Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

DOYLESTOWN HEALTH CARE CENTER

DOYLESTOWN, OH · 78 certified beds · Last Life Safety survey September 12, 2024

CMS Certification Number 365695 · first certified May 1987

Ownership

Operated by WINDSOR HOUSE, INC. · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within OH

29 citations — more than 85% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 14 citations; the earlier surveys in the window averaged 7.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: May 2026 to May 2027. This facility’s last Life Safety survey was September 2024. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 29 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	29
Median facility in OH	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
May 23, 2019	4
May 26, 2022	11
September 12, 2024	14

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0712	Have simulated fire drills held at unexpected times.	3	2024-09-12
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-09-12
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	2	2024-09-12
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	2	2024-09-12
K-0511	Have properly installed electrical wiring and gas equipment.	2	2024-09-12
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2024-09-12
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2024-09-12
K-0913	Ensure operating rooms are properly protected and written records are maintained and available for inspection.	1	2019-05-23

What the citations cover

Citations by CMS category

Smoke Deficiencies 9
Gas, Vacuum, and Electrical Systems Deficiencies 6
Miscellaneous Deficiencies 6
Egress Deficiencies 5
Other 3

Citations by CMS category
Category	Citations
Smoke Deficiencies	9
Gas, Vacuum, and Electrical Systems Deficiencies	6
Miscellaneous Deficiencies	6
Egress Deficiencies	5
Services Deficiencies	3

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

September 12, 2024 — 14 citations

Citations issued on September 12, 2024
Tag	What the surveyor checks	Status
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (October 11, 2024)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (October 11, 2024)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 11, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (October 11, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (October 11, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (October 11, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 11, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (October 11, 2024)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (October 11, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (October 11, 2024)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (October 11, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (October 11, 2024)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (October 11, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (October 11, 2024)

May 26, 2022 — 11 citations

Citations issued on May 26, 2022
Tag	What the surveyor checks	Status
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (July 1, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 1, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 1, 2022)
K-0362	Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.	Deficient, Provider has date of correction (July 1, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (July 1, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (July 1, 2022)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (July 1, 2022)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (July 1, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 1, 2022)
K-0919	Meet requirements for the use of electrical equipment.	Deficient, Provider has date of correction (July 1, 2022)
K-0926	Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.	Deficient, Provider has date of correction (July 1, 2022)

May 23, 2019 — 4 citations

Citations issued on May 23, 2019
Tag	What the surveyor checks	Status
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (June 24, 2019)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (June 24, 2019)
K-0913	Ensure operating rooms are properly protected and written records are maintained and available for inspection.	Deficient, Provider has date of correction (June 24, 2019)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (June 24, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.