Heritage Ridge Senior Living At Johnstown
Inspection history, citations, penalties and survey trends for this long-term care facility in Johnstown, Pennsylvania.
- Location
- 807 Goucher Street, Johnstown, Pennsylvania 15905
- CMS Provider Number
- 395439
- Inspections on file
- 33
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at Heritage Ridge Senior Living At Johnstown during CMS and state inspections, most recent first.
The facility failed to protect several cognitively intact residents from alleged sexual abuse and dignity violations by a male nurse aide and did not promptly implement or enforce safeguards after multiple complaints. One resident who was continent reported being awakened when the aide put his hand inside her pants and touched her genitalia without explanation. Another resident who was incontinent reported that the aide left her naked and exposed with the door and curtain open during incontinence care, made sexualized comments about liking to look at naked women, and discussed prior accusations against him. A third resident reported being startled awake when the aide put his hand inside her brief instead of asking if she was wet, and a fourth resident’s family member reported that the resident called crying, stating the aide had put his hand inside her brief and digitally penetrated her vagina on multiple occasions, causing fear of being raped. Staff reported these allegations up the chain, but leadership, including the social services director, the administrator, and the acting DON, did not treat the events as abuse, allowed the aide to continue working, and failed to consistently honor restrictions that he not work with certain residents, leading surveyors to cite an Immediate Jeopardy deficiency.
The facility failed to follow its abuse policy by not removing a nurse aide from duty or investigating after multiple residents, a family member, and staff reported sexually inappropriate touching and serious privacy violations during incontinence and nighttime care. A cognitively intact resident who was continent reported being awakened with a hand placed inside her pants without explanation, another resident reported being left naked with the door and curtain open while the aide made sexualized comments and discussed prior accusations against him, and a third resident reported being startled awake when the aide put his hand inside her brief instead of asking about her continence. A fourth cognitively intact resident’s family member reported that the resident called crying and said the aide had put his hand inside her brief and that his fingers penetrated her vagina on multiple occasions. Staff repeatedly relayed these allegations up the chain to an LPN, RNs, the Director of Social Services, the Assistant DON, and the Nursing Home Administrator, yet leadership treated the matter as a grievance rather than abuse, did not initiate an abuse investigation, and allowed the aide to continue working.
The facility failed to follow its abuse policy and thoroughly investigate multiple allegations of sexual abuse and dignity violations involving a male nurse aide. One cognitively intact resident who was continent reported that the aide entered her room while she slept and put his hand inside her pants without explanation, and she felt violated. Another resident who was usually incontinent reported that the aide left her naked and exposed with the door and curtain open during incontinence care, made sexualized comments about liking to look at naked women, and discussed prior accusations against him. A third resident reported being startled awake when the aide put his hand inside her brief to check for wetness instead of asking her. A fourth resident’s family member reported that the resident called crying, stating the aide had put his hand inside her brief and digitally penetrated her on multiple occasions and that she feared being raped; staff reported this up the chain to nursing leadership. The administrator and acting DON stated they did not view the allegations as abuse, treated at least one as a grievance only, and did not conduct or document a thorough investigation or obtain statements from residents and involved staff, while the social services director denied that abuse occurred despite contrary staff reports.
Surveyors found that the NHA and DON did not fulfill their defined responsibilities to maintain an abuse-free environment. The NHA was required to direct day-to-day operations in line with regulations and to review and monitor incident and accident reports, including those involving abuse, as part of the facility’s risk management program. The DON was responsible for directing the nursing department and ensuring nursing staff followed established policies and procedures. Despite these duties, deficiencies were cited under F600 (Freedom from Abuse, Neglect, and Exploitation) and related Pennsylvania management and nursing services regulations, indicating that leadership failed to effectively manage the facility to keep residents free from abuse.
A cognitively intact resident who required extensive assistance with ADLs, including incontinence care, reported that a nurse aide completely undressed her during nighttime care and left her naked and exposed with the curtain and door open on more than one occasion while he left the room for supplies. The resident stated that the aide made inappropriate sexualized comments, including asking if she slept nude at home, saying he likes to look at naked women, and claiming he could get away with such behavior. The resident reported feeling exposed and undignified, and the acting DON later confirmed that the experience was undignified, in violation of the facility’s resident rights policy requiring treatment with dignity.
The facility failed to report multiple allegations of sexual abuse and serious violations of privacy and dignity involving four cognitively intact residents and a male nurse aide, despite a policy requiring immediate reporting of suspected abuse to state agencies, law enforcement, resident representatives, and physicians. One resident reported being awakened with the aide’s hand inside her pants and inappropriate genital touching, another reported being left naked and exposed with the door and curtain open while the aide made sexualized comments and discussed prior accusations against him, a third reported being startled awake by the aide’s hand inside her brief instead of being asked about continence, and a fourth reported to family and staff that the aide put his hand inside her brief and digitally penetrated her vagina on multiple occasions. Multiple staff members, including CNAs, an LPN, and RNs, stated they relayed these allegations up the chain of command to the DON, social services, and the administrator, yet leadership treated at least one incident as a grievance rather than abuse and did not notify required external authorities or clinicians.
A resident who was cognitively impaired, dependent for daily care, and receiving tracheostomy care had a physician order for evaluation by a pulmonologist, and nursing documentation confirmed that the pulmonologist evaluated the resident. However, there was no corresponding pulmonology progress note written, signed, and dated in the clinical record for that visit, and the Acting DON confirmed that no such documentation could be found, resulting in a deficiency related to clinical record requirements.
Facility policy required Schedule IV controlled substances to be disposed of per state and federal guidelines, including appropriate accountability. A cognitively intact resident who required staff assistance for all daily care needs had an order for Lorazepam (Ativan) 0.5 mg three times daily. Review of the MAR and controlled drug records showed that the DON destroyed five tablets of the resident’s Ativan without a witness and without obtaining the required second nurse signature for destruction of a Schedule IV controlled substance. In a subsequent interview, the Acting DON confirmed that two nurse signatures were not obtained on the controlled drug log, as required.
The facility did not complete required neurological assessments, including vital signs and neurological checks, after unwitnessed falls for three residents with conditions such as cognitive impairment, Parkinson's disease, multiple sclerosis, and dementia. Documentation was lacking for these assessments following the incidents, and the DON confirmed the omissions.
A resident with dementia and cognitive impairment was repeatedly administered PRN Ativan for restlessness and agitation without documented attempts at non-pharmacological interventions, despite facility policy and physician orders requiring such measures prior to medication use. The DON confirmed these interventions should have been attempted and documented.
Heritage Ridge Senior Living failed to investigate an incident where a resident's spouse attempted to remove her from the facility, leading to police involvement. The resident, who was cognitively intact but had dementia, required extensive assistance. Staff interviews revealed a lack of awareness about the need for an investigation, resulting in non-compliance with federal and state regulations.
A facility failed to notify the Department of Health about an incident involving a resident with dementia, whose spouse attempted to take her from the facility. The situation escalated, requiring police presence and crisis intervention. The resident remained safe at the facility, but the Department of Health was not informed, as confirmed by the DON.
The facility failed to meet the required nurse aide-to-resident staffing ratios on several occasions. With census numbers ranging from 57 to 62 residents, the facility consistently provided fewer nurse aides than required during day, evening, and night shifts. The Nursing Home Administrator confirmed the staffing shortfalls, and no additional higher-level staff were available to compensate for these deficiencies.
The facility failed to meet the required LPN-to-resident staffing ratios on specific days. On one day, the facility had a census of 57 residents, requiring 2.28 LPNs during the day shift, but only 2.07 LPNs were scheduled. Similarly, the night shift required 1.43 LPNs, but only 1.07 LPNs were present. On another day, with a census of 62 residents, the evening shift required 2.07 LPNs, but only 2.00 LPNs were scheduled. The Director of Nursing confirmed the staffing shortfall.
The facility did not provide the required 3.2 hours of direct resident care per day, as evidenced by nursing schedules and staff interviews. On two separate days, the facility provided only 2.86 and 2.00 hours of care per resident, respectively. The DON confirmed the shortfall in care hours.
The facility failed to follow physician's orders for five residents, including not administering medications and not applying prescribed devices. A resident with dementia did not receive constipation treatment, while another with Alzheimer's did not have a palm guard applied. A diabetic resident did not receive insulin and hypoglycemic protocol was not followed. Another resident's percutaneous drain output was not monitored, and a resident with renal failure missed insulin and hypertension medications. The DON confirmed these deficiencies.
The facility did not complete monthly pharmacy medication reviews for several residents from August 2024 to January 2025, as required by their policy. Interviews confirmed the absence of documentation, and the Nursing Home Administrator noted a pharmacy switch in January 2024, assuming the DON was receiving the reviews.
The facility failed to serve palatable food at appropriate temperatures during a lunch meal service. Observations revealed that food items, including barbecued ribs and corn, were served below the required temperature, making them cold and not palatable. Delays in the tray line and tray passing process contributed to this issue, as confirmed by the Director of Dietary.
Heritage Ridge Senior Living failed to ensure a resident was given the opportunity to develop an advance directive, as required by 42 CFR Part 483. The resident, who was mildly cognitively impaired and had multiple mental health conditions, did not have advance directives documented in their medical records. The facility's policy requires that residents or their representatives be provided with information about their rights to accept or refuse medical treatment and to formulate an advance directive, but this was not documented for the resident in question.
A resident with a history of stroke and diabetes repeatedly refused insulin doses, citing concerns about dosage. Despite the resident's requests to speak with the physician, there was no documentation that the physician was informed of these refusals or concerns. The DON confirmed the physician was not notified, which was required.
The facility failed to provide written notices to residents, their representatives, and the ombudsman for hospital transfers of four residents. These residents, with various cognitive and medical conditions, were transferred without the required documentation, as confirmed by the Nursing Home Administrator.
The facility failed to provide written bed-hold notices to residents or their representatives during hospital transfers. This deficiency affected four residents with various medical conditions, including cognitive impairments and chronic illnesses. The Nursing Home Administrator confirmed the oversight, indicating non-compliance with regulatory requirements.
The facility failed to accurately complete MDS assessments for six residents, leading to discrepancies between the MDS coding and actual medical records. Errors included incorrect coding of anticoagulant and opioid administration, hospice care, and the presence of a nephrostomy tube. Interviews with staff confirmed these inaccuracies.
The facility failed to develop comprehensive care plans for three residents. A resident with multiple medical conditions lacked care plans for diabetes and cardiac needs. Another resident with epilepsy did not have a care plan for seizure management. A third resident with PTSD and other mental health issues lacked a care plan for managing triggers and coping strategies. These deficiencies were confirmed by the RN Assessment Coordinator.
The facility did not update care plans for two residents to reflect their current needs. One resident required a daily bed bath and specific skin care due to ichthyosis vulgaris, but the care plan still indicated a preference for showers. Another resident was no longer an elopement risk and did not receive oxygen therapy, yet the care plan was not revised. The DON confirmed the need for updates.
The facility failed to ensure assistance devices were in place for three residents, leading to falls. A resident with cognitive impairment fell due to the absence of a chair alarm. Another resident, at high risk for falls, experienced two falls with a non-functional chair alarm. A third resident was not transferred with a sit-to-stand lift as ordered, resulting in a fall.
The facility failed to provide proper care for two residents with indwelling urinary catheters and nephrostomy tubes. One resident's catheter drainage bag and tubing were observed in contact with the floor, and there was no documented evidence of monitoring urinary output on several dates. Another resident's nephrostomy tube output was not documented as required. Interviews confirmed the lack of adherence to care plans and facility policies.
A facility failed to document the administration of Tramadol, a controlled medication, for a resident with stroke and diabetes. Despite the medication being signed out on several occasions, there was no evidence in the resident's clinical record or MAR that the doses were administered, as confirmed by the DON.
