Inspection visit
Inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**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 ensure that
advanced directives were accurately reflected in residence records for one of 8 residents reviewed
(Resident R70).
Findings:
Review of facility undated policy on Advance directives, revealed that under section Policy: Residents are
afforded the opportunity to create advanced directives for their medical care should they be unable to
communicate them for themselves at the time needed. Under section Purpose To provide instruction and
offering residents the opportunity to create advanced directives. Under section Procedure: #1 If the resident
already has an advanced directive, such directive is copied. If the resident has a MDPOA or other legal
responsible party, a copy of this paperwork is put in the Advanced Directives Legal section of the chart.
They should also be scanned to the Miscellaneous tab of the residence chart in Point Click Care. #2. The
DNR(do not resuscitate) form and other advanced directive information is filed in Advanced Directive
section of the chart. They should also be scanned to the Miscellaneous tab of the residence chart in Point
Click Care. #4. The associate completing the admission process or the social service representative
assisting the resident, and/or responsible party in creating advance directives alert the admitting nurse to
the advanced directive such that the appropriate physician order is obtained.
Review of Resident R70's clinical record revealed that Resident R 70 was admitted to the facility on [DATE],
with diagnosis of but not limited to Chronic Respiratory Failure, Sepsis due to Streptococcus Infection,
Cognitive Communication Deficit.
Review Further review of resident R70 clinical record revealed that Residence DNR status and advanced
directives was not reflected on Resident R 70s electronic medical record. Further, Resident R70s there was
no physician's order for advanced directives and there was no care plan for Resident R70's advance
directives.
Review of resident R 70s. Pennsylvania orders for life sustaining treatment. (POLST) Section A.
Cardiopulmonary Resuscitation (CPR): DNR Do not attempt resuscitation (allow natural death) was
checked. Section B. Medical Interventions: Person has paused and or breathing. Limited Additional
Interventions was checked. Section C. Antibiotics: Determine use or limitation of antibiotics when infection
occurs with comfort as goal was checked. Section D. Artificially Administered Hydration/Nutrition. No
hydration and artificial nutrition by tube was checked. Section E. Discuss with patient. Was checked. Further
review of Resident R70's POLST form revealed that the form was signed by the physician
(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 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
09/19/2024
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 0578
and signed by Resident R70. Further the form was dated [DATE].
Level of Harm - Minimal harm
or potential for actual harm
Interview with Employee E4 conducted on [DATE], at 10: 36 am confirmed that Resident R70 signed a
POLST Form and that resident R70 wanted to be on DNR, use medical treatment, IV fluids and cardiac
monitor as indicated, no hydration/ no artificial nutrition by tube. Further Employee E4 confirmed that
Resident R70's advance directives were not reflected on Resident R70's electronic medical record.
Residents Affected - Few
Interview with Facility Administrator Employee E1, on [DATE], at 10:40 AM confirmed that there was no
advance directive for Resident R70 in his electronic medical record.
28 Pa Code 211.12(d)(3) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
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
09/19/2024
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.
Based on clinical record reviews and interviews with staff, it was determined that the facility failed to notify
the office of the State Long Term Care Ombudsman of facility initiated emergency transfers and facility
initiated discharges for four or four facility-initiated discharges reviewed for three residents (Resident R73,
Resident R74 and Resident R75)
Findings include:
Review of facility document (list of all facility-initiated discharges) revealed that Resident R73 was
discharged from the facility to the hospital on July 26, 2024.
Review of the facility notice of transfer or discharge form for resident R73 revealed that on July 27, 2024,
Resident R73's responsible party was informed of his transfer to the hospital.
Review of resident R73 clinical record revealed no documented evidence that the State Long Term Care
Ombudsman was notified of Resident R 73s facility-initiated discharge (hospital admission).
Further review of the facility document (list of all facility-initiated discharges) revealed that Resident R74
was discharged from the facility to the hospital on May 19, 2024, and on June 23, 2024.
Review the facility notice of transfer or discharge form for Resident R74 revealed that resident R74's
responsible party was informed of his May 19, 2024, hospital transfer and of his June 23, 2024, hospital
transfer.
Review of resident R74's clinical record revealed no documented evidence that the State Long Term Care
Ombudsman was notified of Resident R 74's facility-initiated discharge (hospital admission).
Further review of the facility document (list of all facility-initiated discharges) reveal that Resident R75 was
discharged from the facility to the hospital on July 25, 2024.
Review the facility notice of transfer or discharge form for Resident R75 revealed that resident R75's
responsible party was informed of his July 25, 2024, hospital transfer.
