Heritage Ridge Senior Living At Johnstown

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nursing care and treatment were provided in accordance with professional standards of practice when it did not obtain urine culture and sensitivity results in a timely manner for a resident with an indwelling catheter, bowel incontinence, cognitive impairment, neuromuscular dysfunction of the bladder, and recent diagnoses of UTI and sepsis. An admission MDS showed the resident required assistance with care needs. On April 6, 2026, the resident told the social worker that her urine burned, and the RN was notified and placed the resident on the physician list. A physician order on April 8, 2026 directed staff to obtain a urine specimen for urinalysis to reflux, and the April 9, 2026 nursing note documented 2+ bacteria and that the physician was made aware. Later, on April 21, 2026, the resident was noted to have rapid respirations, bloody stools, and blood in the Foley catheter tubing, and stat bloodwork was ordered. That evening, the CRNP reviewed the bloodwork and ordered another urinalysis to reflux. The April 22, 2026 nursing note documented 4+ bacteria, nitrites, and that culture and sensitivity was pending, and Bactrim DS was ordered. However, the urine culture and sensitivity results for the April 9 urinalysis were not obtained by the facility until May 13, 2026, and the clinical record contained no documented evidence that those results were obtained and reviewed by the physician, delaying treatment of the resident's UTI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were provided showers as scheduled for two residents who were dependent on staff for bathing. The facility policy dated August 21, 2025 stated that residents are bathed or showered to promote cleanliness, provide comfort, and observe skin condition, and that refusals must be documented with the reason and intervention taken. Resident 3’s admission MDS dated April 17, 2026 showed cognitive impairment, dependence on staff for showers/bathing, bowel and bladder incontinence, moisture associated skin damage, diabetes, and obesity. Review of ADL documentation from April 2026 through May 12, 2026 showed she was scheduled for showers twice weekly on Tuesdays and Fridays, but showers were documented as not given on April 14, April 17, April 28, May 8, and May 12, with no documented refusal. On May 12, 2026, Resident 3 was observed fully dressed and sitting in the hallway in her wheelchair. Resident 5’s admission MDS dated May 6, 2026 showed she was cognitively intact, required maximum/substantial assistance for showers/bathing, was occasionally incontinent of bowel and bladder, and had a Stage 2 pressure ulcer, a diabetic foot ulcer, diabetes, and morbid obesity. She reported that she had not had a shower since admission, though she finally received one the day before the interview, and stated that on one scheduled shower day the nurse aide said she would return after supper but did not, and on Mother’s Day the nurse aide never came to get her for a shower. ADL documentation for May 2026 showed she was scheduled for showers twice weekly on Sundays and Thursdays on the evening shift, but showers were documented as not given on May 3, May 7, and May 10, with no documented refusal. The DON confirmed on May 12, 2026 that there was no documented evidence that Resident 3 or Resident 5 received and/or refused their showers on the dates noted.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $11,465

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the medication regimen was free from unnecessary psychotropic medication for two residents with cognitive impairment and dementia-related diagnoses. One resident had diagnoses including dementia, anxiety, and depression, and a physician’s order dated December 31, 2025, included Xanax 0.25 mg every four hours as needed for restlessness/anxiety. The MAR showed multiple administrations in January 2026, including doses given overnight and during the day, and there was no documented evidence that non-pharmacological interventions were attempted before those as-needed doses were administered. The DON confirmed that such documentation was absent and should have been present. A second resident had a diagnosis including Alzheimer’s dementia and an order dated October 6, 2025, for lorazepam 0.5 mg every eight hours as needed for anxiety for 90 days. The MAR showed repeated administrations of lorazepam across late October and November 2025, including evening and early morning doses, and there was no documented evidence that non-pharmacological interventions were attempted before giving the medication. The DON confirmed there was no documented evidence of non-pharmacological interventions before the doses and also stated that the Xanax order for the first resident did not include a duration and lacked documented prescriber rationale to extend the as-needed order beyond 14 days.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide medications according to physician orders for three residents. Resident 6, who was cognitively intact and had diabetes, had orders for 12 units of Humalog lispro insulin subcutaneously before meals with instructions to hold the dose if blood glucose was less than 90 mg/dL. The MAR showed that the insulin was administered when the resident’s blood glucose was 76 mg/dL, 83 mg/dL, and 80 mg/dL, despite the hold parameter in the order. The DON confirmed that the insulin was given on those occasions and should not have been. Resident 9, who was cognitively intact and had orthostatic hypotension, had an order for midodrine 2.5 mg three times daily with instructions to hold for systolic blood pressure greater than 120. The MAR showed midodrine was administered when the resident’s SBP was 144, 145, 144, 124, 136, and 140. Resident 28, who was cognitively impaired and had hypotension, had an order for midodrine 10 mg three times daily with instructions to hold if SBP was greater than 120. The MAR showed the medication was given when SBP was 124, 124, 140, and 134. The DON confirmed that midodrine was administered to Resident 9 and Resident 28 when it should have been held per the physician orders.