A resident with a right femur fracture did not receive their prescribed Coumadin from October 2 through October 15, as documented in the MAR. The resident was supposed to receive 2.5 mg on specific days and 2 mg on others, but the medication was not administered. The DON confirmed the oversight.
The facility failed to label a multi-use vial of Aplisol in the medication room, as it was found open and undated. The manufacturer's directions require vials in use for more than 30 days to be discarded due to potential degradation. An LPN confirmed the vial was not dated and should be discarded, and the DON confirmed it should have been dated and discarded when expired.
A resident with dementia had a physician's order for three stool samples to be tested for occult blood. While the first sample was collected and tested negative, the facility failed to document the collection and testing of the remaining two samples, as confirmed by the DON.
The facility's QAPI committee failed to address recurring deficiencies, including issues with comprehensive care plans, quality of care, and medication management. Despite having plans of correction, the facility did not achieve compliance, as evidenced by repeated deficiencies in the current survey.
A resident with an indwelling urinary catheter was observed with the catheter bag and tubing in contact with the floor, contrary to physician's orders. A nurse aide handled the catheter without gloves and placed it back on the floor before donning gloves. The DON confirmed the improper handling and lack of infection control practices.
The facility failed to comply with Act 52 Infection Control Plan requirements by not reporting health care-associated infections to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from October 2024 through January 2025. The Infection Preventionist, who started in October 2024, was unaware of the reporting requirement until recently, leading to a lack of documented evidence of infection reporting and notification to residents or their responsible parties.
The facility did not comply with the regulation to post or distribute menus to residents at least two weeks in advance. Residents reported not knowing meal details until delivery, and observations confirmed only the current day's menu was posted. The Director of Dietary acknowledged the lack of advance menu distribution.
The facility failed to meet the required NA-to-resident staffing ratios, as observed over several days in January and February 2025. The review of nursing schedules and census data revealed consistent shortages in the number of NAs scheduled during day, evening, and night shifts. Interviews with the Nursing Home Administrator confirmed the staffing deficiencies, with no additional higher-level staff available to compensate for the shortfall.
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions. During the day shift on two days, the facility did not provide the minimum of one LPN per 25 residents. Additionally, the facility did not meet the required staffing ratios on the night shift for nine days, consistently providing fewer LPNs than required by the regulation. The Nursing Home Administrator confirmed these deficiencies, and there were no additional higher-level staff available to compensate for the shortfall.
The facility did not meet the required 3.2 hours of direct resident care per resident for seven days, providing between 2.88 and 3.15 hours instead. This was confirmed by the Nursing Home Administrator after reviewing nursing schedules and conducting staff interviews.
Heritage Ridge Senior Living at Johnstown was found non-compliant with menu and nutritional adequacy requirements. Residents reported receiving meals that did not match the written menu or their tray tickets, with missing items like pancakes, bananas, and condiments. Staff interviews confirmed the lack of adherence to planned menus and the unavailability of condiments, leading to resident dissatisfaction and reliance on personal snacks.
The facility failed to store and prepare food according to professional standards, with numerous items improperly labeled or past discard dates. Observations revealed unsanitary conditions in the kitchen, including debris, grease buildup, and unlabeled pre-poured drinks. The Dietary Manager confirmed these issues, noting that staff were not completing required cleaning tasks.
The facility did not serve food at appetizing temperatures during a lunch meal service. A test tray revealed that the baked ham, scalloped potatoes, and cooked carrots were below the required temperature for hot foods, while the apple juice was above the required temperature for cold foods. The Dietary Director confirmed the food items were not at an appetizing temperature, indicating non-compliance with the facility's policy.
The facility did not ensure dietary staff served the planned portion sizes as per the menu. During a lunch meal, a dietary staff member used her hand and tongs instead of measured utensils to serve steak fries and coleslaw, resulting in inconsistent portions. The Temporary Dietary Manager confirmed the requirement for measured serving utensils was not followed.
The facility failed to update care plans for two residents with specific dietary needs. One resident required a specialized diet and Ensure with meals, but their care plan did not reflect these requirements. Another resident needed dentures to chew food, but this was not addressed in their care plan. The DON confirmed these omissions.
A resident with cognitive impairment and dysphagia was observed eating breakfast without her dentures, which were found soaking in her bathroom. Staff interviews confirmed that the dentures should have been in place to maintain the resident's ability to chew food, as per her care needs and physician's orders.
The facility failed to properly label, date, and secure food items in the nutrition room, and did not discard outdated foods. A thickened dairy drink was found with an outdated opened date, and a container of applesauce was not dated. Interviews with the DON and Dietary Manager confirmed these deficiencies, and the Dietary Manager noted that the refrigerator should be checked daily by dietary staff.
A resident, who was cognitively impaired and required a mechanical lift for transfers, was incorrectly transferred by two nurse aides using a physical assist, resulting in a severe leg laceration. The resident, on anticoagulant medication, suffered significant bleeding and required surgical intervention. The Therapy Director noted the resident was trialed with a physical assist, but the physician's order for a mechanical lift remained unchanged.
A facility failed to provide timely access to medical records for a resident, as requested by her legal representative with a durable healthcare power of attorney. Despite the facility's policy allowing residents access to their records, the request submitted was delayed due to corporate oversight. Interviews with staff revealed that the process was still ongoing, and the Director of Nursing was unaware of the delay, expecting the request to be completed within a week.
A resident with dementia and malnutrition was found with new skin tears, but the facility failed to investigate the cause or rule out neglect, contrary to its policy. The DON confirmed that no investigation was initiated, despite regular wound consultant rounds.
A facility failed to ensure complete and accurate documentation in a resident's clinical record. Despite a registered nurse assessing a resident with dementia and heart failure for bruises, the assessment was not included in the clinical record, violating facility policy and state codes.
The facility's grievance policy lacked a specified time frame for reviewing grievances, and there was no documented evidence of prompt investigation or resolution of grievances for several residents. Issues included insufficient food, dissatisfaction with food quality, and incorrect dietary provisions. An interview with the Nursing Home Administrator confirmed these deficiencies.
Failure to Protect Residents From Alleged Sexual Abuse and Dignity Violations by a Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to promptly implement protective measures after multiple residents made allegations of sexual abuse and dignity violations by a male nurse aide. Facility policy stated that each resident has the right to be free from abuse. Resident 14, who was cognitively intact, minimally dependent for daily care, and always continent of urine, filed a grievance stating that the nurse aide entered her room around 5:00 a.m. while she was sleeping and put his hand inside her pants to see if she was wet, despite her not having a history of incontinence. She reported that he touched her genitalia inappropriately, felt violated, and immediately requested to speak with a nurse, but an LPN did not come until about 7:30 a.m. She stated that when she reported the incident to the LPN, she felt dismissed and that staff treated the matter as unimportant. Resident 6, who was cognitively intact and usually incontinent of urine and bowel, filed a grievance describing an incident during incontinence care with the same nurse aide. She reported that when he answered her call bell at midnight, he initially told her that day shift would change and reposition her, but she insisted he provide care because day shift would not arrive for several hours. She stated that he told her she was not allowed to defecate and reacted by saying, "oh my gosh, you pooped everywhere." He then removed her nightgown and brief and left the room twice to gather supplies, leaving her naked on the bed with the door and curtain open. She reported that he asked if she slept in the nude, said he liked looking at naked women while looking at her, and mentioned another resident he liked to look at naked. She also reported that he told her a coworker had accused him of touching her inappropriately and that he had been supposed to be suspended but was kept on due to staffing needs. Resident 6 stated she was not afraid for herself but feared for residents who could not speak for themselves. Resident 7, who was cognitively intact, required help to get in and out of the bathroom, and was always incontinent of urine and bowel, reported that she did not want the same nurse aide to provide care. She stated that he startled her awake by sticking his hand inside her brief to see if she was wet and that he should have asked her first, as other staff did. She reported that she did not like him putting his hand in her brief and did not want him back in her room. Resident 1, who was cognitively intact, required observation for ambulation, and was frequently incontinent of urine and bowel, was the subject of a grievance initiated by a family member. The family member reported that Resident 1 called her at 1:00 a.m. crying, stating that the nurse aide had put his hand inside her brief while she was sleeping and that his fingers penetrated her vagina, and that he had done this two or three other times. The family member reported that Resident 1 said she was afraid she was going to be raped and believed the aide had been fired, which made her feel safe, although he had not been terminated at that time. Following the incident with Resident 1, another nurse aide reported that Resident 1 told him "that man put his hand in my pants and touched my private area," and he immediately informed an LPN. The LPN stated that Resident 1 told her the male nurse aide on night shift put his hand inside her brief and that his fingers penetrated her vagina, and the LPN reported this to an RN. The RN reported that she immediately informed the Director of Social Services, stating that Resident 1 said the aide put his hand in her brief and his finger inside her vagina, and was told by the Director of Social Services and the Assistant DON that they were already aware of the situation, so she took no further action. Another RN reported asking the Nursing Home Administrator about filling a night-shift schedule hole because she believed the aide would not be returning after the allegations, and the Administrator stated he was not aware of the allegation. The Director of Social Services later stated she did not believe any abuse had occurred, emphatically denied that the resident had been sexually abused, and denied being told by the family member, RN, or Administrator that the aide had touched the resident’s crotch or digitally penetrated her. An undated list from the acting DON showed that the nurse aide was not permitted to work with Residents 1, 6, or 7, and that he was not to work with Resident 6 after her allegation on January 2, 2026, and not to work with Resident 7 after her allegation of sexual abuse in January 2026. However, task records showed that he continued to work with Resident 6 on multiple dates in January, March, and April 2026, and with Resident 7 on several dates in February and April 2026. The acting DON acknowledged that the aide should not have worked with Residents 6 or 7 on those dates. The Nursing Home Administrator and acting DON stated that they did not consider the allegation involving Resident 1 and the aide to be abuse and treated it as a grievance, and the acting DON stated she was not aware of any sexual abuse allegations. The Administrator stated that when he became aware of the allegation, he had the Director of Social Services speak with Resident 1 and was told that the resident’s story had changed, so they concluded the incident did not happen. Surveyors determined that the facility failed to ensure immediate and adequate safeguards to protect residents from sexual abuse by the aide, resulting in an Immediate Jeopardy finding.
