F 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical record, facility documentation, and interview with staff it was determined that the facility
failed to issue the resident/responsible party a Notice of Medicare Non-Coverage (NOMNC) prior to
termination of Medicare A services, as required for one of three resident records reviewed (Resident
CL118).
Residents Affected - Few
Findings include:
Interview with the Nursing Home Administrator, Employee E1, conducted on November 3, 2023, at
approximately 12:00 p.m. revealed the facility did not have a policy regarding notice of Medicare
non-coverage.
Review of Resident CL118 revealed that the resident was admitted to the facility on [DATE], with Medicare
Insurance Coverage for skilled nursing care. Further review of clinical record revealed that the resident was
discharged from the facility on July 8, 2023.
There was no documented evidence that a Notice of Medicare Non -Coverage (NOMNC-written notice to
the resident, beneficiary, or resident representative, of the right to an expedited review of a Medicare
service termination of Medicare A Services prior to the discharge from the facility) was provided to the
Resident CL118 or the resident's responsible party.
Interview on November 3, 2023, at 12:30 p.m. with Nursing Home Administrator, confirmed that the facility
had no documented evidence that a Notice of Medicare Non-Coverage (NOMNC) had been issued to
Resident CL118 prior to the termination of the Medicare A service.
28 Pa. Code 201.29 (f) Resident Rights
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 9
Event ID:
395864
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview with staff and review of facility provided documentation, it was determined that the
facility did not ensure that an allegation regarding nursing aide practicing administering medication was
thoroughly investigated (Employee E12)
Residents Affected - Few
Findings include:
Review of nurse aide, Employee E12's personnel file, revealed that Employee E12 was hired on July 20,
2023, for a full time nurse aide position.
Review of witness statement provided by Nursing Home Administrator, dated August 23, 2023, stated the
following: while sitting at the nurses station I observed that [Employee E12] was passing medications, to my
knowledge she was only a CAN (nurse aide). This happened on multiple occasions but when asking it was
stated she took her test and she was just waiting for her license. Notified director of nursing and then
informed of the nepotism. (Employee E12 was director of nursing's daughter in-law). Director of nursing did
not want to reprimand her daughter in law and both resigned that day.
Review of Employee E12's 'exit interview form' dated August 24, 2023, reason for termination was
'involuntary' due to other: falsely documenting.
Review of facility reported incident dated August 24, 2023, noted medication administration records were
reviewed and it is noted 08/15/2023 - 08/24/2023, [Employee E12] signed as the person administering the
medications on the unit.
Review of facility provided investigation report failed to include witness statements from residents and
facility staff. Further the investigation report did not included list of medications which were administered by
Employee E12 as well as list of residents which were assessed after incident.
28 Pa Code 211.12(c )(d)(1)(5) Nursing Services
28 Pa Code 201.14(a)Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 2 of 9
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the
review of clinical records and interview with staff, it was determined that the facility failed to notify the
resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer
in a timely manner, after a selected resident was transferred to the hospital for one of nine residents
reviewed. (Resident R2)
Findings Include:
Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R2 dated August 29,
2023, revealed that the resident was admitted to the facility on [DATE]. Further clinical record review
revealed Resident R2's responsible party was her daughter.
Review of nursing note for Resident R1 dated July 29, 2023, revealed that the resident was discharged to
the hospital related to a fall.
Review of clinical record revealed no evidence that Resident R2's representative was notified of the transfer
to the hospital and the reasons for the transfer in writing, and in a language and manner they understood.
Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on
November 3, 2023, at 9:42 a.m. confirmed that the Residents R2's representative was not notified in writing
of the reasons for the transfer, and in a language and manner they understood.
28 Pa. Code 201.14(a) Responsibility of license
28 Pa. Code 201.29(a) Resident rights
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 3 of 9
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0625
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the resident or the resident’s representative in writing how long the nursing home will hold the
resident’s bed in cases of transfer to a hospital or therapeutic leave.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record review and staff interview, it was determined that the facility failed to ensure that the resident
and resident representative receive written notice of the facility bed-hold policy at the time of a
facility-initiated transfer to a hospital for one of nine residents reviewed. (Resident R2)
Findings include:
Review of MDS (Minimum Data Set-Assessment of resident care needs) for Resident R2 dated August 29,
2023, revealed that the resident was admitted to the facility on [DATE]. Further clinical record review
revealed Resident R2's responsible party was her daughter.
Review of nursing note for Resident R1 dated July 29, 2023, revealed that the resident was discharged to
the hospital related to a fall.
Further review of Resident R2's clinical record revealed that there was no documented evidence that
Resident R1's representative was provided with a written notice of the facility bed-hold policy at the time of
Resident R1's facility-initiated transfer to the hospital.
Interview with the Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, on
November 3, 2023, at 9:42 a.m. confirmed that the Residents R2's representative was not provided with the
bed hold policy upon transfer.
28 Pa Code 201.14(a) Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 4 of 9
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record reviews and interviews with staff, it was determined that the facility failed to accurately
complete a resident assessment related to discharge status for one of 27 residents reviewed (Resident R9).
Residents Affected - Few
Findings include:
Review of undated facility policy titled, Electronic Transmission of the MDS, indicated that all MDS
(Minimum Data Set - a mandatory periodic resident assessment tool) assessments, including significant
change, will be transmitted in accordance with OBRA regulations (schedule of assessments that will be
performed for a nursing facility resident at admission, quarterly, and annually, whenever the resident
experiences a significant change in status, and whenever the facility identifies a significant error in a prior
assessment).
