HERITAGE RIDGE SENIOR LIVING AT WINDY HILL
For profit - Limited Liability company
90 Beds
PRESBYTERIAN SENIOR LIVING
Data: November 2025
Trust Grade
50/100
#436 of 653 in PA
Photo by Google Maps
Photo by Tim Weston
Photo by Heritage Ridge Senior Living at Windy Hill
Photo by Denise Shimel
1 / 5 photos
Last Inspection: July 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Heritage Ridge Senior Living at Windy Hill has a Trust Grade of C, indicating it is average compared to other nursing homes. It ranks #436 out of 653 facilities in Pennsylvania, placing it in the bottom half of the state, and #6 out of 6 in Centre County, meaning there are no better local options. The facility's trend is worsening, with issues doubling from 8 in 2024 to 16 in 2025. Staffing is a relative strength with a 3 out of 5 rating and a turnover rate of 54%, which is around the state average. While there have been no fines, which is good, the facility has less RN coverage than 81% of Pennsylvania facilities, which raises concerns about the level of oversight. Recent inspections revealed several concerning incidents, including poor food storage practices in the kitchen, where equipment was found to be dirty and improperly maintained, creating a risk for foodborne illness. Additionally, the facility failed to provide required written notifications to residents regarding transfers to hospitals, which is important for their rights and understanding of care. There was also a reported lack of follow-through on maintaining a resident’s range of motion therapy after discharge from physical therapy, suggesting gaps in ongoing care. Overall, while there are some strengths, these weaknesses highlight the need for careful consideration.
- Trust Score
- C
- In Pennsylvania
- #436/653
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- Each resident gets 31 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 34%
No red flags
8 → 16 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 16 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 54%
Near Pennsylvania avg (46%)
Higher turnover may affect care consistency
Chain: PRESBYTERIAN SENIOR LIVING
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 31 deficiencies on record
Jul 2025
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's injury of unk...
Read full inspector narrative →
Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to thoroughly investigate a resident's injury of unknown origin for one of 18 sampled residents (Resident 12).Findings include:The policy entitled Abuse, Neglect, Exploitation, or Misappropriation Reporting and Investigating, last reviewed without changes on February 26, 2025, revealed if resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator, and other officials according to state law. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of the residents. All allegations are thoroughly investigated.Clinical record review revealed the facility admitted Resident 12 on May 19, 2024. Nursing documentation dated April 15, 2025, at 1:38 PM indicated nursing staff noted a bruise to Resident 12's inner thigh. Review of the facility investigation revealed the facility only obtained one witness statement from the nurse aide discovering the bruise and the statement indicated Resident 12's bruise was found during morning care and the Resident 12 stated he did not know how he obtained the bruise.Nursing documentation dated June 17, 2025, at 7:00 PM noted nurse aides indicated when providing evening care and assisting Resident 12 into bed, the nurse aides noticed a large bruise to his left shoulder/back. Documentation noted the nurse assessed the area and the bruise measured 12 by 20 centimeters. Documentation noted Resident 12 does not know what happened. Documentation noted staff were educated on proper use of the sit to stand lift, as well as following therapy orders for transfers. Review of the facility investigation into Resident 12's bruise revealed the facility only obtained two witness statements from the nurse aides discovering the bruise. Further review revealed no evidence of staff education, or any statements other than from the staff discovering Resident 12's bruise.Interview with the Nursing Home Administrator on July 10, 2025, at 10:49 AM confirmed these findings.The facility failed to thoroughly investigate Resident 12's bruises to rule out abuse or prevent further injuries.28 Pa. Code 201.18(e)(1) Management28 Pa. Code 201.29(a)(c) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services to maintain or improve the ability to perform activities of daily living for one of two residents reviewed for eating concerns (Resident 12).Findings include:Clinical record review for Resident 12 revealed an MDS (Minimum Data Set, assessment completed at specific intervals to determine care needs) assessment dated [DATE], that staff assessed Resident 12 as requiring the supervision with set up help only for eating. Resident 12's next MDS assessment dated [DATE], revealed staff assessed Resident 12 as now requiring extensive assistance of one staff for eating.There was no documented evidence in Resident 12's clinical record to indicate that the facility identified or assessed Resident 12's decline in her ability to perform this activity of daily living.Interview with Employee 2 (registered nurse assessment coordinator) on July 10, 2025, at 11:45 AM confirmed these findings and stated that she would submit a screen for speech therapy to assess Resident 12's decline in his ability to feed himself.The surveyor reviewed the above findings for Residents 12 with the Director of Nursing and the Nursing Home Administrator on July 9, 2025, at 12:05 PM. The facility was unable to provide any further documentation that the facility assessed Resident 12's decline in eating ability or implemented any measures to mitigate the decline.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for one of one...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for one of one resident reviewed for concerns (Resident 43) and failed to provide the highest practicable care regarding pacemaker care for one of one resident reviewed (Resident 384). Clinical record review for Resident 43 revealed a diagnosis list that included hypertension (high blood pressure), essential hypertension, and paroxysmal atrial fibrillation (an irregular heartbeat that comes and goes).
Review of Resident 43's current care plan revealed the resident has an altered cardiovascular status related to the medical history. An intervention included to administer medications as ordered.
A review of the current physician orders for Resident 43 dated May 6, 2025, indicated for staff to administer Metoprolol Succinate ER Extended Release (a medication that is used to treat high blood pressure and/or heart rate) 25 milligrams (mg) give one tablet orally at bedtime related to essential hypertension. Hold if systolic blood pressure (SBP, the top number of a blood pressure reading where the heart contracts) less than or equal to 110 or a heartrate less than or equal to 70.
A review of the Medication Administration Record (MAR) for Resident 43 revealed that the Metoprolol was marked as administered outside of the physician specified parameters for the following:
May 9, 2025: the pulse was documented as 62.May 10, 2025: the pulse was documented as 65. May 11, 2025: the pulse was documented as 70.May 13, 2025: the pulse was documented as 62. June 9, 2025: the pulse was documented as 67.June 10, 2025: the pulse was documented as 69.June 11, 2025: the pulse was documented as 70. July 4, 2025: the pulse was documented as 68. July 8, 2025: the pulse was documented as 63.
There was no documentation for Resident 43 as to why the medication was administered outside of the specific physician ordered parameters.
The above information for Resident 43 was reviewed in a meeting with the Director of Nursing (DON) on July 10, 2025, at 12:24 PM.
The DON confirmed on July 10, 2025, at 12:59 PM that there was no documented evidence as to why the medication was administered outside of the physician ordered parameters.
Clinical record review for Resident 384 revealed an order dated July 3, 2025, for him to have a chest x-ray because he had tachycardia (fast heart rate) and a fever.
The results of the chest x-ray indicated that Resident 384 had some infiltrates (areas that are whiter, such as fluid, inflammatory cells, or other material). The x-ray also noted that Resident 384 had a cardiac pacemaker (a device that is used to regulate the hearts rhythm.
Review of Resident 384’s pacemaker care plan initiated on June 9, 2025, revealed an intervention to monitor pacemaker checks. Review of Resident 384’s current physician order revealed no evidence of orders for pacemaker checks.
An interview with the DON on July 9, 2025, at 12:20 PM revealed that she was unaware and unsure if Resident 384 had a pacemaker but would investigate and get back to the surveyor.