Failure to Implement Abuse Policy and Protect Residents From Alleged Sexual Misconduct
Penalty
Summary
The deficiency involves the facility’s failure to implement its abuse policy by not immediately protecting residents from a nurse aide whose conduct gave rise to reasonable suspicion of sexual abuse, and by failing to investigate multiple allegations of abuse, neglect of dignity, and privacy violations. The facility’s written policy stated that any employee whose conduct created reasonable suspicion of resident abuse could be immediately removed from the floor and, where appropriate, suspended without pay pending investigation, and that all possible incidents of abuse were to be investigated. Despite this, the facility did not remove the implicated nurse aide from resident care or initiate abuse investigations after multiple complaints and grievances from staff and residents. Evidence of prior concerning conduct was documented in the aide’s disciplinary file. A nurse aide reported that the implicated aide asked her personal questions, told her to get on her knees while she was helping provide care for a resident, and then slapped her buttock, stating she was not the first co‑worker he had done this to. Another LPN reported she was aware that the same aide had sexually assaulted a nurse aide who then quit because nothing was done about it. These reports were known to staff, and one LPN stated she was very concerned for other residents, particularly a comatose resident, yet the aide continued to work his regular assignments. Multiple cognitively intact residents reported inappropriate and intrusive touching by the aide during incontinence or nighttime care. One resident who was always continent of urine and had no history of incontinence reported that the aide entered her room around 5:00 a.m. while she was sleeping and put his hand inside her pants to see if she was wet without explanation, which she described as inappropriate and a violation of her dignity and rights. Another resident, usually incontinent, reported that the aide left her naked on the bed twice with the door and curtain open while gathering supplies, made comments about her bowel movements, asked if she slept nude, stated he liked looking at naked women, and told her that he had been accused of touching a nurse aide but was not properly suspended due to staffing. A third resident, always incontinent, stated she did not want the aide to care for her because he startled her awake by sticking his hand inside her brief to check for wetness instead of asking her, unlike other staff. A further allegation involved a cognitively intact resident who was frequently incontinent. Her family member reported that the resident called crying during the night and said the aide had put his hand inside her brief while she was sleeping and that his fingers penetrated her vagina, and that this had occurred two or three other times, causing her to fear being raped. The resident later told another aide that a man had put his hand in her pants and touched her private area, and she was upset. That aide immediately reported to an LPN, who then reported to an RN, who in turn reported to the Director of Social Services and the Assistant DON, stating that the resident said the aide’s finger had penetrated her vagina. A separate RN later asked the Nursing Home Administrator if the aide needed to be replaced on the night shift because a resident said he had “fingered” her, and the administrator was not aware of the allegation at that time. Despite these multiple, consistent reports from residents, family, and staff, the Nursing Home Administrator and acting DON stated that they did not consider the allegation regarding the resident who reported digital penetration to be abuse and documented it only as a grievance. They further stated that the facility did not investigate the allegations made by the four residents because they did not believe the incidents occurred and therefore felt no investigation was needed. The Director of Social Services stated emphatically that she knew no abuse had taken place, denied being told about the specific sexual nature of the allegations, and maintained that the resident would have told her if it had happened. The aide continued to work, including on the same hall as residents who had expressed fear or discomfort, contrary to the facility’s own abuse policy requiring immediate protection and investigation when abuse was reasonably suspected.
Failure to Investigate Multiple Allegations of Sexual Abuse by a Nurse Aide
Penalty
Summary
The deficiency involves the facility’s failure to conduct thorough investigations into multiple resident allegations of sexual abuse by a nurse aide, and failure to follow its own abuse policy requiring immediate removal of the accused staff from resident contact pending investigation. The facility’s policy on abuse, neglect, exploitation or misappropriation, dated August 21, 2025, required that all allegations be thoroughly investigated and that any employee accused of resident abuse be placed on leave with no resident contact until the investigation was complete. Despite this, the personnel file for Nurse Aide 1 showed only scattered, non-consecutive suspension days for an incident involving one resident and no documented discipline for another resident’s allegation, and there was no evidence that he was removed from resident care while allegations were being reviewed. The Nursing Home Administrator and acting Director of Nursing acknowledged that they did not conduct investigations into the allegations because they did not believe abuse had occurred and instead treated at least one allegation as a grievance. One cognitively intact resident (Resident 14), who was always continent of urine and required minimal help with daily care, reported in a grievance that around 5:00 a.m. a male nurse aide entered her room while she was sleeping and put his hand inside her pants to see if she was wet, without explanation, even though she had no history of incontinence. She stated in interview that he touched her inappropriately, that she felt violated, and that she immediately requested to speak to a nurse but was not seen until about 7:30 a.m., at which time she reported the incident to an LPN. She further stated that the Director of Nursing did not take her seriously and that she felt her complaint was dismissed. There was no documented evidence that the facility obtained statements from this resident or involved staff, or that a thorough investigation was completed to rule out sexual abuse. Another cognitively intact resident (Resident 6), who required assistance for ADLs and was usually incontinent of urine and bowel, filed a grievance stating that during incontinence care the same nurse aide left her naked on her bed twice with the door and curtain open while he left the room to gather supplies. She reported that he commented that she was not allowed to defecate, remarked on her soiling, asked if she slept in the nude, and told her he liked looking at naked women, including another woman there who did not like him doing it either. She also reported that he told her he had been accused of touching another nurse aide, that his suspension days were split so they did not affect his paycheck because staffing was short, and that other residents had complained about his care and comments. In interview, she confirmed feeling exposed and stated she feared for residents who could not speak for themselves. There was no documentation of interviews with her or staff, or of a comprehensive investigation into her allegations. A third cognitively intact resident (Resident 7), who required help to get in and out of the bathroom and was always incontinent of urine and bowel, stated in interview that she did not want this nurse aide to provide care because he startled her awake by sticking his hand inside her brief to see if she was wet, instead of asking her as other staff did. She reported that she did not like him putting his hand in her brief and did not want him back in her room. There was no documented evidence that the facility obtained statements from her or staff or conducted a thorough investigation into her allegation to rule out sexual abuse. A fourth cognitively intact resident (Resident 1), who required observation for ambulation and was frequently incontinent of urine and bowel, was the subject of a grievance initiated by her family member and Power of Attorney. The family member reported that the resident called her at about 1:00 a.m. crying, stating that the male nurse aide had put his hand inside her brief while she was sleeping and that his fingers penetrated her vagina, and that he had done this two or three other times; the resident reportedly expressed fear that she would be raped. The family member stated she informed the Director of Social Services that the resident said the aide had stuck his hand in her crotch, and that the resident later believed the aide had been fired when he had not. Staff interviews corroborated that the resident told a nurse aide and an LPN that the male aide had put his hand in her pants and digitally penetrated her, and that this was reported up the chain to an RN, who then reported it to the Director of Social Services and the Assistant DON. Another RN reported asking the Nursing Home Administrator if the aide would be replaced on night shift because a resident said he had fingered her, and the Administrator was not aware of the allegation at that time. Despite these reports, the Nursing Home Administrator and acting Director of Nursing stated that they did not consider the allegation regarding Resident 1 to be abuse and documented it only as a grievance. The acting DON stated she was not aware of any sexual abuse allegations, and the Director of Social Services emphatically denied that any abuse occurred, stating she knew there was no abuse and denying that she had been told about digital penetration or inappropriate touching, contrary to other staff accounts. The aide denied touching any residents inappropriately and claimed he could determine wetness by looking at the brief. Across all four residents’ cases, there was no documented evidence that the facility obtained written statements from the residents, from the staff who received the reports, or from staff who interviewed the residents, and no evidence of a thorough investigation including interviews with all pertinent staff to rule out that sexual abuse may have occurred, in violation of facility policy and state regulatory requirements.
Failure of NHA and DON to Ensure an Abuse-Free Environment
Penalty
Summary
The deficiency involves the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failing to effectively manage the facility to ensure that residents' environment remained free from abuse. The NHA’s job description specified responsibility for directing day-to-day facility functions in accordance with federal, state, and local regulations, including planning, developing, organizing, implementing, evaluating, and directing facility programs and activities. The NHA was also responsible for reviewing incident and accident reports, including those related to falls, injuries of unknown origin, and abuse, and for monitoring these to determine the effectiveness of the facility’s risk management program. The DON’s job description stated that the DON was to plan, organize, develop, and direct the overall operation of the nursing department in accordance with applicable regulations and as directed by the Administrator or Medical Director, to ensure the highest degree of quality care at all times. The DON’s administrative functions included ensuring that all nursing staff followed established departmental policies and procedures. Survey findings under 42 CFR 483.12 (F600 – Freedom from Abuse, Neglect, and Exploitation) determined that, despite these defined responsibilities, the NHA and DON did not fulfill their essential job duties to maintain an environment free from abuse, resulting in cited deficiencies under federal and Pennsylvania state regulations.
Failure to Maintain Resident Dignity During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity during incontinence care. Facility policy on Resident Rights, dated August 21, 2025, states that residents have the right to a dignified existence and to be treated with dignity. A quarterly MDS assessment for Resident 6, dated March 27, 2026, documented that the resident was cognitively intact and required extensive assistance with ADLs, including incontinence care. During a night shift on January 1, 2026, while providing incontinence care, Nurse Aide 1 completely undressed the resident and left the room to obtain supplies, leaving the resident fully naked and exposed with the curtain and door open. He then returned and again left the room during care while the resident remained naked and exposed with the curtain and door open. According to a grievance dated January 2, 2026, and a subsequent interview on April 13, 2026, the resident reported that she did not like the way Nurse Aide 1 provided care, stating that he left her naked and exposed and spoke inappropriately to her. She stated that he asked if she slept nude at home, told her he likes to look at naked women, and said he had been staring at a naked woman there. She reported that he told her it did not matter that she did not like it because he could get away with it, and that he bragged about things he was doing and getting away with, including being suspended but having his suspension staggered because the facility needed him to work. The resident stated she felt exposed and undignified being left naked with the curtain and door open. The acting DON confirmed on April 13, 2026, that this was an undignified experience for the resident.
Failure to Report Multiple Allegations of Sexual Abuse and Violations of Dignity
Penalty
Summary
The deficiency involves the facility’s failure to report multiple allegations of sexual abuse and violations of dignity and privacy involving four cognitively intact residents to required external authorities, despite its own policy mandating immediate reporting of suspected abuse, neglect, exploitation, or misappropriation. The facility’s policy, dated August 21, 2025, required that the administrator or the individual making the allegation immediately report suspicions to the state licensing agency, local/state ombudsman, the resident’s representative, adult protective services, law enforcement, the attending physician, and the medical director. Surveyors found no documented evidence that these entities were notified regarding the allegations against a male nurse aide (Nurse Aide 1), and interviews with the Nursing Home Administrator and acting Director of Nursing confirmed that they did not report the incidents because they did not believe abuse had occurred. One cognitively intact resident (Resident 14), who was documented as always continent of urine and requiring minimal help with daily care, filed a grievance stating that around 5:00 a.m. a male nurse aide entered her room while she was sleeping and put his hand inside her pants to see if she was wet, without explaining what he was doing. She reported that he touched her genitalia inappropriately and that she felt violated, especially because she had no history of incontinence and could have been asked. She stated she requested to speak with a nurse immediately, but an LPN did not come until about 7:30 a.m., at which time she reported the incident to LPN 2. LPN 2 reported that she immediately informed the Director of Nursing, but that the Director of Nursing did not take the allegation seriously and the aide continued working. Another cognitively intact resident (Resident 6), who required assistance with incontinence care and was usually incontinent of urine and bowel, filed a grievance describing an incident during nighttime incontinence care with the same aide. She reported that he initially refused timely care, told her she was not allowed to defecate, commented that she had “pooped everywhere,” removed her nightgown and brief, and left her naked on the bed with the door and curtain open while he left the room twice to gather supplies. She stated he asked if she slept nude at home, said he liked looking at naked women while looking at her, and mentioned another woman he liked to look at naked. She also reported that he told her a coworker had accused him of touching her inappropriately and that he was supposed to be suspended, but staffing needs prevented a proper suspension. She stated she was not afraid for herself but feared for residents who could not speak for themselves. A third cognitively intact resident (Resident 7), who required help to get in and out of the bathroom and was always incontinent of urine and bowel, reported that she did not want the same aide to provide care because he startled her awake by sticking his hand inside her brief to check for wetness instead of asking her, as other staff did. She stated she did not like him putting his hand in her brief and did not want him back in her room. A fourth cognitively intact resident (Resident 1), who required observation for ambulation and was frequently incontinent of urine and bowel, was the subject of a grievance initiated by her daughter-in-law and Power of Attorney. The family member reported that the resident called her at about 1:00 a.m. crying, stating that the aide had put his hand inside her brief while she was sleeping and that his fingers penetrated her vagina, and that this had occurred two or three other times, causing the resident to fear she would be raped. Staff interviews corroborated that Resident 1 reported digital penetration by the aide to multiple staff members. A nurse aide (Nurse Aide 3) stated that Resident 1 told him that the male night-shift aide put his hand in her pants and touched her private area, and he immediately reported this to LPN 4. LPN 4 reported that Resident 1 told her the male aide put his hand inside her brief and his fingers penetrated her vagina, and LPN 4 immediately reported this to RN 5. RN 5 stated she then reported to the Director of Social Services that Resident 1 said the aide put his hand in her brief and his finger inside her vagina, and was told by the Director of Social Services and the Assistant Director of Nursing that they were already aware of the allegation, so she took no further action. Another RN (RN 6) reported that when staff asked if the aide would be working after the allegations, she approached the Nursing Home Administrator about replacing him on the night shift and informed him that a resident said the aide had “fingered her” two nights earlier; the Administrator stated he was not aware of the allegation. The Nursing Home Administrator and acting Director of Nursing stated in interview that they did not consider the allegation involving Resident 1 and the aide to be abuse and treated it only as a grievance. The acting Director of Nursing stated she was not aware of any sexual abuse allegations. The Administrator stated that when he became aware of the allegation, he had the Director of Social Services speak with Resident 1 and was told that the resident’s story had changed, so they concluded the incident did not occur. The Director of Social Services emphatically denied that any abuse occurred, stated she knew there was no abuse and wished people would stop saying that, and denied being told by the family member, RN 5, or the Administrator that the aide had touched the resident’s crotch or digitally penetrated her. Despite multiple resident grievances, resident and family reports of inappropriate genital touching and digital penetration, and staff reports up the chain of command, there was no documentation that these allegations were reported to the Department of Health, ombudsman, resident representatives, adult protective services, law enforcement, attending physicians, or the medical director, in violation of facility policy and state regulatory requirements.
