Resident 67 tested positive for COVID on July 16 and remained in the same room with Resident 61, who tested negative. Four days later, Resident 79 tested positive but continued sharing space with negative roommate Resident 73. By July 21, two more positive residents were still rooming with negative partners.
The administrator admitted she made the decision not to separate COVID-positive residents based on her experience at a previous facility, despite having no medical credentials or infection control training. Both the facility's infection preventionist and director of nursing were on vacation when the first staff member tested positive on July 16.
"She stated that she is not medical professional and does not have the Infection Preventionist credentials and she made made the decision not to cohort COVID-19 positive residents together," inspectors wrote after interviewing the administrator on July 26.
The facility's own policy, reviewed in May 2023, required isolation of COVID-positive residents in private rooms or with other confirmed positive residents. The policy specifically stated that "only patients with the same respiratory pathogen should be housed in the same room."
Federal inspectors observed the consequences of these failures during their July visit. Resident 67, who had tested positive, walked down the hallway to the nurses station with a surgical mask hanging off his ear rather than properly covering his face. Multiple residents and staff were in the hallway at the time.
Another resident wandered freely between rooms, including entering a COVID-positive resident's room twice to collect belongings before staff finally redirected him. Thirteen residents gathered in the third-floor dining room for breakfast, with not all wearing masks despite the outbreak.
The infection preventionist confirmed that staff had been instructed to close the dining room to limit virus spread, but those guidelines were ignored.
Testing records revealed the scope of the outbreak. Four staff members tested positive between July 23 and July 25. The facility could not provide complete testing logs for all staff working on the affected third floor, making it impossible to determine if CDC guidelines were followed.
No contact tracing documentation existed at the time of the inspection. The facility's infection control logs failed to identify any signs or symptoms displayed by residents or staff, despite the ongoing outbreak.
The administrator's decision contradicted both CDC guidance and the facility's own policies. Pennsylvania Department of Health guidelines from May 2023 required comprehensive infection prevention measures, including immediate testing of anyone with mild COVID symptoms and isolation protocols for positive cases.
The facility policy mandated that asymptomatic residents with close contact to infected individuals receive three viral tests over five days. It also required restricting positive residents to their rooms with doors closed, or implementing engineering strategies to minimize airflow if doors remained open for safety reasons.
None of these protocols were properly implemented during the outbreak. Residents 61, 73, 63, and 77 remained at increased risk for contracting COVID due to their continued exposure to positive roommates.
The administrator explained her reasoning during the July 26 interview, stating that cohorting COVID-positive residents was "no longer required" based on her previous workplace experience. She acknowledged that when the initial outbreak began, key infection control personnel were unavailable, leaving her to make medical decisions without appropriate expertise.
A second nurse at the facility held infection control preventionist certification, but there was no indication this person was consulted during the critical early days of the outbreak.
The facility's failures extended beyond room assignments. Staff testing appeared incomplete, with inspectors unable to verify that all third-floor workers received appropriate screening. The lack of contact tracing meant potential exposures went unidentified and unmonitored.
Inspectors also discovered training deficiencies unrelated to the COVID outbreak. Employee 13, a contracted registered dietitian who began work on May 20, never received required abuse prevention training. She confirmed during a July 25 interview that she was never trained on the facility's abuse prohibition policies before starting her duties.
The administrator acknowledged the facility had no written records showing the dietitian received mandatory training on abuse prevention and prohibition policies.
The COVID outbreak highlighted broader systemic issues at Ridgeview Healthcare. The facility also failed to ensure proper medical director participation in quality assurance meetings. Between March and July 2024, no physician attended the required quarterly Quality Assurance Process Improvement Committee meetings, missing five consecutive monthly sessions.
The medical director's absence from these meetings violated federal requirements for physician oversight of quality improvement initiatives. The administrator confirmed this failure during the July 26 inspection.
Federal regulations require nursing homes to maintain comprehensive infection control programs, especially during respiratory illness outbreaks. The facility's policy acknowledged CDC guidance but implementation fell short when leadership was tested.
The week-long delay in proper isolation protocols exposed vulnerable residents to preventable risk. Residents 61, 73, 63, and 77 continued living with COVID-positive roommates while the administrator relied on experience from a different facility rather than following established medical guidelines.
The outbreak occurred more than four years after COVID-19 protocols were established nationwide. By July 2024, nursing homes had extensive experience managing respiratory virus outbreaks, making the facility's failures particularly concerning.
Inspectors found no evidence that the facility followed its own COVID policy or CDC guidance for testing, contact tracing, or resident cohorting during the critical early days of the outbreak. The absence of key personnel exposed gaps in the facility's emergency response capabilities.
The administrator's admission that she lacked medical training yet made infection control decisions underscored the breakdown in proper protocols. Her reliance on experience from a different workplace, rather than following current CDC guidelines and facility policies, put residents at unnecessary risk during a confirmed COVID outbreak.
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
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