A follow-up interview with the DON on July 10, 2025, at 9:45 AM confirmed the above noted findings that there were no orders related to Resident 384’s pacemaker or pacemaker checks. The facility failed to provide the highest practicable care regarding physician ordered medication parameters for Resident 43 and failed to provide the highest practicable care regarding pacemaker care for Resident 384.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Res...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of one resident reviewed (Residents 23).Findings include:Clinical record review revealed the facility admitted Resident 23 on December 26, 2019, with a diagnose of chronic obstructive pulmonary disease with (acute) exacerbation added on October 12, 2023. Observation of Resident 23 on July 8, 2025, at 10:50 AM and 1:25 PM revealed he was in his wheelchair with a nasal cannula (NC, tubing to deliver oxygen to the nose) on and running at 2.5 liters per minute (LPM).Observation of Resident 23 on July 9, 2025, at 10:53 AM revealed Resident 22 was in his wheelchair with oxygen on and running at 2.5 LPM.Review of Resident 23's physician orders revealed a current order for staff to administer Resident 23 oxygen continuous every shift at 1.5 liters via nasal canula.The findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 9, 2025, at 12:00 PM.28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder (P...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder (PTSD), to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 59).Findings include:Clinical record review for Resident 59 revealed that the facility admitted him with a diagnosis of PTSD (PTSD, a mental and behavioral disorder that develops related to a terrifying event), on April 30, 2024.Interview with Resident 59 on July 9, 2025, at 8:45 AM revealed that he has PTSD that is triggered by loud noises, and other people screaming in the middle of the night. He said the screaming startles him and he wakes up panicked wondering what had happened. Further review of Resident 59's care plan revealed no evidence that the facility identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring) for him related to his diagnosis of PTSD. Resident 59's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to develop and implement individualized interventions.These findings were reviewed with the Nursing Home Administrator and Director of Nursing on July 9, 2025, at 12:20 PM. 28 Pa Code 211.12 (d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure a consultant pharmacis...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure a consultant pharmacist reviewed a resident's medication regimen monthly for one of five residents reviewed for potentially unnecessary medications (Resident 65).Findings include:Clinical record review for Resident 65 revealed that the resident was admitted on [DATE]. Clinical record review for Resident 65 revealed a diagnosis list that included Alzheimer's Disease (a brain disorder that affects memory, thinking, and cognitive abilities), cognitive impairment, and anxiety. Review of facility documentation for Resident 65 revealed a monthly medication regimen review dated April 10, 2025, from the consultant pharmacist. Further clinical record review for Resident 65 revealed no documentation that a licensed pharmacist completed required monthly medication regimen reviews for the resident during May and June 2025. Documentation for the completed monthly medication reviews was requested by the surveyor during meetings with the Nursing Home Administrator and Director of Nursing on July 8, 2025, at 2:10 PM and July 9, 2025, at 2:00 PM.An interview with the Director of Nursing on July 10, 2025, at 12:59 PM confirmed there was no further documentation to indicate that Resident 65's monthly medication regimen reviews were completed for May or June 2025. 28 Pa. Code 211.9 (k) Pharmacy services28 Pa. Code 211.12(d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to assist a resident to obtain routine dental care for one of one resident re...
Read full inspector narrative →
Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to assist a resident to obtain routine dental care for one of one resident reviewed for dental concerns (Resident 23).Findings include:Observation and interview with Resident 23 on July 8, 2025, at 10:55 AM revealed he had several missing and broken bottom teeth. Resident 23 stated that he does not remember the last time he was offered dental services.Clinical record review revealed the facility admitted Resident 23 on December 26, 2019, with payment sources that included the state Medicaid benefit. Review of Resident 23's clinical record revealed a physician's order for a dental consult and follow up as needed on January 1, 2025. Further review of Resident 23's clinical record revealed his last dental visit was August 21, 2024.Interview with the Director of Nursing on July 10, 2025, at 10:19 AM confirmed Resident 23 did not receive dental care according to state plan. The facility failed to provide evidence that Resident 23 received routine prophylactic dental cleanings as covered under the State plan.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer for three of five residents reviewed for hospitalization (Residents 28, 59, and 65).Findings Include:Nursing documentation for Resident 65 dated May 15, 2025, at 11:58 PM revealed that the resident had a change in condition and 911 was called. A Medication Administration Note dated May 16, 2025, at 5:36 AM revealed that Resident 65 was admitted to the hospital for a urinary tract infection.A review of the census for Resident 65 revealed that the resident returned to the facility on May 21, 2025. Clinical record review revealed no documentation to indicate that Resident 65 and/or their representative received a written notice of transfer and a written notice of the facility bed-hold policy at the time of transfer. Documentation was also requested by the surveyor during meetings with the Nursing Home Administrator and Director of Nursing on July 8, 2025, at 2:10 PM and July 9, 2025, at 2:00 PM. An interview with the Director of Nursing on July 10, 2025, at 12:59 PM confirmed there was no documentation to indicate that Resident 65 and/or their representative received written notice of transfer and written notice of the facility bed-hold policy at the time of transfer.Clinical record review for Resident 59 revealed that he was transferred to the emergency room to be evaluated for mental status changes, weakness, and frequent falls on March 12, 2025. He was admitted to the hospital from the emergency room for weakness and pneumonia. Clinical record review revealed no documentation to indicate that Resident 59 and/or their representative received a written notice of transfer and a written notice of the facility bed-hold policy at the time of transfer. Documentation was also requested by the surveyor during meetings with the Nursing Home Administrator and Director of Nursing on July 9, 2025, at 2:17 PM. The facility failed to provide a written notice of transfer and a written notice of bed-hold that included all the written components to the resident and/or the resident's responsible party at the time of transfer for Resident 59. Clinical record review revealed Resident 28 was transferred to the hospital from [DATE] to May 2, 2025, for a change in his condition. Further review revealed no documentation to indicate that Resident 28's representative received a written notice of transfer and a written notice of the facility bed-hold policy at the time of transfer. Interview with Employee 4 (social worker) and Employee 5 (admissions) on July 10, 2025, at 9:57 AM confirmed these findings for Resident 28.28 Pa. Code 201.14(a) Responsibility of license28 Pa. Code 201.29(a) Resident rights
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide service...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide services to maintain a resident's range of motion ([NAME]) for one of two residents reviewed for ROM concerns (Resident 19).Findings include:Interview with Resident 19 on July 9, 2025, at 10:30 AM revealed that he receives no follow through after therapy discharges him. He said the therapist will tell him that staff are going to do exercise to his legs, but it either does not happen or does not happen consistently.Clinical record review of a physical therapy Discharge summary dated [DATE], revealed that resident was to receive a restorative active range of motion program (resident can move extremity on his own) and passive range of motion (staff move the extremity through range of motion) program to his lower extremities. Review of the facility's task documentation revealed that Resident 19 was receiving a restorative active assist range of motion program to his bilateral lower extremities that was documented as being done through May 15, 2025. May 16 to 31, 2025, there was no documentation to indicate Resident 19 received the therapy recommended range of motion programs to his bilateral lower extremities.Interview with the Director of Nursing on July 10, 2025, at 10:00 AM revealed that there was a communication issue between therapy and nursing so Resident 19's recommended range of motion program never got initiated until June1, 2025.Review of Resident 19's task documentation for June 2025, revealed that he was to receive active range of motion to his bilateral lower extremities on dayshift daily. Review of the documentation revealed that Resident 19 did not receive active range of motion to his bilateral lower extremities on the following days: June 2, 3, 4, 6, 9, 10, 14, 15, 16, 18, 19, 20, 22, 23, 25, 27, 28, 30, 2025. The Director of nursing was made aware of the concerns related to Resident 19's range of motion program to his lower extremities on July 10, 2025, at 11:05 AM.28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to