Missing Pulmonologist Progress Note After Specialist Evaluation
Penalty
Summary
Surveyors found that the facility failed to ensure that a pulmonologist wrote, signed, and dated a progress note for a resident visit as required. Resident 2’s admission MDS dated February 18, 2026 documented that the resident was cognitively impaired, dependent on staff for daily care needs, and received tracheostomy care. A physician’s order dated February 4, 2026 directed that the resident be seen by a pulmonologist, and a nursing note on the same date at 1:35 p.m. recorded that the pulmonologist had just evaluated the resident. However, as of April 14, 2026, there was no documented evidence in the resident’s clinical record that the pulmonologist had completed a progress note for that visit. During an interview on April 14, 2026 at 6:45 p.m., the Acting Director of Nursing confirmed that she could not locate any documented progress note from the pulmonologist’s visit on February 4, 2026, indicating noncompliance with 28 Pa. Code 211.5(f) regarding clinical records.
Failure to Ensure Proper Witnessed Destruction of a Schedule IV Controlled Medication
Penalty
Summary
Facility policy dated August 21, 2025 required that Schedule IV controlled substances be disposed of in accordance with state regulations and federal guidelines, including appropriate accountability. A quarterly MDS assessment dated January 21, 2026 documented that Resident 1 was cognitively intact but required staff assistance for all daily care needs. Physician’s orders dated October 28, 2025 directed that Resident 1 receive 0.5 mg Lorazepam (Ativan), a Schedule IV anti-anxiety medication, three times daily. Review of Resident 1’s Medication Administration Records for February and March 2026 showed that on March 21, 2026 the Director of Nursing destroyed five tablets of the resident’s Ativan but did so without a witness, and therefore without obtaining the required second nurse signature for destruction of a Schedule IV controlled substance. In an interview on April 13, 2026, the Acting Director of Nursing confirmed that there were not two nurse signatures on the controlled drug log for this destruction and acknowledged that there should have been. These findings show that the facility failed to ensure proper accountability and destruction procedures for a Schedule IV controlled medication for one resident, in violation of 28 Pa. Code 211.9(h) Pharmacy Services and 28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure that neurological assessments, including vital signs and neurological checks, were completed following unwitnessed falls for three residents. According to the facility's policy, neurological assessments are required after unwitnessed falls, head trauma, or as indicated by the resident's condition, and should include frequent vital signs. The protocol specifies checks every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, and then every four hours for 24 hours. For one resident with mild cognitive impairment and Parkinson's disease, documentation showed an unwitnessed fall with a head injury and subsequent hospital visit. Upon return from the hospital, there was no evidence that neurological checks or vital signs were completed as required by protocol. The DON confirmed that these assessments should have been performed. Another resident, cognitively intact with multiple sclerosis, experienced an unwitnessed fall, but there was no documentation of neurological checks or vital signs following the incident, which was also confirmed by the DON. A third resident, who was cognitively impaired with dementia and had wandering behaviors, also had an unwitnessed fall. Again, there was no documented evidence that neurological assessments or vital signs were completed per protocol after the fall. The DON confirmed the lack of documentation for this resident as well. These findings indicate that the facility did not follow its own policy for post-fall neurological assessments for multiple residents.
Plan Of Correction
Unable to retroactively complete neurological assessment. Resident who had an unwitnessed fall have the potential to be affected. Education provided to licensed nurses on initiating neurological assessment per facility policy with an unwitnessed fall. The Director of Nursing or designee will audit and review incident reports (unwitnessed falls) to ensure neurological assessments have been completed per facility policy with unwitnessed falls. Audits will be conducted as follows: 1.) Up to 4 records will be reviewed daily for 4 weeks. 2.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Attempt Non-Pharmacological Interventions Before PRN Antianxiety Medication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary psychotropic medications by not attempting non-pharmacological behavioral interventions prior to administering 'as needed' antianxiety medication. Facility policy required that non-pharmacological approaches be used to minimize medication use, permit the lowest possible dose, and allow for discontinuation when possible. Despite this, review of the Medication Administration Record (MAR) for a cognitively impaired resident with dementia, who exhibited wandering behaviors and received both antipsychotic and antianxiety medications, showed multiple administrations of Ativan (Lorazepam) for restlessness and agitation over a period of time. There was no documented evidence that non-pharmacological interventions were attempted before administering Ativan on any of the recorded occasions. The physician's orders specifically required staff to monitor the resident's behavior every shift and document non-pharmacological interventions. The Director of Nursing confirmed that these interventions should have been attempted and documented prior to each administration of the medication, but this was not done.
Plan Of Correction
Unable to retroactively chart non-pharmacological interventions prior to administration of psychotropic medication. Residents who are ordered as needed (PRN) psychotropic have the potential to be affected. Education provided to licensed nurses on charting non-pharmacological interventions prior to the administration of a psychotropic medication. The Director of Nursing or designee will audit and review incident reports to ensure the necessary reporting is completed. Audits will be conducted as follows: 3.) Up to 5 records will be reviewed daily for 4 weeks. 4.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Investigate Incident Involving Resident's Spouse
Penalty
Summary
Heritage Ridge Senior Living at Johnstown was found to be non-compliant with federal and state regulations due to a failure to conduct a thorough investigation following an incident involving a resident. The incident involved a cognitively intact resident with dementia, who required extensive assistance with daily care needs. The resident's spouse attempted to remove her from the facility, made threats towards staff, and the police were called to de-escalate the situation. Despite the severity of the incident, the facility did not conduct a thorough investigation as required by their policy. Interviews with facility staff revealed a lack of awareness regarding the necessity of an investigation when a family member is involved in such incidents. The Director of Nursing and the Nursing Home Administrator both indicated they were unaware that an investigation was needed. The Administrator had signed a document barring the resident's spouse from the property but did not initiate an investigation into the incident. This oversight led to the facility's failure to meet the requirements for investigating, preventing, and correcting alleged violations as outlined in 42 CFR Part 483 and the 28 PA Code.
Plan Of Correction
Investigation and incident report completed for incident occurring on 03/20/2025 for resident #2. Residents who receive care and services at the facility have the potential to be affected. Director of Nursing was educated by the Administrator on the when to investigate and initiate an incident report in reference to family members/visitors and when police come into the facility to investigate an incident. The Administrator or designee will audit and review incident reports to ensure the necessary investigation is completed. Audits will be conducted as follows: 1.) Up to 5 records will be reviewed daily for 4 weeks. 2.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Notify Department of Health of Incident
Penalty
Summary
The facility failed to notify the Department of Health about an incident involving a resident, which had the potential for harm. The incident involved a resident who was cognitively intact but required extensive assistance with daily care needs and had a diagnosis of dementia. On a specific date, the resident's spouse attempted to take her from the facility, but she was unable to stand to get into the car. This led to the spouse becoming extremely frustrated with both the resident and the staff. The situation escalated to the point where police presence was required, and the police had to contact crisis services due to a comment made by the spouse. After the situation was de-escalated, the resident remained safe at the facility, and her daughter was informed and agreed that the facility was the safest place for her. However, the Director of Nursing confirmed that the Department of Health was not notified of this incident, which constitutes a failure to meet the regulatory requirement for notification.
Plan Of Correction
Unable to retroactively notify the Department of Health of incident that had the potential for harm to a resident. Residents who receive care and services at the facility have the potential to be affected. Director of Nursing was educated by the Administrator on reporting incidents that have the potential for harm to a resident to the Department of Health. The Director of Nursing will review questionable incidents with the Administrator to ensure compliance in reporting. The Administrator or designee will audit and review incident reports to ensure the necessary reporting is completed. Audits will be conducted as follows: 3.) Up to 5 records will be reviewed daily for 4 weeks. 4.) Then up to 10 records will be reviewed monthly for 2 months. Results of the audits will be provided by the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide-to-resident staffing ratios on multiple occasions. On March 31, 2025, the facility had a census of 57 residents, necessitating 5.70 nurse aides during the day shift, 5.18 during the evening shift, and 3.80 during the night shift. However, the facility only provided 5.27, 4.40, and 3.17 nurse aides, respectively, for these shifts. Similarly, on April 2, 2025, with a census of 58 residents, the facility required 5.70 nurse aides during the day shift, 5.27 during the evening shift, and 3.87 during the night shift, but only provided 4.97, 4.17, and 3.37 nurse aides, respectively. On April 3, 2025, the facility's census increased to 62 residents, requiring 5.80 nurse aides during the day shift and 5.64 during the evening shift. However, the facility only provided 4.00 and 4.20 nurse aides, respectively. The Nursing Home Administrator confirmed that the facility did not meet the required staffing ratios for the days reviewed. No additional higher-level staff were available to compensate for these deficiencies, leading to a failure in meeting the regulatory staffing requirements.
Plan Of Correction
Unable to retroactively correct staffing ratios for Certified Nurse Aides (CNAs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1. Generous Sign on Bonus 2. Flexible Scheduling 3. Benefits Package for full-time employees 4. Wage analysis completed 5. "Kudos" recognition program 6. Referral bonus 7. Agency Contracts 8. Administrative Coverage 9. Attend Job Fair Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on specific days, as evidenced by a review of nursing schedules and staffing information. On March 31, 2025, the facility had a census of 57 residents, necessitating 2.28 LPNs during the day shift, but only 2.07 LPNs were scheduled. Similarly, the night shift required 1.43 LPNs, but only 1.07 LPNs were present. On April 3, 2025, with a census of 62 residents, the evening shift required 2.07 LPNs, but only 2.00 LPNs were scheduled. In all instances, there were no additional higher-level staff available to compensate for the staffing shortfall. The Director of Nursing confirmed during an interview on April 10, 2025, that the facility did not meet the required LPN-to-resident staffing ratios for the specified days. This deficiency was identified through a comprehensive review of the facility's census data and nursing time schedules, which highlighted the shortfall in staffing levels necessary to comply with the regulations effective July 1, 2023.
Plan Of Correction
Unable to retroactively correct staffing ratios for Licensed Practical Nurses (LPNs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1. Generous Sign on Bonus 2. Flexible Scheduling 3. Benefits Package for full-time employees 4. Competitive Wages 5. "Kudos" employee recognition program 6. Referral bonus 7. Agency Contracts 8. Administrative Coverage 9. Attend Job Fair Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Meet Required Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules and staff interviews. Specifically, on March 31, 2025, the facility provided only 2.86 hours of direct care per resident, and on April 3, 2025, only 2.00 hours of direct care per resident was provided. The Director of Nursing confirmed that the facility did not meet the required daily hours of direct care on these dates.
