Beacon Ridge, A Choice Comm

F-F658, revealed that the facility's QAPI committee failed to successfully implement their plans to ensure ongoing compliance with regulations regarding the clarification of physician's orders.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending July 27, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.

The facility's plans of correction for deficiencies regarding ensuring that the resident environment was free of accident hazards, cited during the survey ending on July 27, 2023, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under

F-F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the environment was free of accident hazards.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 23 395702 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395702 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beacon Ridge 1515 Wayne Avenue Indiana, PA 15701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 The facility's plan of correction for a deficiency regarding a failure to provide proper incontinent and catheter care and/or toileting, cited during the survey ending July 27, 2023, revealed that the facility would complete Level of Harm - Minimal harm or audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited potential for actual harm under

F-F690, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding incontinent/catheter care and/or toileting. Residents Affected - Some

The facility's plan of correction for a deficiency regarding a failure to provide oxygen therapy as ordered by

the physician, cited during the survey ending July 27, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F695, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing oxygen therapy as ordered by the physician.

The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending July 27, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.

The facility's plan of correction for a deficiency regarding appropriate food storage cited during the survey ending July 27, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under

F-F805 on February 21, 2024.

28 Pa. Code 211.12(d)(3)(5) Nursing Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 23 395702 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395702 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beacon Ridge 1515 Wayne Avenue Indiana, PA 15701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 31760

Residents Affected - Many Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that a microwave used to reheat resident food was clean (Bayside Nourishment Center), and failing to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (Bayside Nourishment Center).

Findings include:

The facility's policy regarding food and supply storage, dated January 16, 2024, revealed that most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by, or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed; do not sell products in retail areas or place them on patient trays/resident plates past the date on the product. Foods past the use-by, sell-by, best-by, or enjoy by date should be discarded. Cover, label, and date unused portions and open packages. Products are good through the close of business on the date notes on the label. Date and rotate items: first in, first out (FIFO). Discard food past the use-by or expiration date.

The facility's policy regarding thawing frozen meat/poultry/seafood, dated January 16, 2024, indicated to count the day the raw meat was removed from the freezer as day one; it must be cooked by the end of +4 days. Label with the date it was removed from the freezer and date by which it must be used by. Add a yellow dot to the orange label to indicate a product that is thawing. If the package leaks as it thaws, the meat poultry must be used as soon as it thaws (usually +2 days).

Observations in the main kitchen of the walk-in freezer on June 3, 2024, at 9:21 a.m. revealed that there was

a clear plastic bag that contained Danishes that was out of the original packaging carton that was not dated with the date that they were opened and/or a use by date. There was a clear plastic bag that contained dinner rolls that was out of the original packaging carton that was not dated with the date that they were opened and/or a use by date.

Interview with the [NAME] Manager at the time of observation confirmed that the Danishes and dinner rolls should have been dated with the date that they were opened and a use by date.

Observations in the main kitchen of the walk-in cooler on June 3, 2024, at 9:24 a.m. revealed that on the bottom shelf there was a metal pan that contained a five-pound roll of ground hamburger that had a red juice

in the bottom of the metal pan. There was a date of May 28, 2024, on the package. However, there was no date when the ground meat was removed from the freezer to be thawed, and there was no date as to when

the ground meat was to be cooked by. Interview with the [NAME] Manager at the time of observation revealed that the date on the package was the date that they took the ground meat from the freezer to be thawed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 23 395702 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395702 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beacon Ridge 1515 Wayne Avenue Indiana, PA 15701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Interview with the Regional Dietary Manager on June 3, 2024, at 1:04 p.m. confirmed that staff should have placed an orange sticker on the pan that had the ground meat thawing to indicate the date when the product Level of Harm - Minimal harm or was removed from the freezer to be thawed and should also have a date when it was to be cooked by. potential for actual harm

Observations of the microwave used to reheat resident food in the Bayside Nourishment Center June 6, Residents Affected - Many 2024, at 8:57 a.m. revealed that there was food splattered on the inside of the door, all three inside walls, the top inside wall, and on the plate and bottom wall. Interview with the Staff Development/Registered Nurse at

the time of the observation confirmed that the microwave needed to be cleaned.

Observations of the ice machine in the Bayside Nourishment Center on June 6, 2024, at 9:03 a.m. revealed that the drainpipe coming from the ice machine extended down into and past the rim of a funnel-shaped pipe that extended up from the floor drain. There was no air gap between the end of the ice machine's drain pipe and the floor drain.

