F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
Based on a review of facility policies, clinical records, and interviews with staff, it was determined that the
facility failed to promptly inform the resident's representative of a significant change in the resident's
condition and hospital transfer. This failure affected one of three residents reviewed (Resident R1).Review
of the facility policy titled Change in a Resident's Condition or Status, dated February 2024, indicated that
the facility is required to notify the resident and/or the resident's representative of any significant change in
condition, including transfer to the hospital.Review of the resident's clinical record revealed that Resident
R1 legally designated her family member as Power of Attorney, dated August 1, 2023.Review of the
medical provider notes for Resident R1 dated January 9, 2025, at 9:31 a.m., documented: Patient seen and
examined at request for changing condition. Aide reports noticing large amounts of blood on the floor,
wheelchair, and bathroom floor. Upon immediate evaluation, patient resting in bed; gown covered with
blood, dried blood on sheets, and large amount of blood on floor and wheelchair cushion. Patient awake,
alert, appears weak and pale with some increased confusion. Noted rectal bleed. Reviewed with unit
manager and agreed to transfer resident to the emergency room for further evaluation.Further review of the
resident's clinical record revealed a nursing note authored by Licensed Nurse Employee E2 dated January
9, 2025, at 4:02 p.m., approximately six hours after the resident's noted change in condition and hospital
transfer. The note stated the resident was sent to the hospital per medical provider instructions for rectal
bleeding and transfer to the main hospital for gastrointestinal bleeding. The note further indicated that the
niece was contacted at that time to provide an update and address questions and concerns.Interview with
Licensed Nurse Unit Manager Employee E2 on January 29, 2025, at 1:30 p.m. revealed she was on duty on
January 9, 2025, when she received notification of Resident R1's change in condition and need for
emergency hospital transfer. Employee E2 stated she contacted emergency services and completed
paperwork to accompany the resident to the hospital. Employee E2 reported that it is ultimately the bedside
nurse's responsibility to notify the resident's family and assumed that Licensed Nurse Employee E3 had
notified the resident's representative. Employee E2 confirmed it was not until later that
afternoon-approximately five to six hours after the transfer-that she personally spoke with the resident's
family member and confirmed the resident had been sent to the emergency room, at which time it was
evident the representative had not been notified immediately.Interview with Licensed Nurse Employee E3
On January 29, 2025, at 2:00 p.m. confirmed she was on duty on January 9, 2025, and assigned to
Resident R1. Employee E3 stated she was called to the resident's room by an aide due to concerns of large
amounts of blood on the resident's bedding, gown, sheets, and floor. Upon arrival, the physician assistant
was already assessing the resident, and a decision was made to transfer the resident to the hospital.
Employee E3 acknowledged it was her responsibility to notify the resident's representative; however, she
assumed the unit manager had completed the notification while making emergency calls and preparing
transfer
(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 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
01/29/2026
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
documentation. Employee E3 confirmed she did not verify that notification had occurred and was unaware
the resident's representative had not been informed.Interview with the Nursing Home Administrator on
January 29, 2026, at 1:10 p.m., confirmed there was a lapse in timely notification to the resident's
representative regarding the resident's significant change in condition and hospital transfer. The
administrator acknowledged a communication breakdown, citing a failure to clearly assign responsibility for
notifying the resident's representative. 28 Pa. Code 201.29 (c.3)(2) Resident Rights28 Pa. Code 211.12
9(d)(1)(2)(3) Nursing Services
Event ID:
Facility ID:
396078
If continuation sheet
Page 2 of 2