implement interventions promote acceptable parameters of nutritional status for one of five residents reviewed for nutritional concerns (Residents 28).Findings include: The facility policy entitled Weight assessment and Intervention, last reviewed without changes February 26, 2025, revealed residents are weighed upon admission and at intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of five pounds or more since the last weight assessment is retaken the next day for confirmation. Undesirable weight change is evaluated by the treatment team whether the criteria for significant weight change has been met. The physician and the multidisciplinary team identify conditions and medications that may be causing weight loss or increasing the risk of weight loss.Clinical record review revealed the facility admitted Resident 28 on February 20, 2025, with diagnoses including severe protein-calorie malnutrition.Review of Resident 28's documentation survey report for meal intakes revealed the following:June 2025, staff documented Resident 28 consumed zero to 25 percent on 52 of 90 meals.July 2025, staff documented Resident 28 consumed zero to 25 percent on 23 of 27 meals.Further review of Resident 28's clinical record revealed the following weight assessments:May 2, 2025, 119.0 poundsMay 3, 2025, 119.0 poundsMay 5, 2025, 114.5 poundsMay 6, 2025, 115.0 poundsJune 1, 2025, 95.0 pounds (a 20- pound, 17.39 percent severe weight loss, weight was crossed out by Employee 1, registered dietician, and she noted re-weighed)June 2, 2025, 103.0 pounds (weight crossed out by registered dietitian, noting re-weighed) July 2, 2025, 91.0 pounds (no evidence of a re-weight obtained the next day as per facility policy)July 7, 2025, 87.0 pounds (a 28- pound, 24.35 percent severe weight loss in two months)Review of Resident 28's clinical record revealed a Nutritional Risk assessment dated [DATE], noted Resident 28 is underweight with increased nutrient needs and impaired nutrient utilization related to low body weight, elevated nutrition requirements, and altered biochemical function. Employee 1 indicated they would monitor Resident 28's nutrition status and update his nutrition plan of care as needed. A Nutritional Risk Assessment date May 13, 2025, was completed with no changes. There was no further assessment of Resident 28's severe weight loss until July 7, 2025.Further review of Resident 28's clinical record revealed there were no weights obtained on Resident 28 from May 6, 2025, to July 2, 2025 (after Employee 1 crossed off other staff members weights assessments obtained on June 1 and June 2, 2025). There was no documentation of Resident 28 refused any weights during this time.Review of Resident 28's physician orders revealed that staff administered Resident 28 Med Pass (fortified nutritional shake) 2.0, 150 ML (milliliter), three times a day from February 21 to May 6, 2025, when Med Pass was discontinued and the facility ordered staff to administer Resident 28 Boost (nutritional supplement) twice a day. Review of Resident 28's Medication Administration Record (MAR, a form utilized to document the administration of medications and supplements) dated May 2025 revealed staff documented Resident 28 consumed less than 25 percent of Boost supplement on 32 of 51 administrations.Review of June 2025 MAR revealed that staff documented Resident 28 consumed less that 25 percent of Boost supplement on 42 of 60 administrations.There was no documentation that Resident 28's physician assessed Resident 28's severe weight loss until July 2, 2025.Interview with Employee 1 on July 9, 2025, at 2:22 PM confirmed these findings for Resident 28. Employee 1 stated that she did not believe the June 1 and June 2 weights were accurate; therefore, she crossed them out. Employee 1 confirmed she did not obtain a reweight or implement any interventions in June 2025, because she felt the weights were inaccurate. Employee 1 confirmed there was no documentation of any attempts to reweigh Resident 28 until July 2, 2025. 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for thre...
Read full inspector narrative →
Based on employee personnel record review and staff interview, it was determined that the facility failed to complete a performance evaluation of each nurse aide at least once every 12 months for three of three nurse aides reviewed (Employees 7, 8, and 9).Findings include:The facility noted the following hire dates for three employees reviewed for performance evaluations (EPR, employee performance review): Employee 7's hire date of November 5, 1991, last EPR was November 14, 2023Employee 8's hire date of June 24, 1996, last EPR was May 26, 2024.Employee 9's hire date of October 31, 2017, last EPR was October 18, 2023.A request to review the annual performance evaluations revealed no documented evidence that the facility completed performance evaluations for Employee 7, 8, and 9 (nurse aides) at least once every 12 months. Interview with the Nursing Home Administrator on July 10, 2025, at 9:40 AM confirmed that performance evaluations were not completed annually on the three employees requested. 28 Pa. Code 201.19 (2) Personnel policies and procedures
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an indi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by three of five residents reviewed (Residents 33, 52, and 61). Findings include:
Clinical record review for Resident 33 revealed the facility admitted her on March 26, 2025, with diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life).
A review of Resident 33's admission Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 31, 2025, indicated that the facility assessed Resident 33 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.
A review of Resident 33's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.
The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on July 9, at 2:30 PM. On July 10, 2025, at 10:00 AM the Director of Nursing confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 33's dementia.
Clinical record review for Resident 52 revealed the facility admitted her on June 11, 2025, with diagnoses including dementia. A review of Resident 52’s MDS, dated [DATE], indicated that the facility assessed Resident 52 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.
A review of Resident 52's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.
The findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on July 9, 2025, at 12:05 PM. On July 10, 2025, at 10:23 AM the Nursing Home Administrator confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 52's dementia prior to surveyor's questioning.
Review of Resident 61’s clinical record revealed that the facility admitted her on March 20, 2024, with a diagnosis of Dementia.
Review of Resident 61’s admission MDS dated [DATE], indicated that the facility assessed Resident 61 as having a diagnosis of Dementia and that the facility would develop a care plan for dementia and cognitive loss.
A review of Resident 61’s care plan revealed that there was no indication the facility developed an individualized person-centered plan of care to address her dementia and cognitive loss, which should reflect family involvement in development.
Interview with Employee 4, social worker, on July 10, 2025, at 10:24 AM confirmed the above findings for Resident 61, and indicated that the individualized dementia care plan for Resident 61 was developed after the concerns were discussed by the surveyor.
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food ite...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen.Findings include:Initial tour of the facility's main kitchen with Employee 6, Director of Dining Services, on July 8, 2025, at 10:00 AM revealed the following:A walk-in freezer contained a cardboard box with several items packaged in slide lock plastic bags. One bag contained baked beans with no label or dates. The other bag contained peeled, whole bananas with no label or dates. A concurrent interview with Employee 6 revealed it was unclear on when the items were packaged or the use by date.The top shelf of a storage unit located under the circulating fans in the walk-in freezer contained several packages of sliced flavored bread. There was a significant accumulation of ice on three of the bread packages. The dry goods storage area contained metal shelving units on wheels. The floor under four of the observed shelves contained a significant accumulation of debris that included dust, unopened eight-ounce soda cans, and various debris (discarded paper products, a condiment packet, a single-use butter packet, and several plastic spoons). A shelf in the kitchen contained two partially used vinegar containers with no open date and a partially used container of syrup with no open date on it. An expandable dough cutter located in a drawer had an extensive build-up of a batter-like substance and multiple areas of rust. The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 8, 2025, at 2:10 PM. A review of tray line food temperature logs on July 9, 2025, at 11:48 AM revealed no documented dinner temperatures for the following dates: May 1, 11, 13, 14, and 18, 2025June 18, 22, 25, and 26, 2025An interview with Employee 6 on July 9, 2025, at 11:50 AM revealed that tray line food temperatures should be documented for each meal service. Employee 6 further noted it was unclear why the dinner food temperatures were not documented for the above dates. This information regarding the food temperatures was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 9, 2025, at 12:00 PM. 483.60(i) Food prepare, distribute, and serve -sanitary/safetyPreviously cited 8/2/2428 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.14(a) Responsibility of licensee
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to offer recommended pneumococcal immunizations for ...