Plan Of Correction
Unable to retroactively correct the hours provided of direct resident care for dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1. Generous Sign on Bonus 2. Flexible Scheduling 3. Benefits Package for full-time employees 4. Competitive Wages 5. "Kudos" employee recognition program 6. Wage analysis completed 7. The facility is near public transportation. 8. Referral bonus 9. Agency Contracts 10. Administrative Coverage 11. Attend Job Fair Monitoring will be captured through auditing Per Patient Day. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Follow Physician's Orders and Document Care
Penalty
Summary
The facility failed to follow physician's orders for care and treatment for five residents. Resident 1, who was cognitively impaired and frequently incontinent of bowel, did not receive Milk of Magnesia as ordered for constipation over a four-day period. The Director of Nursing confirmed the lack of documentation for the administration of the medication. Resident 24, who was cognitively intact and had Alzheimer's disease, did not have a left hand palm guard applied as ordered. The resident reported that the staff often forgot to apply it, and the Director of Nursing confirmed the order was not transcribed correctly. Resident 26, who was cognitively intact with a history of stroke and diabetes, did not receive appropriate care for low blood sugar as per the hypoglycemic protocol. Additionally, insulin lispro was not administered on multiple occasions as ordered. The Director of Nursing confirmed these lapses in care. Resident 37, who had diabetes and renal insufficiency, required monitoring of a percutaneous drain output, but there was no documented evidence of this monitoring over several months. The Director of Nursing confirmed the lack of documentation. Resident 38, who was moderately cognitively impaired with end-stage renal failure and hypertension, did not receive insulin Lantus and amlodipine as ordered on multiple occasions. The Director of Nursing confirmed that the orders were not transcribed correctly, leading to missed medication administrations. These deficiencies highlight a pattern of failure to adhere to physician's orders and document care appropriately for multiple residents.
Plan Of Correction
Resident 1 unable to retroactively address bowel movements, Medical Director (MD) notified. Resident 24 palm guard order was reviewed and updated to include documentation. MD notified. Resident 26 unable to retroactively address hypoglycemic protocol administration documentation, MD notified. Resident 26 insulin orders were reviewed, and resident is receiving insulin as ordered. MD notified. Resident 37 orders were reviewed and updated to include an order to record percutaneous drain output every shift. MD notified. Resident 38 medication administration orders were reviewed and adjusted to dialysis times. MD notified. Residents receiving medications and treatments have the potential to be affected. Licensed staff educated by the Director of Nursing on following physician orders for care and treatment (e.g. order transcription, evaluation, parameters, documentation, physician notification). Code update in Electronic Medical Administration Record (EMAR) to document when glucose level does not require insulin coverage per sliding scale. Education was provided to licensed staff on the new EMAR code. Monitoring will be captured through auditing Medication administration. Audits will be completed as follows: 2 staff med pass observations will be conducted weekly for 4 weeks, then 4 staff med pass observations will be conducted 2 times monthly for 2 months. The med pass observations will be conducted by the Director of Nursing or designee. Results of the med pass observations will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the.
Failure to Conduct Monthly Pharmacy Medication Reviews
Penalty
Summary
The facility failed to ensure that monthly pharmacy medication reviews were completed for seven residents over a period from August 2024 through January 2025. The facility's policy, dated January 2025, required the consultant pharmacist to provide a documented review of each resident's medication regimen at least monthly. However, there was no documented evidence of these reviews in the clinical records of the affected residents during the specified months. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the absence of documented monthly pharmacy medication reviews. The Nursing Home Administrator indicated that the facility had switched pharmacies in January 2024 and assumed that the Director of Nursing was receiving the monthly reviews. This oversight led to the deficiency as the facility did not adhere to its policy and federal regulations regarding drug regimen reviews.
Plan Of Correction
Pharmacy medication reviews were completed for residents 16, 21, 23, 26, 33, 38, and 50. Residents who receive medications or treatments have the potential to be affected. Education was provided to the Director of Nursing on the process for maintaining records of pharmacy medication reviews. Staff educated on the process when pharmacy recommendations are received from pharmacy consultant: they are forwarded to attending provider. Once completed (approved, not approved) recommendations forms are kept in the resident record and a back-up copy in the pharmacy consultant binder. Monitoring will be captured through auditing pharmacy medication reviews. Audits will be conducted on 10 pharmacy recommendations monthly for 1 month, then 5 pharmacy recommendations monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Serve Palatable Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve palatable food at appropriate temperatures, as evidenced by observations during a lunch meal service. The facility's policy, dated January 20, 2025, required hot foods to be held at temperatures of 135 degrees Fahrenheit or above, with efforts to maintain hot food hot and cold food cold at the point of service. However, during the lunch meal tray line on February 10, 2025, the food temperatures were found to be below the required levels. Specifically, the barbecued ribs were at 114 degrees F, baked beans at 127 degrees F, corn at 102 degrees F, and watermelon at 53.1 degrees F. Additionally, pureed versions of these foods were also below the required temperatures, making them cold and not palatable. The delay in the tray line and tray passing process contributed to the food being served at inadequate temperatures. The last tray was placed on the cart at 12:14 p.m., arrived on the unit at 12:17 p.m., and the last tray was served at 12:27 p.m. A test tray removed at 12:42 p.m. confirmed the low temperatures. An interview with the Director of Dietary confirmed that the temperatures were not palatable due to these delays. This deficiency was noted under the regulations 28 Pa. Code 201.18(b)(1) Management and 28 Pa. Code 211.6(f) Dietary Services.
Plan Of Correction
Unable to retroactively correct the temperatures of the food. Residents receiving meals from Dining Services have the potential to be affected. Trays will be distributed within 15 minutes of the cart being delivered to the floor. Monitoring will be captured through auditing test trays. Audits will be conducted 6 trays weekly for 4 weeks, then 3 trays weekly for 2 months. The audits will be conducted by the Director of Dietary, the Dietitian or designee. Results of the audits will be provided to the Administrator by the Director of Dietary and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Assist Resident in Formulating Advance Directive
Penalty
Summary
Heritage Ridge Senior Living was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the rights of residents to formulate advance directives. The facility's policy, dated January 20, 2025, mandates that upon admission, residents or their representatives should be provided with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. However, it was determined that the facility failed to ensure that a resident, identified as Resident 33, was given the opportunity to develop an advance directive or assisted in formulating one. This was based on a review of facility policies, clinical records, and staff interviews. Resident 33, who was mildly cognitively impaired and had a history of mental health conditions including schizoaffective disorder, bipolar disorder, anxiety, depression, and PTSD, did not have advance directives documented in their medical records. The quarterly Minimum Data Set assessment indicated the resident's cognitive and behavioral status, yet there was no evidence in the clinical record that the resident or their representative was offered assistance in formulating an advance directive. The Director of Nursing confirmed the absence of documentation regarding the opportunity for the resident to formulate an advance directive.
Plan Of Correction
The Director of Nursing provided resident 33 with information on how to formulate advance directives. Baseline audit was completed to identify residents without advanced directives and residents/resident representatives were provided with information on how to formulate advance directives. Advance directive status will be evaluated at the time of admission. Residents who do not have advance directives will be provided with information on formulating advance directives. Advance directive status will be reviewed quarterly. Monitoring will be captured through auditing advance directive status as follows: up to 3 clinical records weekly for 4 weeks, then up to 6 clinical records 2 times monthly for 2 months. The audits will be conducted by the Social Worker or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at the QAPI Committee meeting.
Failure to Notify Physician of Insulin Refusals
Penalty
Summary
The facility failed to notify a resident's attending physician about the resident's repeated refusals of insulin medication and requests to speak with the physician. The resident, who was cognitively intact and had a history of stroke and diabetes, was prescribed insulin lispro and insulin glargine. Despite the resident's refusals of these medications on multiple occasions, there was no documented evidence that the physician was informed of these refusals or the resident's request for clarification on insulin dosages. The resident refused her insulin doses on several dates in January and February, citing concerns about the dosage being too high. A nurse's note indicated that the physician was aware and would review the insulin and medications on rounds, but there was no documentation confirming that the physician addressed the resident's concerns. An interview with the Director of Nursing confirmed that the physician was not notified of the resident's continued refusals and requests for clarification, which should have been done.
Plan Of Correction
Resident 26 insulin orders were reviewed with the provider and adjustments were made to resident's insulin orders through collaboration with resident and provider. Baseline audit was completed on residents with insulin orders to identify other residents that are refusing insulin. The Director of Nursing provided education to licensed staff on notifying the provider when residents refuse insulin and documenting that the provider was notified. Monitoring will be captured through auditing insulin administration. Audits will be conducted on 4 resident records weekly for 4 weeks, then 8 resident records 2 times monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Provide Written Notice for Resident Transfers
Penalty
Summary
The facility failed to comply with the regulatory requirements for notifying residents, their representatives, and the ombudsman in writing about transfers and the reasons for hospitalization. This deficiency was identified for four residents during a review of clinical records and staff interviews. The facility did not provide the required written notices for these transfers, which is a violation of the specified regulations. Resident 13, who was cognitively impaired and had diagnoses including heart failure and diabetes, was found on the floor with injuries and was transferred to the emergency room. There was no documented evidence of a written notice provided to the resident, their representative, or the ombudsman regarding this transfer. Similarly, Resident 23, who was cognitively intact but dependent on staff, was transferred to the hospital due to an inability to answer orientation questions, without the required written notice being documented. Resident 33, with mild cognitive impairment and mental health diagnoses, agreed to a hospital transfer for a mental health evaluation, yet no written notice was documented. Resident 37, who was cognitively intact and had multiple health issues, was transferred to the hospital on several occasions due to medical concerns, but again, no written notices were documented for these transfers. The Nursing Home Administrator confirmed the lack of written notices for these residents' transfers during an interview.
Plan Of Correction
Residents 13, 23, 33, and 37 were provided with notice of transfer. Ombudsman was notified of transfers for the months of January and February. Baseline audit was completed to identify residents that were transferred out of the facility during the months of January and February. A binder has been designated to maintain records of notice of transfer and Ombudsman notification. Education was provided to Social Worker and/or Designee on the process for maintaining records of notice of transfer and Ombudsman notification. Monitoring will be captured through auditing notice of transfer and Ombudsman notification of transfer. Up to 2 clinical records will be reviewed weekly for 4 weeks, then up to 4 clinical records 2 times monthly for 2 months. The audits will be conducted by the Social Worker or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Provide Bed-Hold Notices During Resident Transfers
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to residents or their representatives at the time of transfer to a hospital for four residents. This deficiency was identified through a review of clinical records and staff interviews. The residents involved had various medical conditions, including cognitive impairments, heart failure, diabetes, metabolic encephalopathy, schizoaffective disorder, bipolar disorder, post-traumatic stress disorder, obstructive uropathy, and renal insufficiency. Each resident was transferred to the hospital for different reasons, such as falls, mental health evaluations, abnormal blood work, and issues with medical devices like nephrostomy tubes. Despite these transfers, there was no documented evidence that the required bed-hold notices were provided to the residents or their responsible parties. The Nursing Home Administrator confirmed that the facility did not issue these notices during the transfers. This oversight was noted for residents who were cognitively impaired, dependent on staff for daily care, or had significant medical and mental health conditions, highlighting a failure to comply with the regulatory requirements for informing residents and their representatives about the bed-hold policy.
