F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of facility policy, facility provided documentation, and staff interviews, it was determined that the
facility failed to protect one of four residents (Resident R1) from sexual abuse, prevent psychosocial and/or
physical harm, and physical discomfort that resulted in actual harm for Resident R1.
Findings include:
Review of facility policy Resident Rights dated 3/4/25, indicated residents have a right to be free from
mental physical, sexual abuse, exploitation, neglect, and involuntary seclusion: no one may mistreat,
threaten, or coerce a resident in anyway.
Review of the facility policy Abuse and Neglect dated 3/4/25, indicated Abuse is the willful infliction of injury,
unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental
anguish. Sexual abuse is defined as non-consensual sexual contact of any kind. Sexual abuse includes
unwanted touching, sexual harassment, inappropriate comments or requests of a sexual nature, and all
types of sexual assault or battery. Sexual assault or battery includes rape, sodomy, coerced nudity, and
sexually explicit photographing. Sexual contact with any person incapable of giving consent is also
considered sexual abuse. If residents are touched against their will or are incapable of stopping a person
from touching them inappropriately it is considered sexual abuse.
Review of the admission record indicated Resident R1 admitted to the facility on [DATE].
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25,
indicated the diagnoses of dementia (a general term for loss of memory, language, problem solving and
other thinking abilities that are severe enough to interfere with daily life), multiple sclerosis (MS - immune
system eats away at protective covering of nerve cells), anxiety disorder (a group of mental illnesses that
cause constant fear and worry and are characterized by sudden feelings of worry, fear, and restlessness),
and neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem).
-Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in
detecting cognitive impairment) score of four. The distribution indicated zero to seven as severe cognitive
impairment.
-Section GG0130 Self Care indicated resident is dependent for eating, oral hygiene, toileting, lower body
dressing, personal hygiene, transfers, and wheelchair propelling.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
395011
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Actual harm
Residents Affected - Few
Review of Resident R1's current care plan indicated the resident has impaired cognitive function and
impaired thought processes related to dementia. Monitor, document, and report to physician any changes
in cognitive function.
Review of Resident R1's social services progress note dated 3/17/25, at 5:57 p.m. indicated social service
was made aware that Confidential Employee (CE) E1 witnessed Resident R1's husband inappropriately
touching the resident's genital area. Social Service (SS) Employee E2 and Director of Nursing (DON) asked
Resident R1's husband to leave the facility. DON asked Resident R1 if her husband was touching her
inappropriately. Resident responded, YES. DON asked resident if she wanted her husband's visitation to
continue. Resident responded, No. SS Employee E2 repeated the series of questions with Resident R1 and
received the same answers. The DON and SS Employee E2 later repeated the series of questions for a
third time with Resident R1 and received the same answers.
Review of facility provided document Sexual: Family to Resident dated 3/17/25, at 1:30 p.m. indicated CE
Employee E1 reported to the DON and SS Employee E2 that she observed Resident R1's husband
touching Resident R1 inappropriately in the vaginal area.
Further review of the facility provided document Sexual: Family to Resident dated 3/17/25, at 1:30 p.m.
indicated Resident Description: Unable to give description. When asked if the husband touched Resident
R1 inappropriately, Resident R1 nodded her head Yes. Emotional support provided. No physical injuries
were noted post episode.
During an interview on 3/26/25, at 11:52 a.m. CE Employee E1 indicated on 3/17/25, in the morning a duty
was to pass out the daily chronicle (a listing of activities/events) and Resident R1's husband was in the
room. Later that afternoon, mail was being delivered to the resident rooms, approximate time was 1:30 p.m.
as a scheduled activity was due at 2:00 p.m. CE Employee E1 entered Resident R1's room to deliver mail
to Resident R2 who had the privacy curtain pulled due to using the bedside commode. CE Employee E1
turned away from the pulled privacy curtain towards Resident R1 and observed Resident R1's husband
sitting in the chair, had Resident R1's blanket pulled up, and observed his fingers inside of Resident R1's
vagina. The husband had a glove on one hand, and specifically had his middle and ring fingers inside
Resident R1's vagina. Resident R1 was lying in bed like always and looked teary eyed. CE Employee E1
immediately told nursing what was observed. The husband told Nurse Aide (NA) Employee E3 he wanted
to speak to CE Employee E1 personally but CE Employee E1 refused to speak with Resident R1's
husband. CE Employee E1 indicated frequently hearing the nursing staff speak with Resident R1's husband
telling him he can't touch his wife every 15 minutes with that glove on and the husband's response was
always She's my wife, I can touch her if I want. CE Employee E1 was visibly shaken and pale during the
interview and indicated being traumatized from what was observed and fearful of the husband.
