Inspection·August 5, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to provide adequate supervision to monitor a resident's whereabouts and prevent an elopement for one of four sampled residents. (Resident 8) Findings include: Clinical record review revealed that Resident 8 had diagnoses that included mood disorder, amnesia, bipolar disorder, and depression. Review of a facility incident report dated August 2, 2024, revealed that at 8:18 p.m., staff noted that the resident was not in his room. Further review of the clinical record revealed that staff documented that the resident had not been seen since before dinner and that his dinner meal tray remained in his room untouched. The facility was unable to locate the resident and was unaware of his location until the following day, August 3, 2024. In an interview on August 5, 2024, at 11:57 a.m. the Administrator confirmed that the facility was unable to locate the resident on August 2, 2024. In an interview on August 5, 2024, at 4:28 p.m. the Assistant Director of Nursing confirmed that that the resident did not have physician orders that permitted him to be out of the building unsupervised. CFR 483.12(d)(1)(2) Free of Accident Hazards/Supervision Previously cited 7/1/24 28 Pa. Code 201.18(b)(1)(3) Management. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services. 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 3 Event ID: 395277 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 395277 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Harborview Rehabilitation Care Center at Doylestow 432 Maple Avenue Doylestown, PA 18901 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)