Interview with the Director of Maintenance on June 6, 2024, at 2:53 p.m. confirmed that the ice machine in

the Bayside Nourishment Center did not have an air gap between the drain pipe and the floor drain for back-flow prevention.

28 Pa. Code 211.6(f) Dietary Services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 23 395702 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395702 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beacon Ridge 1515 Wayne Avenue Indiana, PA 15701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 19102

Residents Affected - Some Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending July 27, 2023, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of

the current survey, ending June 6, 2024, identified repeated deficiencies regarding professional standards being met, quality of care, that the resident's environment was free of accident hazards, urinary catheter care, issues with oxygen therapy, preventing issues with the accountability of controlled medications (drugs with the potential to be abused), ensuring that food was properly stored, and following infection control practices.

The facility's plan of correction for a deficiency regarding a failure to clarify physician's orders, cited during

the survey ending July 27, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under

F-F812, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding food storage.

The facility's plans of correction for deficiencies regarding infection control practices, cited during the survey ending July 27, 2023, revealed that the facility would complete audits and report the results of the audits to

the QAPI committee for review. The results of the current survey, cited under

F-F880.

28 Pa. Code 201.14(a) Responsibility of Licensee.

28 Pa. Code 201.18(e)(1) Management.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 395702 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395702 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beacon Ridge 1515 Wayne Avenue Indiana, PA 15701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 41233 potential for actual harm Based on review of policies and clinical records, as well as observations and staff interviews, it was Residents Affected - Few determined that the facility failed to ensure that proper infection control practices were followed during wound care for two of 33 residents reviewed (Residents 45, 59).

Findings include:

The facility's policy regarding hand hygiene, dated January 16, 2024, indicated that hand hygiene is an important infection control measure to prevent illness in skilled nursing homes, and that hands should be sanitized or washed before and after the use of gloves.

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated April 21, 2024, revealed that the resident was moderately cognitively impaired, had diagnoses that included peripheral vascular disease (a circulatory condition that reduces blood flow to the limbs). Physician's orders, dated May 24, 2024, included an order to cleanse the left foot with normal saline solution, pat dry, apply betadine, a heel cushion and soft rolled gauze wrap.

Observations on June 4, 2024, at 2:05 p.m. revealed that Licensed Practical Nurse 8 removed Resident 59's right and left foot dressing; removed her gloves, and without performing hand washing or sanitizing her hands; donned new gloves; cleansed the left foot with normal saline solution, patted it dry, applied betadine,

a heel cushion and soft rolled gauze wrap; and then removed her gloves, and without performing hand washing or sanitizing her hands, donned new gloves. Licensed Practical Nurse 8, then cleansed the right foot with normal saline solution; patted it dry; applied betadine, a heel cushion and a soft rolled gauze wrap; removed her gloves; and washed her hands.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 45, dated May 20, 2024, revealed that the resident was severely cognitively impaired and had diagnoses that included peripheral vascular disease. Physician's orders, dated May 24, 2024, included an order to cleanse the third digit of the right foot with normal saline solution, pat dry, apply medihoney (a healing cream) and a calcium alginate dressing (specialty dressing used for high drainage) to

the wound.

Observations on June 4, 2024, at 2:41 p.m. revealed that Licensed Practical Nurse 8 cleansed Resident 45's wound on the third digit of his right foot with normal saline solution, patted it dry, applied medihoney and a calcium alginate dressing to the wound base, removed her gloves to begin care on a second wound, and donned new gloves without performing hand washing or sanitizing her hands.

Interview with Licensed Practical Nurse 8 on June 4, 2024, at 3:10 p.m. confirmed that while performing wound care on Resident 45 and 59, she did not perform hand hygiene after removing her gloves and donning new gloves.

Interview with the Director of Nursing on June 4, 2024, at 3:18 p.m. confirmed that Licensed Practical Nurse 8 should have washed her hands or sanitized them after removing her gloves and before donning new gloves, and she did not.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 395702 Department of Health & Human Services Printed: 09/24/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395702 B. Wing 06/06/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Beacon Ridge 1515 Wayne Avenue Indiana, PA 15701

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 28 Pa. Code 211.12(d)(1)(5) Nursing Services.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 395702