Read full inspector narrative →
Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to offer recommended pneumococcal immunizations for five of five residents reviewed for immunizations (Resident 11, 18, 19, 23 and 29).Findings include:The policy entitled Pneumococcal Vaccine, last reviewed February 26, 2025, indicates that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the vaccine within 30 days of admission. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with the current CDC (Center for Disease Control and Prevention) recommendations at the time of the vaccinations.Review of Resident 11's clinical record revealed that the facility admitted her on January 28, 2021. Documentation in Resident 11's clinical record revealed that she received a pneumococcal vaccine (Prevnar 13) prior to her admission in 2016, and the PPSV23 in 2001. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated October 2024, the facility is to decide together with the resident, if the resident would like an updated pneumococcal vaccine.There was no documented evidence to indicate that the facility offered Resident 11 an updated pneumococcal vaccination. Review of Resident 18's clinical record revealed that the facility admitted her on March 6, 2023. Documentation in Resident 18's clinical record revealed that she received a pneumococcal vaccine (Prevnar 13) prior to her admission in 2015, and the PPSV23 in 2008. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated October 2024, the facility is to decide together with the resident, if the resident would like an updated pneumococcal vaccine.There was no documented evidence to indicate that the facility offered Resident 18 an updated pneumococcal vaccination. Review of Resident 19's clinical record revealed that the facility admitted him on July 23, 2022. Documentation in Resident 19's clinical record revealed that he received a pneumococcal vaccine (Prevnar 13) prior to his admission in 2022. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated October 2024, Resident 19's pneumococcal vaccinations would not be complete until he received a PCV20 or PCV21 one year after he received his Prevnar 13. There was no documented evidence to indicate that the facility offered Resident 19 an updated pneumococcal vaccination. Review of Resident 23's clinical record revealed that the facility admitted him on December 26, 2019. Documentation in Resident 23's clinical record revealed that he received a pneumococcal vaccine (Prevnar 13) prior to his admission in 2015, and the PPSV23 in 2011. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated October 2024, the facility is to decide together with the resident, if the resident would like an updated pneumococcal vaccine.There was no documented evidence to indicate that the facility offered Resident 23 an updated pneumococcal vaccination. Review of Resident 29's clinical record revealed that the facility admitted her on October 29, 2019. Documentation in Resident 29's clinical record revealed that she received a pneumococcal vaccine (Prevnar 13) prior to her admission in 2018, and the PPSV23 in 2018. According to the CDC guidance entitled Pneumococcal Vaccination Timing dated October 2024, the facility is to decide together with the resident, if the resident would like an updated pneumococcal vaccine.There was no documented evidence to indicate that the facility offered Resident 29 an updated pneumococcal vaccination. 483.80(d) Influenza and Pneumococcal ImmunizationsPreviously cited 8/2/2428 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.18(b)(1) Management28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of ...
Read full inspector narrative →
Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 7, 8, and 9).Findings include:During a meeting with the Nursing Home Administrator and Director of Nursing on July 8, 2025, at 2:00 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 7, 8, and 9 (nurse aides).Interview with the Nursing Home Administrator and Director of Nursing on July 10, 2025, at 10:05 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training. 28 Pa. Code 201.19 (7) Personnel policies and procedures28 Pa. Code 201.20(a)(6)(d) Staff development
MINOR
(C)
Minor Issue - procedural, no safety impact
Garbage Disposal
(Tag F0814)
Minor procedural issue · This affected most or all residents
Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage in the facility's main dumpster area.Findings include:Observation of the...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to properly contain and dispose of garbage in the facility's main dumpster area.Findings include:Observation of the facility's main dumpsters on July 8, 2025, at 10:45 AM, located outside of a rear egress door from the facility's main kitchen revealed the following: There was debris and garbage on the ground surrounding the dumpster that included the following: four feet tall weeds, one to two inches of stagnant water ponding in a metal containment area underneath the container that held the facility's generator fuel supply, seven wooden boards of a fence that surrounded the dumpster area that each contained three rusted nails (for a total of 21) protruding from the boards and posing a risk of injury, an accumulation of dead leaves, discarded cardboard, and various discarded items on the ground (hair nets, gloves, paper products, and pieces of wood). The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on July 8, 2025, at 2:10 PM. 28 Pa. Code 201.14(a) Responsibility of licensee
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select policies and procedures, clinical record review, and staff interview, it was determined that the fac...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to ensure licensed nursing staff were knowledgeable in the necessary care and services for one of one resident reviewed with a peripherally inserted central catheter (Resident CR1; Employee 3)
Findings include:
A request for the facility policy regarding a peripherally inserted central catheter (PICC, thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) was made by the surveyor to the Nursing Home administrator (NHA) on December 11, 2024, at 11:20 AM and the Director of Nursing at 12:53 PM.
A review of the policy provided by the facility titled, Intravenous Device Care, noted care of intravenous devices (a device utilized to administer treatments or medications directly into a vein) provided in accordance with current research and practice guidelines with an objective to maintain intravenous device and prevent obstruction. The procedure portion included a section titled, PICC Line Care. This policy did not address if licensed practical nurses (LPNs) may utilize and care for the PICC or any specialized trainings or competencies associated with a PICC.
An interview with the Director of Nursing on December 11, 2024, at 2:24 PM revealed that the policy provided was from the previous ownership of the facility and as of November 1, 2024, the facility currently follows the state guidelines for a PICC, and no further documentation was provided.
An interview with Employee 1, licensed practical nurse, and Employee 2, registered nurse, on December 11, 2024, at 10:50 AM revealed that LPNs in the facility do not utilize a PICC to administer medications.
Closed record review for Resident CR1 revealed the resident was admitted to the facility from November 9, 2024, to November 27, 2024.
An admission History and Physical signed November 12, 2024, revealed Resident CR1 had a development of osteomyelitis (an infection of the bone) and a PICC line placed. The resident was admitted to the facility on [DATE], for physical therapy, occupational therapy, and intravenous antibiotics.
Nursing documentation dated November 25, 2024, at 8:30 AM revealed the resident has a PICC line in the right upper arm.
A review of the November 2024, Medication Administration Record (MAR) for Resident CR1 revealed that the resident had an order initially dated November 9, 2024, for Cefepime (an antibiotic) two grams to be administered intravenously 100 milliliter per hour over 30 minutes twice daily.
Further review of Resident CR1's MAR dated November 2024, revealed that Employee 3, LPN, initialed at least five times for the administration of the Cefepime from November 9, 2024, through November 27, 2024. The DON confirmed during the interview on December 12, 2024, at 2:24 PM that Employee 3 was an LPN.
The facility could not provide any intravenous or PICC line competencies or specialized trainings (per Pa. Code 21.145b., IV therapy curriculum requirements, an IV therapy course provided as part of the LPN education curriculum relating to specific curriculum requirements for LPN programs; or as a stand-alone course offered by a provider) completed by Employee 3 after being requested by the surveyor.
Interview via phone with the NHA on December 12, 2024, at 11:27 AM confirmed that the facility had no evidence of any competencies or specialized trainings completed with Employee 3.
28 Pa Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a)(6)(d) Staff development
28 Pa Code 211.12 (c)(d)(1)(5) Nursing services
Aug 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for ...
Read full inspector narrative →
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for two of 17 residents reviewed (Residents 25 and 53).
Findings include:
Clinical record review for Resident 25 revealed a diagnoses list that included: a need for assistance with personal care, weakness, and contracture of the muscles.
A current care plan for Resident 25 revealed the resident is at risk for falling related to gait abnormality, a history of pain, incontinence, and other medical areas. An intervention listed on the care plan included to keep the call bell in reach.
Observation of Resident 25 on July 31, 2024, at 9:48 AM revealed he was in bed. The call bell was observed not within reach with the call bell cord tucked between the resident's right side rail and mattress and the activator hanging down under the bed almost touching the floor.
Observation of Resident 25 on August 1, 2024, at 11:10 AM revealed he was in bed. The call bell was observed out of his reach with the call bell cord tucked between the resident's right side rail and mattress and the activator was on the floor. A concurrent interview with Resident 25 revealed the resident replied, Good question, when asked if he knew where the call bell was. The resident further attempted to access the call bell and was unable.