Plan Of Correction
Residents 13, 23, 33 and 37 were provided with a copy of the bed hold notice. A baseline audit was completed to identify other residents who were transferred out of the facility for the months of January and February. A binder has been designated to maintain records of bed hold notifications. Education was provided to the Admissions Director on the process for maintaining records of bed hold notification. Monitoring will be captured through auditing notice of transfer and Ombudsman notification of transfer. Two clinical records will be reviewed weekly for 4 weeks, then 4 clinical records 2 times monthly for 2 months. Audits will be conducted by the Admissions Director or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete accurate Minimum Data Set (MDS) assessments for six residents, as evidenced by discrepancies between the MDS coding and the residents' actual medical records. For Resident 9, the MDS did not reflect the administration of apixaban, an anticoagulant, despite physician orders and medication administration records indicating its use. Similarly, Resident 17's MDS failed to indicate hospice care, although the resident was under hospice services as per physician orders and care plans. Resident 21 and Resident 26's MDS assessments did not reflect the administration of opioids, despite records showing they received oxycodone and tramadol, respectively. Additionally, Resident 37's MDS inaccurately coded the presence of an ostomy instead of a nephrostomy tube, which was documented in the care plan and physician orders. Furthermore, Resident 42's MDS inaccurately indicated the administration of an opioid, although there was no documented evidence of such medication being given during the assessment period. Interviews with the Registered Nurse Assessment Coordinator and the Director of Nursing confirmed these inaccuracies in the MDS assessments. These discrepancies highlight a failure in accurately reflecting the residents' medical status and treatments in the MDS assessments, as required by the Long-Term Care Facility Resident Assessment Instrument User's Manual.
Plan Of Correction
Minimum Data Set (MDS) assessments were updated for residents #9, 17, 21, 26, 37, 42 and resubmitted. Residents who have a Minimal Data Set (MDS) completed and require coding related to care needs have the potential to be affected. Director of Nursing provided education to the Minimal Data Set (MDS) Coordinator on accuracy of assessments related to coding resident abilities and care needs via Resident Assessment Instrument (RAI) manual. Monitoring will be captured through auditing Minimal Data Set (MDS) assessments for care needs and coding. Review up to 2 clinical records weekly for 4 weeks, then 4 clinical records twice monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as required by regulations. Resident 7, who was cognitively intact and had multiple medical conditions including coronary artery disease, congestive heart failure, and diabetes, did not have care plans addressing her diabetic needs, cardiac needs, or the use of a cardiac pacemaker. Despite having physician's orders for various medications and treatments, there was no documented evidence of care plans to manage these conditions. Resident 16, who was cognitively impaired and had a diagnosis of epilepsy, was receiving anticonvulsant medication. However, the facility did not develop a care plan to address the resident's seizure disorder and the need for anticonvulsant medication. This lack of documentation was confirmed by the Registered Nurse Assessment Coordinator during an interview. Resident 33, who was mildly cognitively impaired and had multiple mental health diagnoses including PTSD, did not have a care plan addressing his PTSD, triggers, and coping strategies. Although the resident was receiving routine psychological services and had a trauma assessment completed, the facility failed to document a care plan for these needs. The Registered Nurse Assessment Coordinator confirmed the absence of such a care plan during an interview.
Plan Of Correction
Resident #7, 16, 33 care plans reviewed and revised to capture resident centered goals and interventions implemented. Residents who require a resident centered care plan have the potential to be affected. Director of Nursing provided education to interdisciplinary team as well as Minimum Data Set (MDS) coordinator on creating resident centered care plans. Monitoring will be captured through auditing specific care needs. Up to 4 clinical records will be reviewed weekly for 4 weeks, then up to 8 clinical records twice monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to update and revise the care plans for two residents to reflect their current care needs. For Resident 9, a quarterly Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and required substantial assistance for showering and bathing. The resident had a diagnosis of congestive heart failure and a history of falls, with a care plan indicating a preference for showers twice a week. However, physician orders required the resident to receive a complete bed bath daily with specific skin care instructions due to ichthyosis vulgaris. The Director of Nursing confirmed that the care plan needed updating to reflect these changes. For Resident 13, the quarterly MDS assessment showed cognitive impairment and a need for assistance with daily care. The care plan indicated the resident was an elopement risk and required oxygen therapy. However, elopement risk evaluations showed the resident was not at risk, and there was no evidence of oxygen therapy being administered. The Director of Nursing confirmed that the resident was no longer an elopement risk and did not receive oxygen therapy, indicating that the care plans should have been revised accordingly.
Plan Of Correction
Resident #9 order was reviewed and had been followed. The care plan was reviewed and revised to capture the resident specific care needs. Resident #13 the care plan was reviewed and revised. Residents receiving specific care have the potential to be affected. Director of Nursing provided education to the Interdisciplinary team as well as the Minimum Data Set (MDS) coordinator on updating care plans to include specific care needs. Monitoring will be captured through auditing specific care needs. Review 3 clinical records will be reviewed weekly for 4 weeks, then 6 clinical records twice monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Ensure Assistance Devices for Resident Safety
Penalty
Summary
The facility failed to ensure that assistance devices to prevent accidents or injury were in place for three residents. Resident 13, who was cognitively impaired and required assistance for daily care, had a physician's order for a chair alarm on his wheelchair. However, during an incident on July 20, 2024, the chair alarm was not present, and the resident fell while attempting to move from his wheelchair to the bathroom. The Director of Nursing confirmed the absence of the chair alarm at the time of the fall. Resident 17, who was cognitively intact but at high risk for falls due to deconditioning and gait balance problems, experienced two falls where the chair alarm was not functioning. On October 5, 2024, the resident slid off his wheelchair while trying to plug in a radio, and on November 11, 2024, he was found on the floor with an abrasion on his back. In both instances, the chair alarm did not sound. Resident 24, who required assistance and had Alzheimer's disease, was not transferred using a sit-to-stand lift as ordered, leading to a fall on June 11, 2024. The Director of Nursing confirmed that the sit-to-stand lift was not used during the transfer.
Plan Of Correction
Resident 13 and 17 chair alarm is in place and functioning. Resident 24 transfer status reviewed and remains unchanged. Baseline audit was completed on residents that have assistive devices in place. Director of Nursing provided education to nursing staff related to checking placement of assistive devices (e.g. fall mats, alarms, transfer device). Monitoring will be captured through auditing assistive devices. Audits for assistive devices in place will be conducted as follows: 4 clinical records will be reviewed weekly for 4 weeks, then 10 clinical records will be reviewed 2 times monthly for 2 months. The audits will be conducted by the Director of Nursing or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Provide Proper Catheter and Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters and nephrostomy tubes, as evidenced by observations and documentation reviews. Resident 1, who was cognitively impaired and required assistance with care needs, had an indwelling urinary catheter. Observations revealed that the catheter drainage bag and tubing were in direct contact with the floor, contrary to facility policy. Additionally, there was no documented evidence of monitoring and documenting the resident's urinary output on several specified dates and shifts, as required by the care plan and facility policy. Resident 37, who was cognitively intact and required assistance with care needs, had a nephrostomy tube due to diagnoses including diabetes and obstructive uropathy. The facility's policy required monitoring and documenting the nephrostomy tube output, but there was no documented evidence of this being done on multiple specified dates and shifts. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure to adhere to the care plans and facility policies. The deficiencies highlight the facility's failure to ensure that residents with urinary catheters and nephrostomy tubes received appropriate care and monitoring. The lack of adherence to established protocols for catheter and nephrostomy tube care, as well as the failure to document output, contributed to the deficiency findings. These actions and inactions were confirmed through staff interviews and a review of clinical records.
Plan Of Correction
Resident 1: Indwelling urinary drainage bag and tubing were removed from the floor and catheter bag changed immediately. Unable to retroactively document catheter output. Resident 37: Unable to retroactively document Nephrostomy tube output. An observation audit was completed to identify other residents with urinary catheters to validate catheter drainage bag and tubing were not in contact with the floor. Documentation audit completed related to obtaining catheter output. Nursing staff were educated by the Infection Control Nurse on keeping indwelling urinary catheter bag and tubing off the floor, Chain of Infection, and documentation. Monitoring will be captured through visual observation for placement of catheter bag and tubing. Complete 2 resident observations weekly for 4 weeks, then 4 resident observations 2 times monthly for 2 months. Monitoring will be captured through auditing charting of output on indwelling foley catheters. Audits will be conducted on 2 resident records weekly for 4 weeks, then 4 resident records 2 times monthly for 2 months. The audits will be conducted by the Infection Control Nurse or designee. Results of the audits will be provided to the Administrator by (DON) and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the Interdisciplinary team at QAPI Committee meeting.
Failure to Document Administration of Controlled Medications
Penalty
Summary
The facility failed to maintain accountability for controlled medications for one resident, identified as Resident 26. The facility's policy required that the individual administering medication must initial the resident's Medication Administration Record (MAR) after giving each medication. However, there was no documented evidence in Resident 26's clinical record, including the MAR, that the signed-out doses of Tramadol, a narcotic pain medication, were administered on specific dates and times in January and February 2025. Resident 26 was cognitively intact and required assistance with personal care needs, with diagnoses including stroke and diabetes. Physician's orders indicated that the resident was to receive 25 mg of Tramadol every eight hours as needed for pain. Despite the controlled drug record showing that Tramadol was signed out on several occasions, the Director of Nursing confirmed that there was no documentation in the resident's clinical record to indicate that these doses were administered.
Plan Of Correction
Resident 26 MAR was reviewed and reconciled. Residents with orders for controlled medication have the potential to be affected. Director of Nursing provided education to licensed nurses on documentation of controlled medication administration and controlled medication reconciliation. Monitoring will be captured through auditing Medication administration. Audits will be completed as follows: 2 staff med pass observations will be conducted weekly for 4 weeks, then 4 staff med pass observations will be conducted 2 times monthly for 2 months. Results of the med pass observations will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure that Resident 21 was free from significant medication errors. A review of the clinical records and staff interviews revealed that Resident 21, who was cognitively intact and required assistance for personal hygiene due to a right femur fracture, did not receive the prescribed medication, Coumadin, from October 2 through October 15, 2024. The medication orders specified that 2.5 mg of Coumadin should be administered every Monday, Wednesday, and Friday, and 2 mg every Tuesday, Thursday, Saturday, and Sunday. However, the Medication Administration Record (MAR) for October 2024 showed no documented evidence of Coumadin administration during this period. The Director of Nursing confirmed that the medication should have been administered as ordered.
Plan Of Correction
Resident 29 Coumadin orders were reviewed; resident is receiving Coumadin per physician orders. Residents who receive Coumadin have the potential to be affected. Baseline audit was completed on residents receiving Coumadin. The Director of Nursing completed education to licensed nurses on the process for obtaining Coumadin orders, including transcription of orders. Monitoring will be captured through auditing Coumadin orders. Audits will be conducted on up to 2 clinical records weekly for 4 weeks, then up to 2 clinical records twice monthly for 2 months. Audits will be conducted by the Director of Nursing. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at the QAPI Committee meeting.
Improper Labeling of Aplisol Vial
Penalty
Summary
The facility failed to properly label a multi-use vial of Aplisol in the medication room, as observed during a survey. The manufacturer's directions for Aplisol, a tuberculin purified protein derivative, specify that vials in use for more than 30 days should be discarded due to potential oxidation and degradation affecting potency. However, during an inspection of the medication room refrigerator, a multi-use vial of Aplisol was found open and undated, indicating non-compliance with labeling requirements. An interview with an LPN at the time of the observation confirmed that the vial was not dated and should be discarded. Further confirmation from the Director of Nursing reiterated that the vial should have been dated upon opening and discarded once expired. This deficiency was noted under the regulations for pharmacy and nursing services, highlighting a lapse in the facility's adherence to proper medication labeling and storage protocols.
