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Inspection visit

Inspection

HORSHAM CENTER FOR JEWISH LIFECMS #3960782 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0573 Level of Harm - Potential for minimal harm Residents Affected - Some Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Based on staff interviews, review of facility policy and review of facility documentation, it was determined that the facility failed to ensure that medical records requested by/and or on behalf of residents were provided in a timely manner for 3 out of 3 records reviewed. (Resident R1, Resident R2, and R3)Review of the facility policy, Release of Information, with a revision date of November 2009 indicated that the resident may initiate a request to release information to anyone he/she wishes and that such request will be honored only upon the receipt of written, signed, and dated request from the resident or representative. The policy also stated that a resident may have access to his or her records within 24 hours (excluding weekends or holidays) of the resident's written request. Continued review of the policy indicated that a resident may obtain photocopies of his or her records by providing the facility with at least a forty-eight hour (excluding weekends and holidays) advanced notice of such request, and that a fee may be charged for copying services. Review of a medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R1 on July 3, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until July 21, 2025. Review of medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R2 on August 8, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until September 5, 2025. Review of a medical records request documentation from the facility's Medical Records Department indicated that the facility received a signed request for the release of medical records for Resident R3 on July 16, 2025. Continued review of the documentation from the facility's Medical Records Department indicated that the medical records were not sent to the requestor until August 4, 2025.During an interview with Employee E3 (Medical Records Director) on October 30, 2025, at 2:00 p.m. the above referenced medical records request documentation for Resident R1, R2 and R3 was reviewed with Employee E3. During the above reference interview with Employee E3, it was discussed that the medical records request made by the resident and/or on behalf of the resident were not released to the requestor in a timely manner. 28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a)(b) 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 2 Event ID: 396078 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 396078 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Horsham Center for Jewish Life 1425 Horsham Road North Wales, PA 19454 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 staff interviews and the review of facility documentation, it was determined that the facility failed to ensure that a complete and thorough investigation was conducted for bruises of unknown origin for 1 out of 1 residents reviewed (Resident R4).Findings include:Review of the facility policy, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating with a revision date of September 2024 indicated that all allegations are thoroughly investigated to the best of the facility's ability. The policy also indicated that the individual conducting the investigation reviews documentation and evidence; reviews the resident's medical records; interviews the person(s) reporting the incident, and interviews available staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Review of Resident R4's October 2025 physician orders included the diagnoses of cerebral infarction (a type of stroke); anxiety (a feeling of worry, nervousness, or unease about something with an uncertain outcome); depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things and activities you once enjoyed); dementia (a loss of thinking, remembering and reasoning skills); hypertension (high blood pressure), and diabetes (a condition that happens when your blood sugar/glucose is too high).Review of a nursing note dated October 19, 2025 at 11:30 a.m. documented that on the above referenced date the nurse aide (Employee E4) caring for the resident on the 7:00 a.m. through the 3:00 p.m. shift discovered a bruise to the resident's posterior head. The area was dark purple in color and measures 7.5 cm x 3.5 cm. Continued review of the above referenced note indicated that when the nurse touched the referenced area, the resident showed signs of mild pain. Review of Nurse aide, Employee E4's statement dated October 19, 2025 indicated: When I was giving [Resident R4] care, I noticed around 10:30 a.m. a black and blue bruise on the back of her head and I notify the nurse. Review of the investigation indicated that witness statements from licensed nurses and nurse aides on various shifts worked on October 17, 2025-through October 19, 2025 stated that they either did not see the referenced bruise on her head, or they were not assigned to the resident at all during any the referenced shifts. Continued review of the investigation indicated that the resident's nurse aide (Employee E4) who was assigned to the resident on October 18, 2025 on the 7:00 a.m. through the 3:00 p.m. nursing shift was not interviewed regarding the bruise of unknown origin. During an interview with the Assistant Director of Nursing (Employee E5, ADON) on October 31, 2025 at 12:53 p.m. the above-referenced investigation regarding the resident's bruise of unknown origin was discussed and reviewed. During the interview the ADON confirmed that Nurse aide, Employee E4 was the assigned nurse aide for the resident on October 18, 2025 during the 7:00 a.m. through the 3:00 p.m. nursing shift, and that the assigned nurse aide was not interviewed by the facility during the investigation.28 Pa. Code 201.18(b)(1)(3) Management.28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(c) Resident rights28 Pa. Code 211.10(d) Resident care policies28 Pa. Code 211.12(d)(1) Nursing services28 Pa. Code 211.12(d)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 396078 If continuation sheet Page 2 of 2

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Citations

2 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.

  • 0573GeneralS&S Bno actual harm

    F573 - The resident has the right to access personal and medical records pertaining

    Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

  • 0610GeneralS&S Dpotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

FAQ · About this visit

Common questions about this visit

What happened during the November 24, 2025 survey of HORSHAM CENTER FOR JEWISH LIFE?

This was a inspection survey of HORSHAM CENTER FOR JEWISH LIFE on November 24, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HORSHAM CENTER FOR JEWISH LIFE on November 24, 2025?

Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Let each resident or the resident's legal representative access or purchase copies of all the resident's records."

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.

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.