Employee 3, registered nurse, was advised of the finding for Resident 25 on August 1, 2024, at 11:13 AM and further assisted the resident with accessing the call bell.
Clinical record review for Resident 53 revealed a diagnoses list that included: a need for assistance with personal care, dementia, age-related physical debility, and muscle weakness.
A current care plan for Resident 53 revealed the resident is at risk for falling related to gait abnormality, cognition deficit, incontinence, attempting to crawl out of bed, and multiple other medical issues. An intervention listed on the care plan included to keep the call bell in reach.
Observation of Resident 53 on August 1, 2024, at 9:17 AM and 11:14 AM revealed she was in bed. The call bell was observed out of her immediate reach with the activator hanging down below the bed and almost touching the floor.
Employee 3, registered nurse, was advised of the finding for Resident 53 on August 1, 2024, at 11:17 AM.
The above information for Residents 25 and 53 were reviewed with the Nursing Home Administrator and Director of Nursing on August 1, 2024, at 2:05 PM.
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide a writt...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy to the resident or responsible party for two of seven residents reviewed for hospitalizations (Residents 8 and 13).
Findings include:
Review of Resident 8's clinical record revealed that she was admitted to the hospital on [DATE]. Resident 8 was still hospitalized at the time of the full health survey. There was no documented evidence in Resident 8's clinical record to indicate that the facility provided her responsible party written information on the facility's bed hold policy.
Observation on August 2, 2024, at 12:15 PM confirmed that Resident 8's bed hold forms were still sitting in an envelope at the facility's front desk. Interview with the Director of Nursing on August 2, 2024, at 12:55 PM confirmed that if a resident's responsible party is unable to be contacted regarding a transfer, then the notice is sent out via the mail.
Review of Resident 13's clinical record revealed that she was admitted to the hospital on [DATE]. There was no documented evidence in Resident 13's clinical record to indicate that the facility provided her responsible party written information on the facility's bed hold policy.
Interview with Employee 1, admissions, on August 2, 2024, at 9:18 AM confirmed the above findings for Resident 13.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.29(f) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to identify and refer a resident with a diagnosed mental disorder for level II review for one of one res...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to identify and refer a resident with a diagnosed mental disorder for level II review for one of one resident reviewed for PASRR (Pre-admission Screening and Resident Review) compliance (Resident 10).
Findings include:
The PA-PASRR-ID form (Pennsylvania Pre-admission Screening and Resident Review; PA-PASRR, federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care) dated February 2016 and revised in September 2018, lists examples of serious mental illness including psychotic disorder and schizophrenia.
The revised PA-PASRR-ID bulletin number 01-14-13, 03-14-10, 07-14-01, 55-14-01 dated March 1, 2014, revealed that nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need to be completed. Nursing facilities will communicate the need to have a PA-PASRR-EV done by notifying the Department's (Department of Public Welfare, now the Department of Human Services) Office of Long-Term Living, Bureau of Quality and Provider Management, Division of Nursing Facility Field Operations via the MA 408 form (a form used to notify the Department of a change in a resident's target status).
Review of the MA 408 form dated March 2020 indicates that with a change in a resident's condition (any change in the individual's condition that affects the target status) the nursing facility is to send or fax the original form within 48 hours to their (Department of Public Welfare's) nursing facility field operations office.
Review of Resident 10's clinical record revealed a PA-PASARR dated November 24, 2004, that documented no disorders that would trigger a level II review. The assessment indicated that there were no diagnoses of neurocognitive disorders or serious mental illness, a level II review was not necessary, and to admit Resident 10 as a regular admission. The form was reviewed by the Department of Human Services (DHS) on January 5, 2005.
Resident 10's clinical record identified her as having a diagnosis of paranoid schizophrenia (a mental disorder where a person experiences fear that feeds into their delusions and hallucinations) that was added to her plan of care on January 20, 2005. There was no evidence that the facility notified the appropriate agencies related to Resident 10's identified target diagnosis.
Interview with the Director of Nursing on August 2, 2024, at 9:30 AM acknowledged the above findings for Resident 10.
28 Pa. Code 201.14 (a) Responsibility of Licensee
28 Pa. Code 211.5(f)(iv)(vi) Medical records
28 Pa. Code 211.12 (d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide cul...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed (Resident 10).
Findings include:
Clinical record review for Resident 10 revealed a current care plan entitled Behavioral Symptoms that identified her as having PTSD (Post Traumatic Stress Syndrome, a mental and behavioral disorder that develops from experiencing a traumatic event). The care plan goal was that Resident 10 would remain stable with interventions and medications as ordered. Further review of her care plan revealed that the facility failed to identify triggers that may retraumatize her related to her diagnosis of PTSD.
A physician's progress note provided to the surveyor on August 2, 2024, at 9:30 AM dated November 24, 2004, indicated that Resident 10 was admitted from a personal care home after an alleged rape by another resident. The note also indicated that Resident 10 was in a motor vehicle accident in 1987 and suffered head trauma. Neither of the two events were identified in her plan of care as the cause of her PTSD but were provided to the surveyor as the identified cause of Resident 10's PTSD.
Interview with the Director of Nursing on August 2, 2024, at 9:45 AM confirmed the above noted findings related to Resident 10's diagnosis of PTSD.
The facility failed to identify care plan triggers that may retraumatize Resident 10 related to her diagnosis of PTSD.
28 Pa Code 211.12 (d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for two of five residents r...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for two of five residents reviewed for immunization concerns (Residents 7 and 168).
Findings include:
Clinical record review for Resident 7 revealed that the facility admitted her on March 12, 2024. Review of her immunizations in her clinical record revealed that there was no documentation related to the pneumococcal conjugate vaccines (vaccines administered to prevent pneumonia).
Clinical record review for Resident 168 revealed that the facility admitted her on July 17, 2024. Review of her immunizations in her clinical record revealed that there was no documentation related to the pneumococcal conjugate vaccines.
The Director of Nursing was made aware of concerns with Resident 7 and 168's pneumococcal vaccinations on August 2, 2024, at 1:01 PM.
The facility failed to ensure the Residents 7 and 168 received the appropriate vaccinations as recommended.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food conta...
Read full inspector narrative →
Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen.
Findings include:
An observation of the facility's main kitchen on July 30, 2024, at 9:37 AM revealed the following:
A speed rack located beside the ovens was observed with trays of potatoes, as well as another tray at the bottom of the rack holding a container with a variety of equipment such as spatulas, spoons, labels, and pens. The tray contained dried spills and food splatter.
A drawer unit under a preparation table across from the ovens was dusty, contained dried food debris, and food splatter.
Lower shelves of preparation and storage tables throughout the kitchen where food preparation equipment was stored were observed with dust, crumbs, and dried spills.
Flooring throughout the kitchen under preparation tables, steam tables, oven, coolers, and along wall edges, was observed with dirt and debris buildup, dried food, wrappers, soiled plastic spoon, and dried spills.
A three-tier black cart beside the dishwashing area was observed with clean plate bases and lids. The cart handles and edges of the shelves were soiled with debris and dried food.
A table where open boxes of sugar packets and hot chocolate packets were stored contained significant dust and debris behind and around the containers.
The floor of the walk-in cooler contained a buildup of dirt and debris.
The flooring in the dry storage area was significantly worn with multiple cracked tiles.
Employee 3, production manager, was observed walking in and out of the kitchen multiple times during the above observations. Employee 3 had a full beard without any covering.
A follow up observation in the main kitchen on August 1, 2024, at 12:04 PM revealed Employee 4 and Employee 5, dietary aides, working in the kitchen production area preparing lunch service trays. Employee 4 and Employee 5 both had visible facial hair without any protective covering.