Plan Of Correction
The undated multi-use vial of Apisol was immediately disposed of, and another multi-use vial was replaced. Residents who have orders for Tuberculosis (TB) skin test have the potential to be affected. Baseline audit was completed to ensure that Apisol vials were dated for 28 days after opening. Licensed staff were educated by Staff Development Nurse on the process for dating prescribed items when opened and their recommended expiration date. Monitoring will be captured through auditing prescribed items for dating items when opened with their recommended expiration date. Audits will be conducted 2 times weekly for 4 weeks on 4 medications, then once monthly for 2 months on 4 medications. The audits will be conducted by the Staff Development Nurse or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the Interdisciplinary team at QAPI Committee meeting.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory services as ordered by the physician for a resident. The resident, who was cognitively impaired and had a diagnosis of dementia, was noted to have a large bowel movement with red staining on the sheets. Following this observation, a physician ordered three stool samples to be collected for immuno-fecal occult blood testing, with instructions to record each collection in the resident's electronic health record and notify the physician if any results were positive. The first stool sample was collected and tested negative for occult blood. However, there was no documented evidence that the remaining two stool samples were collected and tested, as required by the physician's order. This was confirmed by an interview with the Director of Nursing, who acknowledged the lack of documentation for the remaining tests. This failure to follow through with the physician's orders resulted in a deficiency in the facility's laboratory services.
Plan Of Correction
Resident 29 - unable to retroactively address labs not obtained, MD notified. Residents who are ordered labs have the potential to be affected. Director of Nursing completed education to licensed nurses on the process for ordering labs included transcription to medication administration recorded/treatment administration and supplemental documentation (e.g. bowel movements). Monitoring will be captured through auditing lab orders. Audits will be conducted on 4 clinical records weekly for 4 weeks, then 10 clinical records twice monthly for 2 months. Audits will be conducted by the Director of Nursing. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
QAPI Committee Fails to Address Recurring Deficiencies
Penalty
Summary
The facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The current survey identified repeated deficiencies related to the development and implementation of comprehensive care plans, updating and revising care plans, providing quality of care, maintaining a safe environment free of accident hazards, and ensuring proper storage and labeling of medications. Additionally, the facility failed to maintain compliance with regulations regarding the accurate accounting of controlled medications and ensuring food was palatable and served at the proper temperature. The facility's plans of correction for deficiencies cited during the previous survey ending February 29, 2024, included completing audits and reporting the results to the QAPI committee for review. However, the current survey revealed that the QAPI committee failed to successfully implement these plans to ensure ongoing compliance with the regulations. Specifically, deficiencies were noted under F656 for comprehensive care plans, F657 for updating/revising care plans, F684 for quality of care, F689 for a safe environment, F755 for pharmacy services, F761 for medication storage and labeling, and F804 for food palatability and temperature. The repeated deficiencies indicate that the facility's QAPI committee was ineffective in maintaining compliance with the cited regulations. Despite having plans of correction in place, the facility did not achieve the necessary improvements, as evidenced by the recurrence of the same issues in the current survey. The lack of effective implementation and monitoring of corrective actions contributed to the ongoing non-compliance with the required standards.
Plan Of Correction
The center will continue to meet related to Quality Assurance Performance Improvement (QAPI) and if a plan is ineffective after reviewing, the plan will be revised and with further auditing and surveillance initiated. Residents affected by previous deficiencies have the potential to be affected. The administrator will provide education to the quality assurance performance improvement committee on the committee's role in improvement activities regarding federal regulations. Monitoring will be captured through auditing quality assurance performance improvement minutes monthly for 3 months. The audits will be conducted by the Administrator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Improper Infection Control Practices with Urinary Catheter
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the handling of a resident's indwelling urinary catheter. The resident, who was cognitively impaired and required assistance with care needs, had an indwelling urinary catheter due to a neurogenic bladder and had experienced a urinary tract infection in the past 30 days. During an observation, it was noted that the resident's catheter drainage bag and tubing were in direct contact with the floor, which is against the physician's orders that specified the catheter should be secured to the bed frame and not touch the floor. A nurse aide, upon being interviewed, confirmed the improper placement of the catheter bag and tubing. The aide then picked up the catheter bag and tubing with bare hands, without wearing gloves, and placed them back on the floor before donning gloves and placing the items into a dignity bag. The Director of Nursing confirmed that the nurse aide should have worn gloves when handling the catheter bag and tubing and should not have placed them on the floor while putting on gloves.
Plan Of Correction
Nurse Aide 1 received one on one education regarding catheter bag care, hand hygiene and use of personal protective equipment. Residents who have an indwelling Foley catheter have the potential to be affected. Nursing staff were educated by the Infection Control Nurse on hand hygiene, standard precautions, providing catheter care and the Chain of Infection. Monitoring will be captured through staff observations for hand hygiene. Observations will be conducted on 20 staff weekly for 2 weeks, then 10 staff weekly for 2 weeks, then 10 staff twice monthly for 2 months. The audits will be conducted by the Infection Control Nurse or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the Interdisciplinary team at QAPI Committee meeting.
Failure to Report Health Care-Associated Infections
Penalty
Summary
The facility failed to comply with the requirements of the Act 52 Infection Control Plan, specifically regarding the reporting of health care-associated infections. According to the review of ACT 52 of 2007, Chapter 4, section $1303.404, nursing homes are required to electronically report health care-associated infection data to the department and the authority using nationally recognized standards based on CDC definitions. Additionally, section §1303.405 mandates that the occurrence of a health care-associated infection in a health care facility be deemed a serious event, requiring written notification to be documented. However, the facility was unable to provide documented evidence of reporting these infections to the Pennsylvania Patient Safety Reporting System (PA-PSRS) or of sending written notifications to residents or their responsible parties from October 2024 through January 2025. The deficiency was further highlighted during an interview with the facility's Infection Preventionist (IP) on February 11, 2025. The IP, who had been in the role since October 23, 2024, admitted to not reporting infections to PA-PSRS from the time she assumed her position until the end of January 2025. She stated that she was unaware of the requirement to report health care-associated infections to PA-PSRS until recently, indicating a lack of awareness and training regarding the facility's obligations under the Act 52 Infection Control Plan.
Plan Of Correction
Data previously collected for October 2024 through January 2025 will be retroactively entered to be captured into the Pennsylvania Patient Safety Reporting System (PA-PSRS). Residents with facility health care-associated infections reportable to the Pennsylvania Patient Safety Reporting System (PA-PSRS) as per the Act 52 Infection Control Plan have the potential to be affected. Education provided to the Infection Control Nurse by the Director of Nursing on the process for reporting health care-associated infections to the Pennsylvania Patient Safety Reporting System (PA-PSRS). Monitoring will be captured through auditing The Act 52 Infection Control Plan Pennsylvania Patient Safety Reporting System (PA-PSRS). Audits on PA-PSRS will be performed monthly for 3 months. The audits will be conducted by the Infection Control Nurse or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Post Menus in Advance
Penalty
Summary
The facility failed to comply with the regulation requiring menus to be planned and posted or distributed to residents at least two weeks in advance. During an interview with a group of residents, it was revealed that they were unaware of what meals would be served until they were delivered, as they did not receive menus in advance. Observations during meal delivery confirmed that only the current day's menu was posted in the hallway, with no advance menus available for residents. The Director of Dietary confirmed that the facility was not posting or distributing menus in advance as required.
Plan Of Correction
Unable to retroactively correct the posting of the menus. Residents receiving meals from Dining Services have the potential to be affected. Menus will be posted in the dining room two weeks in advance. The menu will be posted on channel 2 two weeks in advance, which is available in resident rooms for viewing. Monitoring will be captured through auditing. The dining room will be checked to ensure the menus are posted. Channel 2 will be viewed to ensure menus are available. Audits will be done weekly for 4 weeks, then monthly for 2 months. The audits will be conducted by the Director of Dietary or designee. The results of the audits will be provided to the Administrator by Dietary Director and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) to resident staffing ratios as mandated by regulations effective July 1, 2024. The deficiency was identified through a review of nursing schedules, staffing information, and staff interviews. Specifically, the facility did not provide the required number of NAs per residents during the day, evening, and night shifts for several days between January 19 and February 11, 2025. This failure was observed on 12 out of 21 days for the day shift, 11 out of 21 days for the evening shift, and 14 out of 21 days for the night shift. The review of facility census data revealed specific instances where the number of NAs scheduled was below the required ratio. For example, on January 19, 2025, with a census of 56 residents, the facility required 5.60 NAs during the day shift but only provided 5.30 NAs. Similar discrepancies were noted on other days, such as January 20, 2025, where 4.57 NAs were provided against a requirement of 5.40 NAs. These staffing shortages were consistent across multiple days and shifts, indicating a systemic issue in meeting the staffing requirements. Interviews with the Nursing Home Administrator confirmed the facility's failure to meet the required staffing ratios. The report does not mention any additional higher-level staff available to compensate for these deficiencies, further highlighting the staffing shortfall. The lack of adequate staffing could potentially impact the quality of care provided to residents, although the report does not explicitly state any direct consequences or risks resulting from the deficiency.
Plan Of Correction
Unable to retroactively correct staffing ratios for Certified Nurse Aides (CNAs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1.) Generous Sign on Bonus 2.) Flexible Scheduling 3.) Benefits Package for full-time employees 4.) Wage analysis completed 5.) "Kudos" recognition program 6.) Referral bonus 7.) Agency Contracts 8.) Administrative Coverage Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
LPN Staffing Deficiency
Penalty
Summary
The facility failed to meet the required LPN-to-resident staffing ratios on multiple occasions. Specifically, during the day shift on two days, the facility did not provide the minimum of one LPN per 25 residents. On January 19 and February 8, 2025, the facility's census was 56, requiring 2.24 LPNs, but only 2.20 LPNs were available. This shortfall indicates a failure to comply with the staffing requirements set forth by the regulation effective July 1, 2023. Additionally, the facility did not meet the required staffing ratios on the night shift for nine days. For instance, on January 19, 2025, with a census of 54, the facility required 1.35 LPNs but only had 1.07 LPNs available. Similar deficiencies were noted on other nights, with the facility consistently providing fewer LPNs than required by the regulation. The Nursing Home Administrator confirmed these deficiencies, and there were no additional higher-level staff available to compensate for the shortfall.
Plan Of Correction
Unable to retroactively correct staffing ratios for Licensed Practical Nurses (LPNs) on dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1. Generous Sign on Bonus 2. Flexible Scheduling 3. Benefits Package for full-time employees 4. Competitive Wages 5. "Kudos" employee recognition program 6. Referral bonus 7. Agency Contracts 8. Administrative Coverage Monitoring will be captured through auditing staff schedules. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Deficiency in Meeting Required Direct Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules and staff interviews, which revealed that for seven out of 21 days reviewed, the facility did not provide the required hours of care. Specifically, on January 19, 20, 25, 26, 28, 30, and February 8, 2025, the facility provided between 2.88 and 3.15 hours of direct care per resident, falling short of the mandated 3.2 hours. The Nursing Home Administrator confirmed the shortfall in care hours during an interview on February 12, 2025.
Plan Of Correction
Unable to retroactively correct the hours provided of direct resident care for dates noted. Residents who receive nursing care services have the potential to be affected. Recruitment and retention activities: 1.) Generous Sign on Bonus 2.) Flexible Scheduling 3.) Benefits Package for full-time employees 4.) Competitive Wages 5.) "Kudos" employee recognition program 6.) Wage analysis completed 7.) The facility is near public transportation. 8.) Referral bonus 9.) Agency Contracts 10.) Administrative Coverage Monitoring will be captured through auditing PPD. Audit will be conducted daily for 12 weeks. The audits will be conducted by the Staffing Coordinator or designee. Results of the audits will be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at QAPI Committee meeting.
