SHENANDOAH, PA - Federal inspectors documented multiple infection control breakdowns at Ridgeview Healthcare & Rehab Center during a July 2024 complaint investigation, including failures to properly isolate COVID-19 positive residents and inadequate testing protocols during an active outbreak.
COVID-19 Outbreak Management Failures
During a July 26, 2024 inspection, surveyors identified significant lapses in the facility's response to an active COVID-19 outbreak on the third floor. At least four COVID-19 positive residents remained housed with COVID-negative roommates for multiple days, directly contradicting both Centers for Disease Control and Prevention guidelines and the facility's own infection control policies.
Inspectors documented that Resident 67, who tested positive on July 16, continued sharing room 301 with COVID-negative Resident 61. Similarly, Resident 79, also positive from July 16, remained with negative roommate Resident 73 in room 304. This pattern continued with residents who tested positive on July 20 and July 21, with the facility making no apparent effort to separate infected individuals from their uninfected roommates.
The facility's own policy, reviewed in May 2023, specifically required isolation of COVID-positive residents in private rooms or cohorting them exclusively with other confirmed positive cases. The policy stated that "only patients with the same respiratory pathogen should be housed in the same room."
Consequences of Improper Isolation
Housing COVID-positive and COVID-negative residents together creates direct exposure pathways for viral transmission. The virus spreads primarily through respiratory droplets and aerosols in enclosed spaces, making shared room arrangements particularly high-risk. Extended close contact—such as sleeping in the same room for multiple days—represents one of the highest-risk exposure scenarios.
Proper isolation protocols exist specifically to create physical barriers between infected and susceptible individuals. When facilities fail to implement these measures, they effectively eliminate one of the most fundamental infection control strategies available. The 5-7 day period documented in this case provided multiple opportunities for transmission to occur.
Staff working in healthcare settings face heightened exposure risks, particularly when infection control measures break down. During the outbreak period, four staff members tested positive between July 23-25, though the facility could not provide documentation showing all staff on the affected floor had been tested according to CDC guidelines.
Missing Documentation and Testing Gaps
Inspectors requested testing logs to verify compliance with outbreak protocols but found significant gaps in documentation. The facility could not demonstrate that all staff working on the third floor had been tested as required by CDC guidance. Resident testing logs for the affected unit were unavailable at the time of the survey's conclusion on July 26.
The facility also failed to maintain contact tracing documentation, which is necessary to identify potential exposures and implement timely interventions. Without systematic contact tracing, facilities cannot determine which residents and staff may have been exposed or require additional monitoring and testing.
CDC guidance and the facility's own policy required testing exposed individuals immediately upon identification of exposure, then again 48 hours later, and a third time 48 hours after the second test. This serial testing approach helps identify infections during the incubation period before symptoms appear.
Observable Breaches in Real-Time
Surveyors witnessed multiple infection control breaches during their observation periods. On July 26 at 1:35 PM, a COVID-positive resident left his room with a surgical mask hanging off one ear, walked down the hallway to the nurses' station without properly wearing the mask, and only corrected the issue after staff intervention. Multiple residents and staff were present in the hallway during this incident, though other residents were not wearing masks.
At 10:45 AM that same day, inspectors observed 13 residents seated in the third floor dining room. Not all residents wore surgical masks, and residents interacted freely with each other. The facility had conducted communal breakfast service in that same dining room that morning, despite the active outbreak.
The facility's Infection Preventionist confirmed during an interview that staff had received instructions to close the third floor dining and activity room to limit viral spread, but staff had not followed these directives.
Administrative Decision-Making During Crisis
The Nursing Home Administrator acknowledged during her July 26 interview that she made the decision not to move or cohort COVID-positive residents, despite this contradicting facility policy and CDC guidance. She explained that both the facility's Infection Preventionist and Director of Nursing were on vacation when the outbreak began on July 16.
The administrator stated she was "not a medical professional" and lacked Infection Preventionist credentials, but based her decision on practices she had observed at a different facility where she previously worked. That facility's approach—not moving COVID-positive residents—became the template she applied at Ridgeview, regardless of current CDC recommendations or the facility's established protocols.
Bowel Incontinence Care Deficiencies
Beyond infection control issues, inspectors identified failures in continence care management. Resident 1 experienced a documented decline from being "always continent of bowels" in December 2023 to "frequently incontinent" by May 2024. Despite this significant functional decline, the facility implemented no individualized interventions to address the bowel incontinence or attempt to restore normal function.
A April 30, 2024 screening document noted that the resident's diet was "a contributing factor of fecal incontinence" and that she required occasional laxatives or enemas. However, the resident's care plan contained only bladder incontinence measures—checking and changing every two hours—with no interventions addressing the bowel issues.
Bowel function decline can result from multiple factors including medication effects, dietary composition, mobility limitations, and inadequate toileting assistance. Systematic assessment and individualized interventions can often improve or restore continence, but these require active clinical management rather than passive acceptance of functional decline.
Additional Issues Identified
Snack service inconsistencies: Multiple cognitively intact residents reported that the facility frequently ran out of evening snacks or failed to offer them consistently. With more than 14 hours between dinner and breakfast, nutritious snacks help maintain adequate caloric intake and prevent overnight hunger. Nine residents across individual and group interviews described these problems, with some reporting they purchased their own snacks due to unreliable facility service.
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.
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