Resident 29 was bending down near her roommate's bed on July 20 when Resident 2 "deliberately pushed her bedside table" into her, striking her in the head, according to inspection records from Ridgeview Healthcare & Rehab Center. The victim told inspectors she was "very angry and upset about the situation" and that her head hurt immediately after the impact.
The facility's incident report noted no visible injuries at the time. But two days later, Resident 29 returned from the emergency department with a concussion diagnosis and complained of pain at a 5 out of 10 level. A physician ordered a follow-up CT scan.
Both residents are cognitively intact, according to their standardized mental status assessments. Resident 29 scored 15 out of 15 on her cognitive evaluation in June, indicating her mental faculties are fully functional. Resident 2 also scored 15 out of 15 on her assessment.
The facility's own abuse prevention policy, last reviewed on June 3, 2024, states that "abuse, neglect, and/or mistreatment of residents will not be tolerated in any manner." The policy requires that investigations "commence immediately upon receipt of the allegation" and that "staff, family members, visitors, and cognitively intact residents that may have observed events at the time of the allegation will be interviewed."
The policy specifically mandates that "signed statements will be obtained" from potential witnesses.
None of this happened.
Employee 12, the registered nurse unit manager who investigated the incident, told inspectors on July 25 that she contacted police and wrote an incident report but "did not obtain any witness statements from residents or staff as per facility policy." She said she informed both the nursing home administrator and director of nursing about the incident.
When inspectors interviewed the nursing home administrator on July 26, he could not provide evidence that the facility had conducted a thorough investigation into Resident 29's abuse report. The administrator was unable to show that the facility's abuse prohibition policy had been implemented properly, particularly the requirement to obtain statements from all potential witnesses.
The investigation failure occurred despite clear facility policy stating that "all necessary steps shall be taken to ensure the provision of a safe and secure environment." The policy emphasizes that investigations must be "initiated immediately by the supervisor on duty" and must be conducted "thoroughly."
Federal inspectors found that Ridgeview Healthcare failed to respond appropriately to the alleged violation, determining the facility had not followed its own procedures for investigating physical abuse allegations between residents.
Resident 29 was admitted to the facility with diagnoses of severe morbid obesity and major depressive disorder. Her roommate, Resident 2, lives with chronic respiratory failure and paralysis on one side of her body.
The incident report from July 20 documented that Resident 29 "had her head down at the time near the table" when the alleged attack occurred. The initial assessment found "no visible redness, no edema, and no hematoma," but Resident 29 reported that her head hurt.
By the time she spoke with inspectors on July 23, three days after the incident, Resident 29 still had a headache from the concussion. She described the incident as an "altercation" with her roommate and emphasized that Resident 2 had acted deliberately in pushing the table into her.
The facility's policy manual makes clear that abuse investigations should be comprehensive and immediate. It requires interviewing not just the alleged victim and perpetrator, but also "staff, family members, visitors, and cognitively intact residents" who might have witnessed the incident.
The policy also states that the facility must take "all necessary steps" to ensure resident safety and that signed witness statements are mandatory components of abuse investigations.
Despite these clear requirements, the registered nurse unit manager acknowledged she had obtained no witness statements whatsoever. The nursing home administrator, when pressed by inspectors, could provide no evidence that the facility had conducted the thorough investigation required by both federal regulations and their own policies.
The failure to investigate properly left unresolved questions about what other residents or staff members might have witnessed the incident between the two roommates. It also meant the facility had no documented statements from potential witnesses who could have provided crucial details about the circumstances surrounding the alleged attack.
Federal inspectors classified the violation as causing "minimal harm or potential for actual harm" and affecting "few" residents. But the failure to investigate properly violated multiple state regulations governing licensee responsibility, management requirements, and resident rights protections.
The inspection found that Ridgeview Healthcare's investigation consisted only of an incident report and a phone call to police, falling far short of the comprehensive inquiry mandated by the facility's own abuse prevention procedures.
Resident 29 continues to experience headaches from her concussion, a reminder of an incident that her nursing home failed to investigate according to its own written standards for protecting residents from abuse.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Ridgeview Healthcare & Rehab Center from 2024-07-26 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Ridgeview Healthcare & Rehab Center
- Browse all PA nursing home inspections