The above information was reviewed with the Nursing Home Administrator and Director of Nursing on August 1, 2024, at 2:02 PM.
483.60 (i)(2) Food store, distribute, maintain, sanitary
Previously cited 8/25/23
28 Pa. Code 201.14 (a) Responsibility of licensee
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide a written notice of transfer that included all the written components to the re...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide a written notice of transfer that included all the written components to the resident and/or the resident's responsible party for two of seven residents reviewed (Resident 8 and 13).
Findings include:
Review of Resident 8's clinical record revealed that the facility transferred her to the hospital on July 23, 2024. Resident 8 was still in the hospital at the time of the full health survey. There was no documented evidence that that the facility attempted to provide Resident 8's responsible party with a transfer notice that included all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address.
Observation on August 2, 2024, at 12:15 PM confirmed that Resident 8's transfer forms were still sitting in an envelope at the facility's front desk. Interview with the Director of Nursing on August 2, 2024, at 12:55 PM confirmed that if a resident's responsible party is unable to be contacted regarding the transfer, then the notice is sent out via the mail.
Review of Resident 13's clinical record revealed that the facility transferred her to the hospital on May 31, 2024. There was no documented evidence that the facility provided Resident 13's responsible party with a transfer notice that included all the above components.
Interview with Employee 1, admissions, on August 2, 2024, at 9:18 AM confirmed the above findings for Resident 13.
28 Pa. Code 201.14(a) Responsibility of license
28 Pa. Code 201.29(a) Resident rights
Aug 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff and resident interview, it was determined that the facility did not develop and implement a comprehensive person-centered care plan to include a...
Read full inspector narrative →
Based on observation, clinical record review, and staff and resident interview, it was determined that the facility did not develop and implement a comprehensive person-centered care plan to include a resident's specific need for a roam alert bracelet and interventions to protect against elopement for one of three residents reviewed for elopement risk (Resident 71).
Findings include:
Review of an admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated June 28, 2023, for Resident 71 revealed the resident's BIMS (BIMS, Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 13-15 indicates an intact cognitive response) was 15.
During an interview with Resident 71 on August 22, 2023, at 11:55 AM, the resident reported that he must wear this thing around his ankle because he left the building when at a routine appointment and he wished that it would be taken off. The resident was referring to a wander alert bracelet (a bracelet that triggers alarms and can lock monitored doors to prevent a resident from leaving unattended). The resident described going to an appointment three days a week. He indicated that the staff from the nursing facility transport him to and from the appointments. He also indicated that he cannot go off the floor where he resides without help from staff when they are available, and he can only go outside when the staff are available.
Clinical record review for Resident 71 revealed a care plan that was initiated June 27, 2023, that indicates the resident has a history of wandering. The goal was that the resident would remain safe inside the buildings and accept redirection as needed. The interventions included to encourage the roam alert at all times, check the roam alert per policy, and ensure that the resident wears well fitting, non-skid footwear.
There was no documented evidence in the care plan to indicate why Resident 71 who had a BIMS of 15 needed a roam alert bracelet.
During an interview with the Director of Nursing on August 25, 2023, at 12:46 PM the surveyor asked why Resident 71 who has a BIMS of 15 requires a roam alert bracelet and how his rights are not violated by restricting his movement in the facility. The Director of Nursing reported the following about the resident. Resident 71 left the appointment before staff arrived to pick him up and he was found wandering in a parking lot. Resident 71's mental status changes frequently due to a chronic medical condition, his cognition (thinking ability) changes throughout the day, and he had made statements that he is leaving. The facility communicated with the staff at the off-site appointment to watch the resident until the facility staff arrive. The resident wandered outside prior to admission to the facility. The activity staff take the resident off the floor he resides on. The Director of Nursing confirmed that the above information about Resident 71 was not in the care plan.
28 Pa. Code: 211.10(a)(c)(d) Resident care policies
28 Pa. Code: 211.12(d)(1)(2)(3) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility fail...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed implement interventions to prevent falls for one of three residents reviewed (Resident 46).
Findings include:
Clinical record review for Resident 46 revealed she was admitted to the facility on [DATE]. On July 31, 2023, she fell in the facility and required hospitalization for a fracture of the greater trochanteric of the left femur (a type of hip fracture) and it was non-operable (did not require surgery). The resident was hospitalized from [DATE] until August 3, 2023.
Review of therapy recommendations for nursing measure orders for Resident 46 dated August 4, 2023, revealed the resident was to transfer by standing pivot (resident stands and staff pivot transfer) only using front wheeled walker, gait belt, shoes, with the assist of two staff, and the staff were not to walk the resident.
Review of an ADL (ADL, activities of daily living, such as bed mobility, transfers, walking toileting, eating, grooming, and hygiene) care plan for Resident 46 dated August 4, 2023, revealed the resident was to be transferred by standing pivot, only using front wheeled walker, gait belt, shoes, with the assist of two staff, and no walking with staff. The resident was to only bear weight on the left leg only.
Review of a nursing note for Resident 46 dated August 7, 2023, at 2:34 PM revealed the resident fell as she was being transferred by stand and pivot with staff when she let go of the toilet and fell forward and hit the right side of her head on the toilet seat. The resident sustained a hematoma (a pool of blood under the skin/bruise) on the right forehead that measured 1.5 cm (centimeters) length x 1.3 cm width x 0.4 cm depth.
Review of the facility's investigation into the fall dated August 8, 2023, at 9:40 AM revealed that the facility reviewed the fall and staff education will be completed for team members to follow care plan of two assist with transfers and toileting.
During an interview with the Director of Nursing on August 25, 2023, at 12:45 PM it was confirmed that the staff did not follow the plan of care and only transferred the resident with the assistance of one staff rather than two staff.
28 Pa. Code 211.1(a)(c)(d) Resident care policies
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12(d)(1)(2) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of one resident rev...
Read full inspector narrative →
Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure the highest practicable pain management for one of one resident reviewed (Residents 37).
Findings include:
An observation and interview with Resident 37 on August 22, 2023, at 12:11 PM revealed the resident sitting in a chair beside her bed. [NAME] patches were observed on the resident's knees. Resident 37 stated the patches were to help lessen the number of pain pills, but she still needs one or two pills a day.
Clinical record review for Resident 37 revealed a physician's order dated June 28, 2023, for the resident to receive Tylenol 325 milligrams (mg), two tabs every four hours as needed for mild to moderate pain on a scale of one to seven. An additional physician's order dated June 28, 2023, indicated the resident was to receive Oxycodone with acetaminophen 5/325 mg tab every four hours as needed for severe pain of eight to 10.
A review of Resident 37's medication administration record for August 2023, revealed resident 37 received the Oxycodone with acetaminophen tablet at least daily throughout the month, and occasionally twice or three times a day. Review of the following dates revealed the Oxycodone with acetaminophen was administered outside of the pain parameters of eight to 10 as ordered.
August 4, 2023, administered for a pain level of six.
August 7, 2023, administered for a pain level of seven.
August 10, 2023, administered for a pain level of three.
August 16, 2023, administered for a pain level of six.
August 17, 2023, administered for a pain level of seven.
Resident 37 had not utilized the as needed Tylenol ordered for a pain level of one to seven at all during August 2023, even though the pain level indicated for the as needed medication was in the range ordered.
In an interview with the Director of Nursing on August 25, 2023, at 11:30 AM she confirmed the above findings.
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate medication security for one of three nursing units (100 Nursing Unit...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure appropriate medication security for one of three nursing units (100 Nursing Unit, Resident 23).
