Pennsylvania Department of Health
JUNIPER VILLAGE AT BUCKS COUNTY REHABILITATION AND SKILLED C
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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JUNIPER VILLAGE AT BUCKS COUNTY REHABILITATION AND SKILLED C - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on April 15, 2026, at Juniper Village at Bucks County Rehabilitation and Skilled Care, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 233802

Component 01

Juniper Village

Based on a Revisit to a Medicare/Medicaid Recertification Survey completed on April 15, 2026, it was determined that Juniper Village at Bucks County Rehabilitation and Skilled Care was not in substantial compliance with the following requirements of the Life Safety Code for an existing Nursing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a two-story, Type III (211), protected ordinary building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Means of Egress - General:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0211 Based on observation and interview, it was determined the facility failed to maintain the means of egress free of impediments to full and instant use, affecting one exit discharge. Findings include: 1. Observation on April 15, 2026, at 11:45 a.m., revealed the courtyard emergency exit stairs had signs of spalling, multiple cracks and missing concrete pieces, creating a trip hazard. Exit Interview with the Director of Environmental Services on April 15, 2026, at 12:30 p.m., confirmed the stair condition. ******************************************* Observations during an onsite Revisit conducted on June 10, 2026, between 8:30 a.m. and 10:00 a.m., determined the following: Item #1- Not Completed. The courtyard emergency exit stairs had signs of spalling, multiple cracks and missing concrete pieces, creating a trip hazard. Exit Interview with the Administrator on June 10, 2026, at 10:00 a.m., confirmed the exit stair condition.

Plan of Correction - To be completed: 07/10/2026

No residents were harmed with this deficient practice. Prime Metal contractor will be coming on 6/29/26 to provide estimate and scope of work for repair. Once estimate is given, approval process will begin with Bensalem Township for appropriate permits.

NFPA 101 STANDARD Fire Alarm System - Testing and Maintenance:

Fire Alarm System - Testing and Maintenance
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0345 Based on document review and interview, it was determined the facility failed to maintain fire alarm systems, affecting one of three required inspections. Findings include: 1. Document review on April 15, 2026, at 9:30 a.m., revealed documentation of the following fire alarm inspections were not available at time of survey: a. semi-annual visual inspection. b. smoke detector sensitivity testing. Exit Interview with the Director of Environmental Services on April 15, 2026, at 12:30 p.m., confirmed the missing documentation. *************************** Observation during an Onsite Revisit conducted on June 10, 2026, between 8:30 a.m. and 10:00 a.m., determined the following: Item #1b - Not Completed. Documentation of smoke detector sensitivity testing was unavailable at time of Revisit. Exit Interview with the Administrator on June 10, 2026, at 10:00 a.m., confirmed the missing Documentation.

Plan of Correction - To be completed: 06/29/2026

It was determined that the Smoke Detector Sensitivity is located on the fire panel. A letter stating such will be provided by contracted provider and kept in the Executive Director and/or Environmental Services Director office.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Electrical Systems - Essential Electric System Maintenance and Testing
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0918 Based on documentation review and interview, it was determined the facility failed to maintain the emergency generator, affecting the entire facility. Observations during an onsite Revisit conducted on April 28, 2026, between 8:00 am and 9:30 a.m., determined the following: Findings include: 1. Document review on April 15, 2026, at 9:30 a.m., revealed the facility lacked documentation showing the following required emergency generator maintenance items had been conducted: a. weekly visual inspection prior to 3/22/2026. b. monthly battery conductance testing. c. monthly 30-minute load. d. monthly transfer switch operation. e. Natural gas reliability letter. Exit Interview with the Director of Environmental Services on April 15, 2026, at 12:30 p.m., confirmed the missing documentation. *************************** Observation during an onsite Revisit conducted on June 10, 2026, between 8:30 a.m., and 10:00 a.m., determined the following: Item #1a - Documentation of monthly battery conductance testing was unavailable at time of Revisit. Exit Interview with the Administrator on June 10, 2026, at 10:00 a.m., confirmed the missing Documentation. All other deficiencies listed under this tag were corrected.

Plan of Correction - To be completed: 06/24/2026

No resident was harmed with this deficient practice. Following revisit on 6/10/26, appropriate equipment was purchased and monthly battery conductance testing began with first test being completed June, 2026.

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