Lutheran Home At Johnstown, The

F-F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding developing and implementing comprehensive care plans.

The facility's plan of correction for a deficiency regarding a failure to update/revise residents' care plans, cited during the survey ending February 29, 2024, 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-F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating/revising residents' care plans.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 29, 2024, 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 395439 Department of Health & Human Services Printed: 09/08/2025 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 395439 B. Wing 02/12/2025

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

Heritage Ridge Senior Living at Johnstown 807 Goucher Street Johnstown, PA 15905

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 deficiencies regarding a safe environment that is free of accident hazards, cited during the survey ending February 29, 2024, revealed that the facility developed plans of correction that Level of Harm - Minimal harm or included completing audits and reporting the results of the audits to the QAPI committee for review. The potential for actual harm results of the current survey, cited under

F-F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards. Residents Affected - Few

The facility's plan of correction for a deficiency regarding pharmacy services accurate accounting of controlled medications, cited during the survey ending February 29, 2024, 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-F755, revealed that the QAPI committee was ineffective in maintaining compliance with regulation regarding pharmacy services accurate accounting of controlled medications.

The facility's plan of correction for a deficiency regarding proper storage and/or labeling of medications, cited

during the survey ending February 29, 2024, 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-F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storing and labeling resident's medications properly.

The facility's plans of correction for deficiencies regarding ensuring that food was palatable and at proper serving temperatures, cited during the survey ending on February 29, 2024, 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-F804.

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 24 of 25 395439 Department of Health & Human Services Printed: 09/08/2025 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 395439 B. Wing 02/12/2025

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

Heritage Ridge Senior Living at Johnstown 807 Goucher Street Johnstown, PA 15905

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 48941 potential for actual harm Based on observations and staff interviews, it was determined that the facility failed to use proper infection Residents Affected - Few control practices to reduce the spread of infections and prevent cross-contamination for one of 29 residents reviewed (Resident 1).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 8, 2024, revealed that the resident was cognitively impaired, required assistance with care needs, had an indwelling urinary catheter (a flexible catheter used to drain urine from the bladder into a drainage collection bag), had diagnoses that included neurogenic bladder (bladder lacks control due to nerve or muscle problems), and had a urinary tract infection in the last 30 days.

A care plan for the resident, dated June 25, 2024, revealed that the resident had an indwelling urinary catheter.

Physician's orders for Resident 1, dated December 30, 2024, included an order for an indwelling foley catheter to straight drainage, ensure catheter tubing and bag are secured to bed frame and not touching the floor, and ensure privacy bag is in place.

Observations of Resident 1 on February 9, 2025, at 2:31 p.m. revealed that the resident was lying in bed with his indwelling urinary catheter drainage bag and the catheter tubing in direct contact with the floor. Interview with Nurse Aide 1, at the time of the observation, confirmed that the catheter bag and catheter tubing should not have been touching the floor. She proceeded to pick the catheter bag and catheter tubing up off the floor with her bare, ungloved hands, then placed the catheter bag and tubing back on the floor, obtained a pair of gloves provided to her by another nurse aide, put the gloves on, and proceeded to place the catheter bag and tubing into the dignity bag.

Interview with the Director of Nursing on February 9, 2025, at 3:20 p.m. confirmed that the nurse aide should have had gloves on when handling Resident 1's catheter bag and tubing, and she should not have placed

the catheter bag and tubing on the floor while donning her gloves.

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

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

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 395439