Findings include:
Observation of a medication administration pass with Employee 3, registered nurse, on August 23, 2023, at 9:40 AM revealed the following:
Employee 3 retrieved Resident 23's Firvanq liquid (Vancomycin, an antibiotic) from the medication room refrigerator, poured the physician ordered dosage, placed the Firvanq on top of the medication cart, proceeded to Resident 23's room, and administered the medication to her at 9:49 AM
Enroute to administering Resident 23's medications, Employee 3 proceeded to the treatment cart labeled 309 -318. She did not unlock the treatment cart prior to opening a drawer and removing Resident 23's Hydrocortisone cream (a steroid to reduce pain, itching, and swelling). She closed the treatment cart, did not lock it, proceeded to Resident 23's room, and administered the Hydrocortisone cream at 9:53 AM. At 9:59 AM, Employee 3 returned to the 309-318 treatment cart, opened a drawer without unlocking the cart, and returned Resident 23's Hydrocortisone cream to the cart. She did not lock the 309-318 treatment cart after returning the Hydrocortisone and before walking up the hall to the medication cart.
Interview and concurrent observation with Employee 3 at 10:02 AM confirmed that Resident 23's Firvanq was left unsecured on top of the medication cart while she administered Resident 23 her medications. Further interview and observation with Employee 3 at 10:08 AM of the 309-318 treatment cart confirmed that she did not unlock or lock the cart while she removed and replaced Resident 23's Hydrocortisone cream. Other resident medications noted in the unlocked 309-318 treatment cart included Betadine (a topical antiseptic), uni-solve adhesive remover (to remove tape residue), Ketoconazole (an antifungal medication), Terbinafine Hydrochloride (an antifungal medication), and Triamcinolone (a rash cream).
Employee 3 did not secure Resident 23's Firvanq medication while away from the medication cart and did not secure the medications in the 309-318 treatment cart while away from it.
Interview on August 23, 2022, at 2:30 PM with the Director of Nursing and Nursing Home Administrator acknowledged the above findings.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infe...
Read full inspector narrative →
Based on review of select facility policies and procedures, observation, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection on one of three nursing units (100 nursing unit, Resident 51).
Findings include:
The facility policy entitled, PSL COVID-19 Quick Reference PPE and Situation Guide last reviewed without changes on July 26, 2023, revealed that staff will wear full PPE (personal protective equipment), including a gown, when entering a patient with suspected or confirmed SARS-COV-2 (COVID-19) infection. PPE is to be changed with each resident encounter.
The facility policy entitled, Pandemic Policy and Procedure Manual last reviewed without changes on July 26, 2023, revealed that the facility will ensure all state, local, and federal infection control guidelines are followed. The facility will provide biohazard and/or standard waste receptacles to meet COVID-19 isolation needs.
The facility policy entitled, Infection Control Plan last reviewed without changes on July 26, 2023, revealed that staff will utilize standard precautions at all times and consider all blood and body fluids to be potentially infectious.
Clinical record review for Resident 51 revealed that her physician ordered droplet and contact isolation for confirmed COVID 19 infection on August 22, 2023.
Nursing documentation dated August 22, 2023, at 8:38 AM revealed that Resident 51 had a temperature of 100.4 degrees Fahrenheit, had scattered low pitched expiratory wheezes, and complained of lower back pain. A rapid (COVID 19) test was completed with positive results.
Observation of the 100 Nursing Unit on August 22, 2023, at 12:30 PM revealed that Employee 1, nurse aide, exited Resident 51's room with an infection control gown, N95 mask, and face shield. Employee 1 walked down the 100-nursing unit hallway and entered the unit's dirty utility room. At 12:31 PM, Employee 1 left the 100-nursing dirty utility room only wearing an N95 and face shield.
Interview with Employee 1 on August 22, 2023, at 1:00 PM confirmed that she cared for Resident 51, that Resident 51 was currently in a droplet and contact isolation (red) area due to being COVID 19 positive and acknowledged that she wore an isolation gown into the 100-nursing unit hallway, a non-isolation (green) area, after providing care to Resident 51. She indicated that the facility did not have an appropriate (red biohazard/isolation bin) garbage receptacle in Resident 51's room, therefore she left Resident 51's room to dispose of the isolation gown in the dirty utility room.
Observation of Resident 51's room on August 22, 2023, at 1:08 PM confirmed that there was no red bin isolation/biohazard garbage receptacle in the isolation room. There was a regular garbage bin available to place garbage after resident care.
Interview with Employee 2, nurse aide, on August 22, 2023, at 1:13 PM revealed that if there was no red isolation garbage receptacle in a resident room, staff were to remove the isolation gown, place it in a regular garbage receptacle, remove and tie the garbage liner, take the bagged gown to the dirty utility room, and dispose of the entire bag in the biohazard red garbage receptacle.
Observation of Resident 51's room on August 23, 2023, at 9:10 AM with the Director of Nursing (DON) again confirmed that there was no red bin, isolation, garbage receptacle in the isolation room. There was a regular garbage bin available to place garbage after resident care. Concurrent interview confirmed that there was no red isolation garbage bin in Resident 51's room, indicated that if there was no red bin in an isolation room, staff were to dispose of potentially infected isolation items in a regular garbage can and not wear potentially COVID 19 infected isolation gowns in non-isolation areas of the facility.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, it was determined that the facility failed to store food and maintain equipment in a sanitary manner and ensure temperature monitoring was in place to prevent...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to store food and maintain equipment in a sanitary manner and ensure temperature monitoring was in place to prevent the potential spread of food borne illness in the facility's main kitchen.
Findings included:
An observation of the facility's main kitchen on August 22, 2023, at 10:30 AM revealed the following:
A large immersion blender was stored and not in use, hanging on the wall in the preparation area. The shaft and blade portion of the blender (the parts which get immersed in food product) was not covered and exposed to dust and debris particles in the area. Employee 4, director of dining, stated it had not been used in a while.
Multiple sheet trays were observed stored in the preparation area on racks and shelves. The trays contained a black buildup, which was flaking on many of the trays.
A trash receptacle was observed pushed under a food preparation table with trash in the bin without a lid covering the bin. Employee 4 left the kitchen at the time of the observation and obtained a lid for the trash receptacle and proceeded to also cover others throughout the kitchen.
A clear plastic container was observed on a lower shelf of a prep table. The container was labeled as thick it, a plastic scoop covered in a white substance was observed sitting on the container on top of a small plastic zipper bag, the scoop was not covered.
Multiple China plates and bowls were observed stored on shelves behind the tray line food serving area. The items were sitting on plastic trays, which contained dust and dried food debris. The China was stored upright, not covered, and exposed to dust and debris particles in the air in the food preparation and serving area.
A two-door upright cooler was observed to have multiple beverages stored in it. Pitchers of liquid were observed stored on the shelves. Four glass pitchers partially full (one containing an orange liquid, one with a white liquid, one with amber colored liquid, and one with a clear liquid) were observed mixed in on the shelves with no lid and not covered. The pitchers were not labeled with the contents, a date they were placed there, or when they needed to be used by. Two open eight-ounce containers of milk were also observed in the cooler, neither contained a date it was opened, and one was labeled with a manufacturer's expiration date of August 21, 2023.
A follow up observation in the facility's main kitchen on August 24, 2023, at 12:04 PM revealed kitchen staff assembling resident meal trays for lunch. Observation of the steam table in which a staff member was serving food from revealed barbecue meatballs, mixed vegetables, rice, and mechanically altered versions of the same foods were being served.