Review of resident R75's clinical record revealed no documented evidence that the State Long Term Care
Ombudsman was notified of Resident R 75's facility-initiated discharge (hospital admission).
Interview with Employee E1, Facility Administrator, conducted on September 18, 2024 at 2:05 PM, revealed
that the facility did not have a process of providing the ombudsman a copy of the discharge notices.
Further, employee E1 confirmed that the ombudsman was not notified of Resident R73, Resident R74 and
Resident R75' discharges to the hospital.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(2) Management
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
09/19/2024
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policies, clinical record reviews, and interviews with staff, it was determined that the facility
failed to develop a baseline care plan within 48 hours of residence admission that includes the minimum
healthcare information necessary to properly care for a resident for four of 16 residents reviewed (Resident
R14, Resident R70, Resident R9, and Resident R120).
Findings include:
Review of facility policy on care planning provided by Employee E2 Revealed that the policy did not address
baseline care plan.
Review of Resident R14's clinical record revealed that resident R14 was admitted to the facility on [DATE],
with diagnoses of but not limited to reduced mobility, Muscle weakness, Cognitive communication deficit,
Altered mental status, Dysarthria, and Anarthria.
Review resident R14's admission MDS (minimum data set- a federally required resident assessment to be
completed at a specific interval) dated August 5, 2024, revealed that under section L0200. Oral dental
status B. (No natural teeth or tooth fragments. Edentulous) was coded No
Interview with facility Regional MDS coordinator, revealed that the admission MDS dated August.5, 2024,
Section L, B was coded in error, and that Section L 0200 B should have been quoted as. Yes. (No natural
teeth)
Observation of resident R14 conducted on September 16, 2024, at 09:21 AM reveal that Resident R14 was
in his room, with breakfast tray- breakfast was approximately 90% consumed- further observation revealed
that resident was edentulous. Further observation revealed that resident R14 was not wearing dentures.
Interview with Resident R14 at the time of the observation revealed that he has dentures but did not like
wearing them.
Further review of Resident R14's clinical record revealed that there was no baseline care plan in place
within 48 hours of Resident R14's admission to the facility.
Review of Resident R70's clinical record revealed that Resident R 70 was admitted to the facility on [DATE],
with diagnosis of but not limited to chronic venous hypertension with ulcer on right lower extremity, Non
pressure chronic ulcer of other part of left lower leg with fat layer exposed, Non pressure chronic ulcer of
buttocks with unspecified severity, Non pressure chronic ulcer of right calf with necrosis of muscles, Chronic
venous hypertension with ulcers of left lower extremity, Muscle weakness, Morbid obesity.
Observation conducted during tour of facility on September 16, 2024, at 11:52 AM revealed that Resident
R17 had bilateral lower extremity dressing. Further observation revealed that Resident R70s lower
extremities were dark in color.
Further review of Resident R70's clinical record reveal that there was no baseline care plan for
(continued on next page)
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
09/19/2024
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 0655
alteration in skin integrity or wound care in place within 48 hours of Resident R70's admission to the facility.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 9's clinical record revealed Resident R9 was admitted to the facility on [DATE] with a
diagnosis that included but not limited to Sepsis (serious condition in which the body responds improperly
to an infection), abnormalities of gait and mobility, and absolute glaucoma (eye that has lost all vision and
has uncontrolled pressure).
Residents Affected - Few
Review of Resident R9's clinical record revealed Resident R9 had a care plan dated August 15, 2024 for
impaired vision, potential for pressure ulcer development, and risk for infection.
Further review of Resident R9's care plan revealed no interventions in place to provide the necessary care
to properly care for Resident R9.
Review of Resident 120's clinical records revealed Resident 120 was admitted to the facility on [DATE] with
a diagnosis that included but not limited to Thoracic Spine fracture (occurs when a bone in the middle
section of the spine collapses), Bipolar Disorder (episodes of mood swing ranging from depressive lows to
manic highs), and muscle weakness.
Review of Resident R120's clinical record revealed Resident 120 had a care plan dated September 13,
2024 for high risk of falls, impaired cognitive function, behavior problem, limited physical mobility, activies of
daily living self-care deficit.
Further review of Resident 120's care plan revealed no interventions in place to provide the necessary care
to properly care for Resident 120.
