Inspection·October 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of Resident #22's medical record revealed an admission date of 01/10/23 with diagnoses including Alzheimer's disease, severe dementia with psychotic disturbance, hypertension, sick sinus syndrome, and chronic kidney disease stage three. Review of the progress notes for Resident #22 revealed a health status note dated 01/20/23 that stated that at approximately 2:50 P.M. on 01/20/23 Resident #22's wife alerted staff that Resident #22 needed help. Resident #22's wife stated that the recliner had tipped forward when Resident #22 attempted to get up. Resident #22 did not complain of any pain, recliner was removed and initiated checks every 15 minutes. Further review of progress notes revealed a progress note dated 01/22/23 that stated Resident #22's right leg was noted to be externally rotated and resident was noted guarding his leg saying, please don't touch it. A call was placed to the physician and waited for a return call. Review of the fall incident report for Resident #22 dated 01/20/23 revealed Resident #22 was in his room sitting in recliner, reclined back visiting with his wife. Resident #22 fell to the right side of the recliner, and the recliner then collapsed causing the resident to land on his right side. The nurse was notified, vital signs, range of motion, neurological assessment, and full body assessment were all within normal limits. Resident #22 was noted to show no signs or symptoms of pain. Resident #22 continued attempting to get himself off the floor. On 01/22/23, an incident report noted that while doing hands on care, the resident was found favoring his right leg. The nurse was notified that the right lower extremity was rotated, the physician was notified, and the resident was sent to the emergency room for evaluation and treatment. The incident report noted that Resident #22 returned from the hospital stay on 01/26/23. Review of the witness statement dated 01/22/23 from State Tested Nurse Aide (STNA) #302 revealed during shift report on 01/21/23 STNA #302 was notified that Resident #22 was laid down prior to evening shift started and that he had been favoring his right hip. STNA #302 checked on Resident #22 shortly after the start of the shift to see if he needed incontinence care and at that time Resident #22 was resting and had no indication of pain. STNA #302 stated that she had checked on Resident #22 throughout the night multiple time and on the last round on 01/22/23 at 5:30 A.M. Resident #22 was checked for incontinence and during that time was when Resident #22's leg was rotated, and the nurse was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 365695 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365695 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Doylestown Health Care Center 95 Black Drive Doylestown, OH 44230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)