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper care for a resident with bilateral nephrostomy tubes. Resident 4’s quarterly MDS showed moderate cognitive impairment, need for staff assistance with daily care, an indwelling urinary catheter, and a diagnosis of obstructive uropathy. After a nephrostomy tube change, the resident had orders to flush both the left and right nephrostomy tubes with 10 mL of sodium chloride 0.9% daily, and to flush the tubes as directed. A nurse’s note documented that when the LPN attempted to flush the resident’s bilateral nephrostomy tubes, the left tube met resistance and was very difficult to flush, and the RN milked the tubing while the flush remained difficult to push through. Review of the MAR and TAR for December and January 2025 found no documented evidence that the left and right nephrostomy tubes were flushed daily per the interventional radiology orders. The DON confirmed that the flush orders should have been added to the MAR or TAR, but they were not, and there was no documented evidence that the tubes were flushed daily or as needed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe, appropriate administration of IV fluids for a resident with a PICC line. Facility policy dated August 25, 2025, required that short and long peripheral and midline catheters used for intermittent infusions be flushed and aspirated for blood return prior to each infusion and at least every 24 hours, with locking after each use, and that flushing before and after medication or fluid administration be documented in the treatment administration record. Resident 9 was cognitively intact, required staff assistance with daily care, had MRSA infection, and was receiving IV medications. The resident had a physician order for 2 grams of Oxacillin Sodium IV every four hours for osteomyelitis. Review of the MARs for November and December 2025 showed the medication was administered every four hours from November 19, 2025, at 8:00 p.m. through December 9, 2025, at 6:00 p.m., but there was no documented evidence that staff flushed the PICC before and after the Oxacillin Sodium administrations. The DON confirmed there was no documented evidence that the PICC was flushed before and after medication administration per facility policy on the dates reviewed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain laboratory studies as ordered by the physician for one resident. The facility’s policy stated that the physician identifies and orders diagnostic and lab testing based on the resident’s needs, and staff are responsible for processing requisitions and arranging for the tests. Resident 13’s quarterly MDS showed the resident was cognitively impaired, dependent on staff for daily care needs, and always incontinent of bladder. A physician order for a urine culture and sensitivity was entered for Resident 13, but review of the clinical record found no documented evidence that the test was completed as of January 14, 2026. The DON confirmed that there was no documented evidence that the urine culture and sensitivity had been completed as ordered.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve palatable food at appropriate temperatures. The facility policy dated August 25, 2025 stated that hot foods would be held at 135 degrees or above and that best efforts would be made to present hot food hot and cold foods cold at point of service using thermal lids, bases, and heated or chilled plates. During interviews, Resident 3 stated on January 12, 2026, that the food is always cold, the bread is stale, and it does not taste good, and Resident 6 stated that the food is like cold dog food. During observation of the lunch tray line, spaghetti, mixed vegetables, garlic bread, side salad, coffee, and juice were placed on the cart between 12:01 p.m. and 12:12 p.m., the cart left the kitchen at 12:17 p.m., arrived on the unit at 12:17 p.m., and the last tray was served at 12:27 p.m. The test tray showed spaghetti at 122 degrees F, pureed mixed vegetables at 144 degrees F, garlic bread at 72 degrees F, side salad at 51 degrees F, coffee at 153 degrees F, and juice at 47 degrees F. The spaghetti was observed to be cold and not palatable, and the Director of Dietary confirmed that the spaghetti was not at a proper temperature.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete accurate MDS assessments for two residents by not coding hospice services in Section O0110K1B during the seven-day look-back period. For Resident 4, physician orders dated May 14, 2025, showed admission to hospice care, and a quarterly MDS dated November 12, 2025, did not check the hospice item even though the DON confirmed the resident was receiving hospice services and the assessment was coded inaccurately. For Resident 41, physician orders dated April 4, 2025, showed admission to hospice care, and a quarterly MDS dated October 20, 2024, also did not check the hospice item; the DON confirmed the resident was receiving hospice services and that the MDS was coded inaccurately.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to discard a multi-use vial of Tubersol and an expired multidose medication for Resident 10 in one medication room. The facility policy for medication administration stated that medications are to be administered safely and timely as prescribed, that expiration dates are to be checked before administration, and that the opened date is to be recorded when a multidose medication is opened. Manufacturer instructions for Tubersol stated that a multi-dose vial should be discarded 30 days after opening. Resident 10 had an order for Omeprazole Oral Solution 2 mg/ml, 20 ml daily for a total of 40 mg. During observation of the medication room refrigerator, surveyors found one open multi-use vial of Tubersol dated as opened and one multidose bottle of Omeprazole Oral Solution for Resident 10 with an expiration date. The DON confirmed that both the Tubersol vial and the Omeprazole Oral Solution should have been discarded when expired.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain complete and accurately documented clinical records for one resident. The facility policy on medication administration stated that after medications are given, staff must document the necessary medication administration and treatment information, including when PRN medications are administered, on the appropriate forms. For a resident with cognitive impairment, assistance needs for daily care, opioid use, and diagnoses including heart failure, physician orders included Tramadol 25 mg every 12 hours for pain. The MAR showed Tramadol was administered repeatedly on multiple October and November 2025 dates and times, but the resident's controlled medication record contained no documented evidence that the Tramadol was signed out for those administrations. The Interim DON stated she was unable to locate the controlled medication record, so there was no documented evidence that the medication was signed out for the listed dates and times.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility’s QAPI committee failed to maintain compliance with nursing home regulations and did not ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. The report states that, based on review of the facility’s plans of correction from the survey ending February 12, 2025, the facility had developed plans that included quality assurance systems and audits to maintain compliance with cited regulations, but the current survey ending January 14, 2026 found repeated deficiencies in accuracy of assessment, quality of care, catheter care, medication labeling and storage, and food being palatable and served at the proper temperature. The current survey identified that the facility’s QAPI committee was ineffective in maintaining compliance with the regulations related to accuracy of assessment, quality of care, catheter care, labeling and storage of medications, and food service temperature and palatability. The report specifically notes repeated citations under F641, F684, F690, F761, and F804, and states that the facility’s prior plans of correction for these areas relied on audits and reporting results to the QAPI committee for review.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.