Ridgeview Healthcare & Rehab Center

F-F610

28 Pa. Code 201.14 (c) Responsibility of licensee

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

28 Pa. Code 201.29(a) Resident Rights

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 16 395929 Department of Health & Human Services Printed: 09/17/2025 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 395929 B. Wing 07/26/2024

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

Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39235

Residents Affected - Few Based on review of clinical records, and staff interviews, it was determined that the facility failed to implement individualized interventions to address a resident's decline in bowel continence in an effort to restore normal bowel function to the extent possible for one resident out of three sampled (Resident 1).

Findings include:

Review of Resident 1's clinical record admission to the facility on [DATE REDACTED], with diagnoses that included Parkinson's disease (a long-term neurodegenerative disease of mainly the chronic obstructive pulmonary disease (COPD), multiple sclerosis, chronic respiratory failure, and hypertension.

The resident's Quarterly Minimum Data Set Assessments (MDS - a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated December 11, 2023, and Annual MDS dated [DATE REDACTED], Section H Bladder and Bowel, both indicated that the was always continent of bowels.

A physician order was noted March 27, 2023, to check and change every (Q) 2 hours bladder incontinence care.

Resident 1's Quarterly MDSs dated May 1, 2024, Section H Bladder and Bowel, noted that the resident was now frequently incontinent of bowels (a decline in bowel function).

The resident's plan of care for bladder incontinence, date-initiated April 3, 2023, revealed planned measures included to establish voiding patterns, check as required for incontinence, date-initiated April 3, 2023, but plan of care was identified for bowel the resident's decline incontinence.

A review of facility provided document entitled Nationwide Bowel and Bladder Continence Screen dated April 30, 2024, indicated the resident is not continent of stools, needs occasional laxative of enema, and that her diet is a contributing factor of fecal incontinence.

A review of a health status note dated April 30, 2024, at 7:02 AM indicated that the resident's bowel/bladder was reviewed and the resident is always incontinent of bowel and bladder. Incontinent program in place.

The Director of Nursing (DON) stated during interview on July 25, 2024, that the only incontinent program the resident was receiving was the check and change every (Q) 2 hours bladder incontinence care and no measures had been attempted to address Resident 1's decline in bowel function.

28 Pa. Code 211.12 (d)(5) Nursing services

28 Pa. Code 211.10 (a)(d) Resident care policies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 16 395929 Department of Health & Human Services Printed: 09/17/2025 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 395929 B. Wing 07/26/2024

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

Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976

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 0809 Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to Level of Harm - Minimal harm or eat at non-traditional times or outside of scheduled meal times. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48276 Residents Affected - Some Based on a review of scheduled facility mealtimes and select facility policy, and resident and staff interviews,

it was determined that the facility failed to consistently provide snacks as desired by residents including four out of the 25 residents sampled (Residents 2, 20, 29, and 84) and experiences reported by residents during

a group interview (Residents 1, 26, 27, 83, and 89).

Findings include:

A review of the facility's policy titled Nourishment: Serving Between Meals and Bedtime Snacks, last reviewed on June 3, 2024, indicated that it is the facility policy to serve residents with extra nourishment to provide energy.

A review of the facility's scheduled mealtimes revealed that the time between dinner and breakfast the next day exceeds 14 hours.

A clinical record review revealed that Resident 29 was admitted to the facility on [DATE REDACTED]. A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated June 10, 2024 revealed that Resident 29 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

A clinical record review revealed Resident 2 was admitted to the facility on [DATE REDACTED]. A review of an annual MDS assessment dated [DATE REDACTED], revealed that Resident 2 is cognitively intact with a BIMS score of 15.

A clinical record review revealed Resident 20 was admitted to the facility on [DATE REDACTED]. A review of a quarterly MDS assessment dated [DATE REDACTED], revealed that Resident 20 is cognitively intact with a BIMS score of 15.

A clinical record review revealed Resident 84 was admitted to the facility on [DATE REDACTED]. A review of an admission MDS assessment dated [DATE REDACTED], revealed that Resident 84 is cognitively intact with a BIMS score of 15.

A clinical record review revealed Resident 1 was admitted to the facility on [DATE REDACTED]. A review of a quarterly MDS assessment dated [DATE REDACTED], revealed that Resident 1 is cognitively intact with a BIMS score of 12.