Review of Resident R9's clinical records revealed a physician order dated, April 12, 2023, which stated
Resident R9 was admitted on Hospice on April 11, 2023. Further review revealed Resident R9 was
discharged from hospice on October 12, 2023.
Review of Resident R9's MDS titled, Significant Change in Status, dated April 18, 2023, was coded No for
Hospice.
Further review of Resident R9's MDS dated [DATE], revealed that Hospice Care was still coded, No.
Interview with the Registered Nurse Assessment Coordinator, Employee E5, conducted on November 3,
2023, at 11:07 a.m. confirmed that the Significant Change in Status MDS, dated [DATE] and July 17, 2023,
for Resident R9 was coded inaccurately.
28 Pa Code 201.14(a) Responsibility of licensee
2 Pa Code 211.5(f) Medical records
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 5 of 9
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to
develop comprehensive care plans to meet care needs for one of nine residents reviewed. (Resident R116)
Findings include:
Review of an undated facility policy titled, Care Planning indicated that residents Care Plan ae based on
Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care
needs) triggers and current needs of the resident.
Review of Resident R116's admission MDS dated , October 23, 2023, revealed Resident R116 was
admitted to the facility on [DATE], and had a BIMS (Brief Interview for Mental Status) score of two,
indicating that the resident had severely impaired cognition.
Review of Resident R116's admission elopement risk evaluation dated, October 20, 2023, revealed that
Resident R116 was a potential elopement risk.
Further review of Resident R116's clinical record revealed no documented evidence a comprehensive care
plan was developed regarding elopement risk.
Interview with the Director of Nursing, Employee E2, was conducted on November 2, 2023, at
approximately 3:34 p.m. where the above-mentioned findings were brought to her attention. Employee E2
confirmed that a care plan regarding Resident R116's elopement risk should have been developed upon
assessment.
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 6 of 9
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of facility provided documentation, and interview with staff, it was determined that facility
did not ensure to complete annual performance evaluation for two out of five nurse aides reviewed
(Employee E8 and E11)
Residents Affected - Few
Findings include:
According to facility provided documentation - nurse aides, Employees E7, E8, E9, E10, and E11 have
been employed at facility for one year or longer.
Requested performance evaluations for nurse aides on November 1, 2023, at 3:05 pm; facility was able to
provide performance appraisal for Employees E7, E9, and E10.
Upon further request for additional performance appraisals, facility was unable to locate performance
evaluations for nurse aides, Employees E7 and E8. Findings confirmed by facility's director of nursing and
administrator.
28 Pa Code 201.20(a)(b)(c)(d) Staff development
28 Pa Code 201.14(a)Responsibility of licensee
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 7 of 9
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0809
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and
requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to
eat at non-traditional times or outside of scheduled meal times.
Based on resident council interview, staff interviews, review of facility policy and reviews of the established
mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided
when 14 hours are between a substantial evening meal and breakfast on the main nursing unit.
Findings include:
A review of facility updated policy titled; Snacks indicated that residents will be offered snacks/nourishment
to meet their needs. Residents are offered regular snacks throughout the day. Further review indicated that
each resident is offered a mid- morning, mid-afternoon, and mid-evening snack as park of the daily
structured program.
A review of the established meal schedule for the residents revealed that the supper meal was scheduled
for 5:00 p.m., and that he breakfasts meal the following morning was offered at 8:00 a.m. This was a
15-hour meal span of time until breakfast the following day.
An interview was conducted on November 1, 2023, at 11:00 a.m. during the resident council with alert and
oriented Residents, R67, R114, R4, R5, R115, R2, R117, revealed that snacks were not offered at bedtime.
Residents reported that they eat dinner at 5:00 p.m. and get hungry at nighttime.
A walkthrough the facility with the Nursing Home Administrator, Employee E1, was conducted on November
2, 2023, at 11:37 p.m. Interviews were conducted with alert and oriented Residents: R66, R115, R64, R65,
who reported they were not aware of snacks being available in the kitchen and that they were not offered a
midmorning, mid-afternoon, and midevening snack since their admission.
An interview with the Dietary aide who was responsible for distributing snacks, Employee E4, conducted on
November 2, 2023, at 12:19 p.m. confirmed that she had not passed out snacks to the residents yesterday
and on this day.
28 Pa. Code: 201.14(a) Responsibility of license
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 8 of 9
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
395864
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/03/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Juniper Village at Bucks County Rehab and Skd Care
3200 Bensalem Boulevard
Bensalem, PA 19020
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on review of facility policy, observations, and interviews with staff, it was determined that the facility
did not ensure that food was stored, prepared, distributed, and served in accordance with professional
standards for food service safety.
Findings include:
Review of facility policy titled, Labeling and Dating of Food undated indicated that all food removed from
original package must have product name, receive date and use by date.
Review of policy titled, Storage- Refrigerator and Freezer undated indicate that all food items in
refrigerators must be properly dated and labeled.
An initial tour of the Food Service Department conducted on November 1, 2023, at 7:00 a.m., with
Employee E3, Food Service Manager, revealed the following:
Observations in the walk-in refrigerator revealed the following items did not have a received and or use by
date: Meatloaf, steak, squash, scones, salmon, roast beef, ham, turkey, and salami.
Further observation revealed four pulled raw beef briskets without a received date, pulled date, and use by
date; and two pans of raw chicken thighs with an expiration date of October 29, 2023.
Observations were confirmed by Employee E3, Food Service Manager, along the duration of the tour of the
dietary department.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.6 (f) Dietary Services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 9 of 9