Interview on September 18, 2024 at 11:40 a.m with Employee E2, Director of Nursing, confirmed Resident
R9 and Resident R120 did not have a completed baseline care plan completed within 48 hours of
admission.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c)Resident care policies
28 Pa. Code 211.12(d)(2) Nursing services
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
09/19/2024
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 policy. Review of clinical records and staff interviews, it was determined that the facility
failed to develop and implement an individualized comprehensive care plan for two of eight residents
observed (Resident 14 and Resident R70)
Findings include:
Review of facility's Care Planning Assessment Policy revealed that under section Policy, residents will
receive initial, quarterly, annual and significant change assessments according to the federal and state
regulations. In addition, the residents will have a care plan created that addresses the individualized needs
the residents present. This process will be accomplished through observation, assessment, interviews
which cover all three shifts and obtain the necessary information from all appropriate disciplines, the
resident, and any other responsible party necessary. Under section Procedure 1. Utilizing information from
the Wellness, Activity, Dietary and Psychosocial Assessments, the MDS is coded per the MDS 3.0 manual,
2. When a comprehensive MDS assessment is done, the RAPS CAA's will be completed for each triggered
area. From the CAA, it is determined which areas need to be care planned to provide the necessary care
for the resident, 3. The Care Plan Team creates these long-term care plans. Areas outside of the triggered
items can also be care planned to provide guidance to staff for care of the resident. (i.e. pain management
or discharge planning), 4. Acute care plans are created by staff for injuries, illnesses, or changes in
condition that may only last 30 days. Once 30 days is over, if the problem remains, a long-term care plan is
created. The Acute Care Plans are kept in the wellness notes section of the chart, 10. In addition, quarterly
reviews and updates are completed by the Care Plan Team to clarify problems, goals and evaluate
effectiveness of the interventions, 13. The MDS Coordinator monitors compliance with assessment, care
planning and filing of assessments and care plans in the appropriate areas.
Review of Resident R14's clinical record revealed that resident R14 was admitted to the facility on [DATE],
with diagnoses of but not limited to reduced mobility, Muscle weakness, Cognitive communication deficit,
Altered mental status, Dysarthria and Anarthria.
Review resident R14's admission MDS (minimum data set- a federally required resident assessment to be
completed at a specific interval) dated August 5, 2024, revealed that under section L0200. Oral dental
status B. (No natural teeth or tooth fragments. Edentulous) was coded No
Interview with facility Regional MDS coordinator, revealed that the admission MDS dated August.5, 2024,
Section L, B was coded in error, and that Section L 0200 B should have been quoted as. Yes. (No natural
teeth)
Observation of resident R14 conducted on September 16, 2024, at 09:21 AM reveal that Resident R14 was
in his room, with breakfast tray- breakfast was approximately 90% consumed- further observation revealed
that resident was edentulous. Further observation revealed that resident R14 was not wearing dentures.
Interview with Resident R14 at the time of the observation revealed that he has dentures but did not like
wearing them.
(continued on next page)
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
09/19/2024
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
Further review of Resident R14's clinical record revealed that there was no individualized comprehensive
care plan in place to address Resident R14's dental issues.
Review of Resident R70's clinical record revealed that Resident R 70 was admitted to the facility on [DATE],
with diagnosis of but not limited to chronic venous hypertension with ulcer on right lower extremity, Non
pressure chronic ulcer of other part of left lower leg with fat layer exposed, Non pressure chronic ulcer of
buttocks with unspecified severity, Non pressure chronic ulcer of right calf with necrosis of muscles, Chronic
venous hypertension with ulcers of left lower extremity, Muscle weakness, Morbid obesity.
Observation conducted during tour of facility on September 16, 2024, at 11:52 AM revealed that resident
R17 had bilateral lower extremity dressing. Further observation revealed that resident R 70s lower
extremities were dark and color.
Further review of Resident R70's clinical record reveal that the care plan for Venous stasis ulcer to bilateral
lower legs r/t Diabetes Date Initiated: 08/28/2024 with goals of: Pressure ulcer will show signs of healing
and remain free from infection by/through review date. Date Initiated: 08/30/2024. Further, there were no
interventions listed in the care plan.
Further review of Resident R70's care plan revealed that the following care plan did not have any
interventions: Falls care plan (no interventions), impaired vision (no intervention) and Potential for pressure
ulcer (no intervention)
28 Pa. Code 211.10(d) Resident care plan policies
28 Pa. Code 211.12(d)(5) Nursing services
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
09/19/2024
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of clinical records, staff interview, and pharmacy review recommendations, it was determined that
the facility failed to act on the pharmacy recommendations in a timely way for three of four residents
reviewed (Resident R10, R14 and R70).
Findings include:
Clinical record review revealed Resident R10 was admitted to the facility on [DATE], with a diagnosis that
included but not limited to Major Depressive Disorder. The physician ordered Mirtazapine (used to treat to
depression) and Citalopram (used to treat depression).