In a concurrent interview with Employee 5, cook, who was standing at the steam table, she indicated the resident trays for all the resident rooms had been completed, and they were serving the dining room area next. When Employee 5 was asked for the log of food temperatures for the items in the steam table noted above that had been served for lunch, Employee 5 stated she had not written them down yet, but she checked them and everything was ok. When asked how she could remember the temperatures of multiple food items to write them down later, Employee 5 stated, she knows they are all hot enough and in the range they should be in, if something is too low, she would take care of it. Employee 5 then stated, that is just the way she did it as it worked for her. Employee 5 then provided a temperature logbook for meals that was sitting on a table behind her. Meal temperature for breakfast, lunch, and dinner for August 23, 2023, (the day prior) were observed in the book on a paper labeled with that date, as well as other sheets for earlier in the month. The next page was blank and not filled out with a date or any temperatures. Employee 5 was then asked if the temperatures of the breakfast meal served earlier in the day for August 24, 2023, were in the book, and Employee 5 stated she had not written them down yet either, and that she just writes them down all at once. There was no evidence of any temperature check for breakfast or lunch served on August 25, 2023, to ensure monitoring was in place to prevent the potential for food borne illness.
The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on August 24, 2023, at 2:05 PM.
42 CFR 483.60(i)(2) Store/Prepare/Distribute-Sanitary
Previously cited 9/9/22
28 Pa. Code 201.14(a) Responsibility of licensee
Mar 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to provide personal...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to provide personal hygiene for four of four residents reviewed (Residents 1, 2, 3, and 4).
Findings include:
Clinical record review for Resident 1 revealed that the facility completed a significant change MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) on December 7, 2022, which indicated that she was cognitively intact, that it was very important to choose between a tub bath, shower, bed bath, or sponge bath, and that she needed physical help by one staff member to complete bathing.
Review of Resident 1's significant change MDS dated [DATE], revealed that staff coded an 8 for bathing during her assessment review lookback period. Review of the MDS coding legend revealed that an 8 indicated that the ADL (activity of daily living) did not occur 100 percent of the time for that activity over the entire 7-day period.
Review of Resident 1's December 2022 and January, February, and March 2023 plan of care (POC) documentation (documentation on how staff provide resident care) and care plan documentation revealed that staff was to provide a bath on Tuesday and Thursday during the evening. POC and nursing documentation revealed that staff provided a whirlpool bath to Resident 1 on the following dates:
December 19, 2022, whirlpool bath
January 4, 2023, hospitalized , 12 days later
January 6, 2023, 4:50 PM, readmitted to the facility, staff indicated that Resident 1's bath was not provided/canceled.
January 16, 2023, whirlpool bath, 10 days later
January 26, 2023, whirlpool bath, 10 days later
February 11, 2023, whirlpool bath, 16 days later
February 14, 2023, whirlpool bath
March 4, 2023, whirlpool bath, 18 days later
March 16, 2023, whirlpool bath, 12 days later
March 25, 2023, 9 days later
Resident 1's POC documentation revealed that staff indicated Not Applicable, Service Not Provided/Canceled, or did not complete the documentation for bathing on the following dates:
February 2, 7, 9, 16, 21, 23, and 28, 2023
March 2, 9, 21, and 23, 2023
Review of a Community Grievance Form (a form to make the facility aware of resident concerns) dated February 13, 2023, revealed that Resident 1's responsible party informed the facility that Resident 1 was to be bathed on Wednesday, February 8, 2023, during night shift. Staff did not bathe Resident 1 until February 11, 2023, when the resident had to ask staff.
Interview with Resident 1 on March 29, 2023, at 2:20 PM revealed that she preferred to receive a whirlpool tub bath instead of a shower. She indicated that she frequently was unable to receive a whirlpool tub bath due to only one staff being available. She noted that she does not refuse to be bathed very often.
Clinical record review for Resident 2 revealed that the facility completed a quarterly MDS on November 22, 2022, which indicated that he needed physical help by one staff member to complete bathing.
Resident 2's significant change MDS completed on January 25, 2023, indicated that it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath and that he needed physical help by two staff members to complete bathing.
Review of Resident 2's December 2022 and January, February, and March 2023 POC documentation and care plan documentation revealed that he preferred showers in the afternoon. POC and nursing documentation revealed that staff provided a shower to Resident 2 on the following dates:
January 4, 2023, shower
January 22, 2023, shower, 18 days later
February 22, 2023, shower
March 5, 2023, shower, 11 days later
March 15, 2023, shower, 10 days later
March 19, 2023, shower
March 28, 2023, 9 days later
Clinical record review for Resident 3 revealed that the facility completed an annual MDS on November 10, 2022, which indicated it was somewhat important to choose between a tub bath, shower, bed bath, or sponge bath and that she was totally dependent on one staff member to complete bathing.
Resident 3's quarterly MDS completed on February 10, 2023, indicated that that she was totally dependent on one staff member to complete bathing.
Review of Resident 3's December 2022 and January, February, and March 2023 POC documentation and care plan documentation revealed that she preferred showers. POC and nursing documentation revealed that staff provided a shower to Resident 3 on the following dates:
January 1, 2023, shower
January 25, 2023, shower, 24 days later
March 8, 2023, shower
March 22, 2023, shower, 14 days later
Clinical record review for Resident 4 revealed that the facility completed an initial MDS on March 21, 2023, which indicated that he did not respond on the importance to choose between a tub bath, shower, bed bath, or sponge bath and that he needed physical help of one staff member to complete bathing.
Review of Resident 4's March 2023 POC documentation and care plan documentation revealed that he preferred to be bathed on Tuesday and Friday in the morning. POC and nursing documentation revealed that staff provided a bed bath to Resident 4 on the following dates:
Monday, March 20, 2023, bed bath
Monday, March 27, 2023, bed bath
There was no documentation that staff provided a tub bath or shower to Resident 4 since care planned on March 14, 2023.
Interview with the Nursing Home Administrator on March 29, 2023, at 1:30 PM acknowledged that staff were not providing showers or baths to residents.
28 Pa. Code 211.12(d)(1)(5) Nursing services
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Concerns
- • 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Heritage Ridge Senior Living At Windy Hill's CMS Rating?
CMS assigns HERITAGE RIDGE SENIOR LIVING AT WINDY HILL an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Heritage Ridge Senior Living At Windy Hill Staffed?
CMS rates HERITAGE RIDGE SENIOR LIVING AT WINDY HILL's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 54%, compared to the Pennsylvania average of 46%.
What Have Inspectors Found at Heritage Ridge Senior Living At Windy Hill?
State health inspectors documented 31 deficiencies at HERITAGE RIDGE SENIOR LIVING AT WINDY HILL during 2023 to 2025. These included: 29 with potential for harm and 2 minor or isolated issues.
Who Owns and Operates Heritage Ridge Senior Living At Windy Hill?
HERITAGE RIDGE SENIOR LIVING AT WINDY HILL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PRESBYTERIAN SENIOR LIVING, a chain that manages multiple nursing homes. With 90 certified beds and approximately 86 residents (about 96% occupancy), it is a smaller facility located in PHILIPSBURG, Pennsylvania.
How Does Heritage Ridge Senior Living At Windy Hill Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, HERITAGE RIDGE SENIOR LIVING AT WINDY HILL's overall rating (2 stars) is below the state average of 3.0, staff turnover (54%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Heritage Ridge Senior Living At Windy Hill?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Heritage Ridge Senior Living At Windy Hill Safe?
Based on CMS inspection data, HERITAGE RIDGE SENIOR LIVING AT WINDY HILL has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Heritage Ridge Senior Living At Windy Hill Stick Around?
HERITAGE RIDGE SENIOR LIVING AT WINDY HILL has a staff turnover rate of 54%, which is 8 percentage points above the Pennsylvania average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Heritage Ridge Senior Living At Windy Hill Ever Fined?
HERITAGE RIDGE SENIOR LIVING AT WINDY HILL has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Heritage Ridge Senior Living At Windy Hill on Any Federal Watch List?
HERITAGE RIDGE SENIOR LIVING AT WINDY HILL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.