A clinical record review revealed Resident 26 was admitted to the facility on [DATE REDACTED]. A review of a quarterly MDS assessment dated [DATE REDACTED], revealed that Resident 26 is cognitively intact with a BIMS score of 15.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 16 395929 Department of Health & Human Services Printed: 09/17/2025 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 395929 B. Wing 07/26/2024

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

Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976

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 0809 A clinical record review revealed Resident 27 was admitted to the facility on [DATE REDACTED]. A review of a quarterly MDS assessment dated [DATE REDACTED], revealed that Resident 27 is cognitively intact with a BIMS score of 15. Level of Harm - Minimal harm or potential for actual harm A clinical record review revealed Resident 89 was admitted to the facility on [DATE REDACTED]. A review of a quarterly MDS assessment dated [DATE REDACTED], revealed that Resident 89 is cognitively intact with a BIMS score of 15. Residents Affected - Some

A clinical record review revealed Resident 83 was admitted to the facility on [DATE REDACTED]. A review of a quarterly MDS assessment dated [DATE REDACTED], revealed that Resident 83 is cognitively intact with a BIMS score of 15.

During an interview on July 23, 2024, at 11:15 AM, Resident 2 stated that a lot of times she is not offered a snack between dinner and breakfast the next day. She stated that about twice a week the facility runs out of snacks. Resident 2 stated that the nursing staff will tell her that snacks are not available.

During an interview on July 23, 2024, at 11:50 AM, Resident 84 stated that often the facility runs out of snacks. He stated that he brings the issue up with the nursing staff, but nothing seems to get done to resolve his concern.

During an interview on July 23, 2024, at 12:15 PM, Resident 29 stated that she rarely is offered an evening snack between dinner and breakfast the next day.

During a resident group interview on July 24, 2024, at 10:00 AM, five of the five residents in attendance stated that they are not consistently offered a nourishing evening snack and sometimes run out of snacks (Residents 1, 26, 27, 83, and 89). Resident 89 stated that she is not always offered a snack between dinner and breakfast the next day. She stated that recently she asked a nurse aide for an evening snack, and the nurse aide went to get her one but never returned. Resident 26 stated that she started buying her own snacks so that if the facility runs out or doesn't offer her something to eat, then she still has something nourishing between meals. Resident 83 stated that she was hungry and asked for a snack two days ago, but

she stated that the facility ran out of snacks and did not provide her anything to eat between dinner and breakfast the next day.

During an interview on July 25, 2024, at 10:55 AM, Resident 20 stated the facility staff are inconsistent about offering an evening snack to residents. She explained that in the evening she is often out of her room and spends time in the activity area in her nursing hall. Resident 20 stated that when she is in the activity room, nursing staff never ask her if she wants a snack.

During an interview on July 26, 2024, at approximately 10:30 AM, the Nursing Home Administrator (NHA) was unable to explain why residents are reporting that the facility is not offering nutritious snacks as desired.

The NHA confirmed that it is the facility's policy to offer and serve residents a nourishing snack in accordance with their needs, preferences, and requests at bedtime on a daily basis.

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 13 of 16 395929 Department of Health & Human Services Printed: 09/17/2025 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 395929 B. Wing 07/26/2024

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

Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 26142 potential for actual harm Based on a review of clinical records, CDC infection control guidance, facility's infection control policy and Residents Affected - Many COVID-19 testing logs, and staff interview it was determined that the facility failed to promptly implement infection control practices for cohorting like respiratory infections and testing for COVID-19 to prevent the spread of COVID-19 infections in the facility placing at least four residents (Residents 61, 73, 63 and 77) at increased risk for contracting COVID and failed to implement effective interventions to prevent the spread of COVID-19 virus.

Findings include:

A review of the Pennsylvania Department of Health 2023-PAHAN-694-5-11-2023 update: Interim Infection Prevention and Control Recommendations for COVID-19 in healthcare settings dated May 11, 2023, revealed, this HAN provides comprehensive information regarding infection prevention and control for COVID-19 in healthcare settings based on changes made by the Centers for Disease Control and Prevention (CDC) on May 8, 2023.

A review of a facility policy for COVID-19 infection control practices reviewed by the facility May 11, 2023 revealed It is the policy of the facility to follow infection control practices recommended by the Centers for Disease Control and Prevention (CDC) to prevent transmission of SARS-CoV-2 infection (COVID-19).

Procedure to include:

-Perform SARS-CoV-2 viral testing: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. Asymptomatic patients with close contact with someone with SARS 0 CoV-2 infection, regardless of vaccination status, should have a series of three viral tests for SARS CoV-2 infection. If the date of discrete exposure is known, testing is recommended immediately and if negative, again 48 hours after the second negative test. This will typically be on day 1(where exposure is day 0), day 3, and day 5.

Isolation of residents:

Isolation in long term care facilities residents include the use of standard and transmission-based precautions for COVID-19, and private room with a private bathroom or with another resident with laboratory confirmed COVID-19, preferably in a COVID-19 care unit and restrict the resident to their room with the door closed. In some circumstances, keeping the door closed may pose resident safety risks and the door might need to be open. If the doors remain open, work with facility engineers to implement strategies to minimize air flow into the hallway. Only patients with the same respiratory pathogen should be housed in the same room.

