments and care plan updates, contributing to the incident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Doylestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sanctuary Wadsworth | 2.7 mi | ★★★★★ | 1 | 0 |
| Autumnwood Nursing & Rehab Center | 4 mi | ★★★★★ | 0 | 0 |
| Altercare Of Wadsworth | 4.2 mi | ★★★★★ | 0 | 0 |
| Apostolic Christian Home Inc | 5.2 mi | ★★★★★ | 0 | 0 |
| Pleasant View Health Care Center | 5.9 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.