Further review of Resident R10's clinical record revealed the physician ordered Mirtazapine and Citalopram
on February 2024. During a drug regiment review on August 15, 2024, the pharmacist recommended that
Mirtazapine and Citalopram be considered for a gradual dose reduction. The pharmacy recommendation
was not addressed by the attending physician until September 17, 2024, a delay of 33 days.
During an interview on September 18, 2024 at 12:00 p.m. Director of Nursing E2 confirmed that the facility
failed to implement the pharmacy recommendations for Resident R10 in a timely manner.
Review of pharmacy consultation report for Resident R14 for August 1 to 31, 2024, revealed a pharmacy
recommendation to: evaluate if atorvastatin 40 MG is indicated at this time, monitor symptoms, follow-up
serum CK concentration in 14 days and to evaluate Eliquis dose for a dose increase twice a day. Further
review revealed that that DON, Employee E2, signed off on the pharmacy review.
Interview with the DON, Employee E2, conducted on September 19, 2023, at 1:20pm confirmed that the
physician reviewed the pharmacy recommendation late. Further Employee E 2 revealed that the facility will
improve their process so that the pharmacy reviews will be reviewed by the physician in a timely manner.
Review of Resident R70's pharmacy consultation report for August 1 to 31, 2024 revealed a comment from
the pharmacist as follow: During the review of Resident R14's medical record, the following irregularities
were noted on the Electronic Medication Administration record. Directions for use was incomplete. Ascorbic
acid order is missing strength. Further, the pharmacy consultation report revealed a recommendation to
Please clarify or correct these items.
Further review of the pharmacy consultation report revealed that the form did not have the signature of the
physician attesting that physician has reviewed the pharmacy report, comments and recommendations.
Interview with the DON Employee E2 conducted on September 19, 2024, at 1:20 pm confirmed that the
form did not have a physician's signature on it attesting that the physician has reviewed the pharmacy
recommendations Further Employee E2 revealed that the facility will improve their process so that the
pharmacy reviews will be reviewed by the physician in a timely manner.
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 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
09/19/2024
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, review of facility policies, review of facility documentation, review of clinical records,
and staff interviews, it was determined that the facility failed to establish an effective infection control
program related to infection surveillance and periodic review of antibiotic use.
Residents Affected - Few
Findings include:
Review of facility policy and antibiotic stewardship reveal that. Under section policy, Juniper Village has a
policy regarding antibiotic stewardship program. Under a section purpose to implement an antibiotic
stewardship program which will promote appropriate use of antibiotics while optimizing the treatment of
infections, at the same time reducing the possible adverse events associated with antibiotic use. Under
section Procedure #1 Accountability, a. The Antibiotic Stewardship Program team will be established to be
accountable for stewardship activities. As a team, they will: i. Review infections and monitor antibiotic usage
pattern on a regular basis, ii. Obtain and review antibiograms or similar information for institutional trends of
resistance, iii. Monitor antibiotic resistance pattern, iv, Report on number of antibiotics prescribed and the
number of residents treated each month, v. Include a separate report for the number of residents and
antibiotic that did not meet criteria for active infection. #5 Tracking a. The Director of Wellness will be
responsible for infection surveillance and MDRO (multi-drug resident organisms) tracking. B. The director of
Wellness will collect and review data.
Review of facility infection control documents revealed no documented evidence that the facility was
tracking the infections in the facility.
Further review of facility infection control documents revealed no documented evidence that the facility
conducted a periodic review of antibiotic use.
Interview with Employee E2 conducted on September 17, 2024 at 1:04 PM revealed that the facility did not
have a system in place to track infections and the use of antibiotics. Further Employee E2 also confirmed
that there was no periodic review of antibiotic use in the facility. Further interview with Employee E2
revealed that the facility will improve their infection control and antibiotic stewardship program to ensure that
infections are monitored and tracked and antibiotic use are reviewed regularly.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(d) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395864
If continuation sheet
Page 9 of 9
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
12 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0374GeneralS&S Epotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F914 - Be designed or equipped to assure full visual privacy for each
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.
FAQ · About this visit
Common questions about this visit
What happened during the September 19, 2024 survey of JUNIPER VILLAGE AT BUCKS COUNTY REHAB AND SKD CARE?
This was a inspection survey of JUNIPER VILLAGE AT BUCKS COUNTY REHAB AND SKD CARE on September 19, 2024. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at JUNIPER VILLAGE AT BUCKS COUNTY REHAB AND SKD CARE on September 19, 2024?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.