The following COVID-19 positive residents remained in their rooms with their roommates who had tested negative for COVID:

Residents testing positive on July 16, 2024, and at the time of the survey beginning on July 23, 2024, continued to reside with roommates who were COVID negative:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 16 395929 Department of Health & Human Services Printed: 09/17/2025 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 395929 B. Wing 07/26/2024

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

Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976

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 Resident 67, COVID positive, cohorted with Resident 61, COVID negative, in room [ROOM NUMBER] bed 1 and 2-D unit Level of Harm - Minimal harm or potential for actual harm Resident 79, COVID positive, cohorted with Resident 73 COVID negative, in room [ROOM NUMBER] bed 1 and 2-D unit Residents Affected - Many Residents testing positive on July 20, 2024, and at the time of the survey beginning on July 23, 2024, continued to reside with roommates who were COVID negative:

Resident 59, COVID positive, cohorted with Resident 63, COVID negative, in room [ROOM NUMBER] bed 1 and 2-D unit

Residents testing positive on July 21, 2024, and at the time of the survey beginning on July 23, 2024, continued to reside with roommates who were COVID negative:

Resident 60, COVID positive, cohorted with Resident 77 COVID negative, in room [ROOM NUMBER] bed 1 and 2-D unit

Testing logs were requested at the time of the survey ending July 26, 2024, to which the facility provided multiple sheets of paper entitled Report of COVID-19 POC testing dated between July 16, 2024, and July 22, 2024. It could not be determined that all staff working on the affected third floor were COVID-19 tested as per CDC guidelines and facility policy.

Testing logs for residents on the third floor were not available at the time of the survey ending July 26, 2024, and it could not be determined if any additional facility staff were tested at the time of the survey.

The following staff members tested positive at the time of the survey:

- One staff member tested positive on July 23, 2024

- two staff member tested positive on July 24, 2024

- one staff member tested positive on July 25, 2024

The facility infection control logs did not identify any signs or symptoms displayed by any of the residents or staff.

At the time of the survey, there was no documentation of any contact tracing for residents or staff.

There was no evidence at the time of the survey that the facility followed their COVID policy and CDC guidance for COVID testing, contract tracing and cohorting residents positive or potentially positive for COVID-19 virus.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 16 395929 Department of Health & Human Services Printed: 09/17/2025 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 395929 B. Wing 07/26/2024

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

Ridgeview Healthcare & Rehab Center 200 Pennsylvania Avenue Shenandoah, PA 17976

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 An observation July 26, 2024 at 1:35 P.M., Resident 67 (tested COVID-19 positive) was observed to leave his room with a surgical mask hanging off his ear. He walked down the hallway to the nurses station without Level of Harm - Minimal harm or the mask properly donned. At the nurses station the nurse advised him to wear the mask properly and asked potential for actual harm him if he wanted to go back to his room. He then turned around and returned to his room. There were multiple residents and staff in the hallway at this time. Staff had surgical masks on, however, the residents in Residents Affected - Many the hallway were not wearing masks.

An observation July 26, 2024 at 10:30 A.M., Resident 41, a cognitively intact resident, exited room [ROOM NUMBER], ambulated in the hallway without a mask and entered room [ROOM NUMBER], in which a currently COVID-19 positive resident resided, and picked up resident belongings, left the room and ambulated back to room [ROOM NUMBER]. Resident 41 then repeated this trip, a second time, at at which time, facility staff, redirected him not to enter a COVID positive room.

An observation July 26, 2024 at 10:45 AM revealed 13 residents were seated in the third floor dining/activity room. Not all residents were wearing surgical masks. Residents were interacting with each other. Communal dining for breakfast that morning was conducted in the dining room.

During an interview July 26, 2024 at 11:30, the facility's Infection Preventionist confirmed that facility staff were instructed to close the third floor dining/activity room to limit the spread of the COVID-19 virus, but staff failed to follow the guidelines to mitigate the spread of the respiratory virus.

During an interview July 26, 2024, at 9 AM, the Nursing Home Administrator confirmed that the facility did not move any of the COVID-19 positive residents, or their COVID negative roommates, on the third floor unit because cohorting COVID positive residents was no longer required. She stated that when the initial staff member tested positive on July 16, 2024, the facility Infection Preventionist and the Director of Nursing were both on vacation. She stated that a second nurse employed at the facility had the infection control Preventionist certification. The NHA 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. She stated that she previously worked for a different facility/corporation that did not cohort or move any COVID-19 positive (with positive) residents so she made the decision not to move any residents with this COVID-19 outbreak in the facility.

28 Pa Code 211.12 (c)(d)(1)(5) Nursing services

28 Pa. Code 211.10 (a)(c) Resident care policies

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 16 395929