Horsham Center For Jewish Life

Based on clinical record review, and staff interviews it was determined that the facility failed to ensure each resident is provided with the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of five resident records reviewed (Resident R1).Findings Include: Review of care plan for Resident R1 dated August 4, 2025, revealed that the resident was at risk to be verbally aggressive (yelling/cursing when redirected) related to dementia.

Interventions included, Psychiatric/Psychogeriatric consult as indicated.Review of clinical record for Resident R1 dated July 1, 2025, revealed that the resident noted to be agitated, resident was going into other residents' rooms, several attempts were made to redirect the resident, and it was unsuccessful.

Staff remained with resident for supervision, and the residents were not cooperative with therapy.Review of physician progress note dated July 9, 2025, revealed that staff reported patient had wandering and some inappropriate behaviors.

Some agitation was noted related to living situation.Review of clinical record for Resident R1 dated August 4, 2025, revealed that resident's sister-in-law, called the social worker and reported that resident was angry, mean and cursing at her and his niece, over the weekend.

Resident appears calm today.

Social Worker sent referral to psych for consultReview of clinical record for Resident R1 dated August 16, 2025, revealed that the resident became increasingly agitated and verbally aggressive toward staff when approached regarding bedtime routine. At around 7 a.m., the nurse was notified by the front desk that resident had called 911.

Dispatch reported that the resident appeared confused and stated he was located outside of the facility.

The resident was reorientated.

Continued review of clinical record revealed that the resident did not leave the facility.Review of clinical record for Resident R1 dated August 23, 2025, revealed that the resident observed to be agitated and combative.

Resident was verbally redirected at times.Review of psych consult binder available at the nurses station revealed that the resident was not on the list to be seen or documentation that the resident was seen.Review of facility electronic communication log between the facility staff and psych provider revealed that a request for psych consultation for Resident R1 was sent 30 days ago. 12 days ago a follow up message was sent for consultation.

Both of the messages were unanswered.Interview with director of nursing, Employee E2 on September 3, 2025, at 1:17 p.m. confirmed that the resident was not seen by psychiatric services and should have been seen as soon as possible.28 Pa.

Code 211.12(d)(1)(3)(5) Nursing services.

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.

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