Non-Compliance with Menu and Nutritional Adequacy Requirements
Penalty
Summary
Heritage Ridge Senior Living at Johnstown was found to be non-compliant with the requirements for menus and nutritional adequacy as per 42 CFR Part 483, Subpart B. The facility failed to ensure that dietary staff served the planned portion sizes and provided condiments according to resident preferences. The facility's policy stated that menus should meet resident choices, including religious, cultural, and ethnic needs, while following national guidelines for nutritional adequacy. However, deviations from the posted menus were not properly recorded or followed. On January 23, 2025, several residents reported receiving breakfast meals that did not match the written menu or their tray tickets. For instance, one resident received a single pancake instead of two, and another resident did not receive the banana or grits as indicated on their tray ticket. Additionally, residents expressed dissatisfaction with the lack of condiments and snacks, with some stating they felt hungry and had to rely on personal snacks. The Dietary Manager confirmed that the breakfast served did not follow the written menu, citing issues such as green bananas and residents' dislike for grits as reasons for the deviations. During the lunch meal on the same day, residents also reported discrepancies between the written menu and what was served. One resident noted the absence of tartar sauce with their fish, while another received chicken tenders instead of fish and expressed a desire for ketchup. Interviews with staff revealed that condiments were not consistently available with meal carts or on resident trays, and the Dietary Manager acknowledged the oversight. The facility's failure to adhere to the planned menus and provide necessary condiments and snacks was evident in the observations and interviews conducted during the survey.
Plan Of Correction
Menus were reviewed for accuracy of portion sizes and specifications. All residents have the potential to be affected. Dietary staff educated on the importance of adhering to portion sizes and menu specifications. Condiments are now available in the nutrition room and can be provided upon request in addition to being provided on the meal tray. Dietary manager or designee to audit for compliance with portion sizes and menu specifications. Audits will be conducted 4 times weekly for 4 weeks, then 2 times weekly for 2 weeks, and periodically thereafter. Results of the audits will be provided to the Administrator by dietary manager and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage and labeling of food items. Observations in the kitchen revealed numerous food items in the dry storage area, walk-in cooler, and walk-in freezer that were not labeled or dated according to the facility's policy. This included opened bags of pasta, bread, and canned goods without discard dates, as well as refrigerated items like chicken noodle soup, gravy, beets, and crushed pineapple that were past their discard dates. Additionally, frozen meat was improperly thawing next to prepared foods, and pre-poured milk and juice cups lacked labels or discard dates. The facility also failed to maintain cleanliness in the kitchen, with observations noting debris on the floor, utensils in drawers with unknown substances, and stainless-steel surfaces with streaks and spots. The deep fryer and surrounding areas had significant grease buildup, and the stove and oven were marked with food or grease splatters. The Dietary Manager confirmed these deficiencies, acknowledging that the dietary staff were responsible for cleaning and sanitizing the kitchen but were not completing their daily cleaning tasks as required.
Plan Of Correction
Food that was not appropriately covered, labeled, or dated was discarded from all storage areas. Sugar replaced without scoop. Debris removed from floors. Debris removed from freezer floor and from behind appliances including the ice machine on 12/18/2024. All residents have the potential to be affected. Dietary staff educated on sanitation policy, monitoring tools, cleaning standards, cleaning schedules and responsibilities sanitizing equipment, food storage policy including labeling and dating. By 12/21/2024. Dietary manager or designee to audit for compliance with sanitation, cleaning standards, cleaning schedules and responsibilities sanitizing equipment, food storage policy including labeling and dating. Audits will be conducted 4 times weekly for 4 weeks, then 2 times weekly for 2 weeks, and periodically thereafter. Results of the audits will be provided to the Administrator by dietary manager and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Failure to Serve Food at Appetizing Temperatures
Penalty
Summary
The facility failed to serve food items at appetizing temperatures during a lunch meal service. According to the facility's policy, hot foods should be held at temperatures of 135 degrees Fahrenheit or above, and cold foods should be held at 41 degrees Fahrenheit or below prior to serving. However, during an observation of the lunch meal service, a test tray was used to measure the temperatures of the food items. The baked ham, scalloped potatoes, and cooked carrots were found to be at temperatures of 119.9 degrees F, 119.4 degrees F, and 119.6 degrees F, respectively, which were below the required temperature for hot foods. Additionally, the apple juice was at 55.6 degrees F, which was above the required temperature for cold foods. The Dietary Director confirmed that these food items were not at an appetizing temperature, indicating a failure to adhere to the facility's policy on food temperatures.
Plan Of Correction
Dietary manager was educated by Nursing Home Administrator or designee on food temperatures and palatability policy on 12/18/2024. All residents have the potential to be affected. Dietary staff and Nursing staff educated on food temperature policy by 12/21/2024. Nursing staff educated regarding passing trays timely when received on the nursing units to preserve temperatures. Dietary manager or designee will audit meals to ensure temperatures at point of service meet requirements. Audits will be conducted on 2 meals daily for 4 weeks, and periodically thereafter. Results of the audits will be provided to the Administrator by dietary manager and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the interdisciplinary team at QAPI Committee meeting.
Inconsistent Portion Sizes Served by Dietary Staff
Penalty
Summary
The facility failed to ensure that dietary staff served the planned portion sizes as outlined in the written menu. On October 24, 2024, during the lunch meal, the menu specified that residents were to receive four ounces of steak fries and four ounces of homemade coleslaw. However, observations in the main kitchen revealed that Dietary staff member 1 was not using a measured serving utensil to portion the steak fries and coleslaw. Instead, she used her gloved hand to grab a handful of steak fries and metal tongs for the coleslaw, leading to inconsistent portion sizes. The Temporary Dietary Manager confirmed that the posted menu required the use of measured serving utensils, which was not adhered to by the dietary staff.
Failure to Revise Care Plans for Specialized Dietary Needs
Penalty
Summary
The facility failed to review and revise care plans for two residents, leading to deficiencies in their care. Resident 2, who was cognitively impaired and required assistance with care needs, had a physician's order for a specialized diet including a carbohydrate-controlled, mechanical soft texture diet with large/double portions and no eggs, as well as Ensure with meals. However, there was no documented evidence that Resident 2's nutrition care plan was updated to reflect these dietary requirements and preferences. Similarly, Resident 4, who was also cognitively impaired and had a diagnosis of dysphagia, had a physician's order for a no added salt, regular texture diet. Observations revealed that Resident 4 did not have her dentures in, which were necessary for her to chew her food, and there was no documented evidence that her care plan addressed her need for dentures. The Director of Nursing confirmed that both residents' care plans should have been revised to reflect their specific needs.
Failure to Ensure Dentures in Place During Meals
Penalty
Summary
The facility failed to ensure that a resident's dentures were in place during meals, which is necessary for maintaining the ability to chew food. This deficiency was identified for one resident who was cognitively impaired and had a diagnosis of dysphagia, requiring assistance with some care needs. The resident was observed eating breakfast without her dentures, which were found soaking in a denture cup in her bathroom. Despite having a physician's order for a regular texture diet, the resident had to gum her food, indicating that her dentures were not in use as required. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and a Nurse Aide, confirmed that the resident should have had her dentures in during breakfast. The Director of Nursing also confirmed that the dentures should have been in place. This oversight in providing necessary assistance for activities of daily living, specifically ensuring the resident's dentures were in place, led to the identified deficiency.
Failure to Properly Label and Discard Outdated Food Items
Penalty
Summary
The facility failed to ensure proper labeling, dating, and securing of food items stored in the nutrition room, as well as the timely discarding of outdated foods. During an observation of the nutrition room's refrigerator on the nursing unit, a thickened dairy drink was found with an opened date of July 18, 2024, despite instructions on the container indicating it should be discarded after seven days of refrigeration. Additionally, a large container of applesauce was observed to be partially covered with plastic wrap and not dated. Interviews with the Director of Nursing and the Dietary Manager confirmed that the thickened dairy drink should have been discarded and the applesauce should have been sealed and dated. The Dietary Manager also confirmed that the nutrition room refrigerator was supposed to be checked daily by dietary staff to ensure food items were labeled, dated, and outdated or unlabeled foods were discarded.
Neglect in Resident Transfer Leads to Severe Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a significant injury. Resident 3, who was cognitively impaired and dependent on staff for transfers, was supposed to be transferred using a full mechanical lift as per physician's orders. However, on July 18, 2024, two nurse aides transferred the resident using a two-person physical assist instead. During this transfer, the resident's right leg was inadvertently bumped against an iron bedpost, causing a large laceration that required surgical intervention. The incident was documented in various witness statements and medical records. The resident was on anticoagulant medication, which likely contributed to the significant bleeding and subsequent hemorrhagic shock. The Therapy Director confirmed that the resident had been trialed with a two-person physical assist, but the physician's order for a mechanical lift was never changed. The Director of Nursing confirmed that the incorrect transfer method led to the injury, and the resident was sent to the hospital and did not return.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records for Resident 2, as requested by her legal representative, Resident Family Member 1, who held a durable healthcare power of attorney. The facility's policy, dated February 23, 2024, states that residents have the right to access their personal and medical records upon request. Despite this policy, the request for Resident 2's medical records, submitted on June 29, 2024, was not fulfilled in a timely manner. The request included all documents and possessions concerning Resident 2, and the appropriate Power of Attorney documents were on file at the facility. Interviews with facility staff revealed a delay in processing the request. Licensed Practical Nurse 5, responsible for medical records, indicated that the process involved corporate oversight and was still ongoing as of August 5, 2024. The Director of Nursing confirmed awareness of the request but was under the impression that it had been completed. She expected the request to be handled within approximately one week. However, the request remained unfulfilled, indicating a failure to adhere to the facility's policy and resident rights as outlined in 28 Pa. Code 201.29(a).
Failure to Investigate New Skin Tears
Penalty
Summary
The facility failed to initiate and conduct a thorough investigation to rule out neglect for a resident who was found with new skin tears. According to the facility's policy on accidents and incidents, all such occurrences involving residents should be investigated and reported to the Nursing Home Administrator. However, in this case, there was no documented evidence of an investigation into the newly identified skin tears on the resident's left forearm and hand, which were noted as new and in-house acquired. The resident, who had diagnoses including dementia and malnutrition, was assessed to have a potential for skin impairment due to fragile skin. Despite this, when two new skin tears were identified, no investigation was initiated to determine the cause or rule out neglect. The Director of Nursing confirmed that an investigation was not completed and acknowledged that the nurse failed to report or initiate an investigation into the new skin tears, despite the wound consultant's regular rounds.
Incomplete Documentation of Resident Assessment
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident, identified as Resident 3. According to the facility's policy on charting and documentation, all objective observations, medications administered, treatments or services performed, changes in condition, events, incidents, or accidents involving the resident, and progress toward changes in the care plan goal and objectives should be documented in the medical record. However, an investigation into an incident involving Resident 3 revealed that the resident had three bruises on her arm. Although a registered nurse assessed the resident and documented the assessment in the investigation documents, this assessment was not included in the resident's clinical record. Resident 3 was cognitively impaired, required staff assistance for care needs, and had diagnoses including dementia and heart failure. The deficiency was confirmed during an interview with the Director of Nursing, who acknowledged that the assessment conducted on the resident was not documented in the clinical record as required. This oversight was a violation of the facility's policy and the relevant state codes governing clinical records and nursing services.
Deficiency in Grievance Handling and Policy
Penalty
Summary
The facility was found to have deficiencies in its grievance policy and handling of resident grievances. The policy, dated February 22, 2024, failed to specify a reasonable expected time frame for completing the review of grievances. Additionally, the facility did not document evidence of prompt efforts to investigate and resolve grievances for eight of the eleven residents reviewed. The grievances included issues such as insufficient food, dissatisfaction with food quality and orders, and incorrect dietary provisions, such as inappropriate liquid consistencies for residents requiring specific dietary modifications. The facility's grievance log from April 2024 showed multiple unresolved grievances, including concerns about food quality and dietary needs. Despite these grievances being logged, there was no documented evidence of investigations or resolutions by May 14, 2024. An interview with the Nursing Home Administrator confirmed the absence of a specified time frame in the grievance policy and the lack of documented efforts to address the grievances. This failure to address grievances promptly and effectively was noted as a deficiency under 28 Pa. Code 201.29(i) Resident Rights.
Latest citations in Pennsylvania
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