During an interview on 3/26/25, at 9:59 a.m. NA Employee E3 indicated being employed as a nurse aide for
over five years and has cared for Resident R1 for a very long time. NA Employee E3 confirmed that CE
Employee E1 reported to her and Licensed Practical Nurse (LPN) Employee E4 that Resident R1's
husband was touching her vaginal area inappropriately. LPN Employee E4 and NA Employee E3
immediately went to Resident R1's room. Observed Resident R1's husband with one glove on the right
hand, sitting in the chair at bedside. Observed Resident R1's brief was ripped and when NA Employee E3
changed the brief post episode, there was a significant amount of Resident R1's pubic hair in the brief that
was not normally there. Staff notified the DON immediately.
The facility failed to protect and ensure that Resident R1 was free from sexual abuse perpetrated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 2 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600
Level of Harm - Actual harm
by the husband. Review of the Centers for Medicare and Medicaid Services psychosocial outcome guide,
application of the reasonable person concept, Resident R1 would have the expectation that she was safe in
her home and treated with respect and dignity. When the reasonable person concept is applied, Resident
R1 would have suffered psychosocial harm and humiliation due to being sexually abused by her husband.
Residents Affected - Few
During an interview on 3/27/25, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing
confirmed that the facility failed to protect one resident (Resident R1) from sexual abuse and prevent
psychosocial and/or physical harm and physical discomfort for Resident R1.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code 201.18 (e)(1) Management.
28 Pa. Code 201.29 (a)(c)Resident Rights.
28 Pa. Code 211.12 (d)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 3 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
Based on review of facility policy, education literature, clinical record review, and staff interviews, it was
determined that the facility failed to recognize and report timely suspicions of sexual abuse for one of three
residents (Resident R1) until it was actually witnessed by a staff member.
Findings include:
Review of the United States Code of Federal Regulations (CFR), 42 CFR §483.5. Sexual abuse
includes, but is not limited to:
-Unwanted intimate touching of any kind especially of breasts or perineal area (are located between the
thighs, including the anus and the scrotum or vagina);
-All types of sexual assault or battery, such as rape, sodomy (sexual intercourse involving anal or oral
copulation), and coerced (persuasion of a person to do something by the use of force or threats) nudity;
-Forced observation of masturbation and/or pornography; and
-Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or
distributing them. This would include, but is not limited to, nudity, fondling, and/or intercourse involving a
resident.
Generally, sexual contact is nonconsensual if the resident either:
-Appears to want the contact to occur, but lacks the cognitive ability to consent; or
-Does not want the contact to occur.
Review of the facility policy Abuse and Neglect dated 3/4/25, indicated Abuse is the willful infliction of injury,
unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental
anguish. Sexual abuse is defined as non-consensual sexual contact of any kind. Sexual abuse includes
unwanted touching, sexual harassment, inappropriate comments or requests of a sexual nature, and all
types of sexual assault or battery. Sexual assault or battery includes rape, sodomy, coerced nudity, and
sexually explicit photographing. Sexual contact with any person incapable of giving consent is also
considered sexual abuse. If residents are touched against their will or are incapable of stopping a person
from touching them inappropriately it is considered sexual abuse.
Review of facility provided education literature, Abuse Prevention Program dated 3/4/25, indicated residents
will be protected from abuse by anyone including, but not limited to facility staff, other residents,
consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors,
or any other individual. Identify and assess all possible incidents of abuse.
Review of Resident R1's social services progress note dated 3/17/25, at 5:57 p.m. indicated social service
was made aware that Confidential Employee (CE) E1 witnessed Resident R1's husband inappropriately
touching the resident's genital area. Social Service (SS) Employee E2 and Director of Nursing (DON) asked
Resident R1's husband to leave the facility. DON asked Resident R1 if her husband was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 4 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
touching her inappropriately. Resident responded, YES. DON asked resident if she wanted her husband's
visitation to continue. Resident responded, No. SS Employee E2 repeated the series of questions with
Resident R1 and received the same answers. The DON and SS Employee E2 later repeated the series of
questions for a third time with Resident R1 and received the same answers.
Interview on 3/26/25, at 9:59 a.m. Nurse Aide (NA) Employee E3 indicated being employed as a NA for
over five years and has cared for Resident R1 for a very long time. NA Employee E3 confirmed that CE
Employee E1 reported to her and Licensed Practical Nurse (LPN) Employee E4 that Resident R1's
husband was touching her vaginal area inappropriately. Indicated I've had suspicion before, but it was never
actually witnessed until now. Sometimes the husband asks to see her rectum. Numerous times the brief is
ripped, he always wears a glove only on one hand. I frequently have to tell him to stop touching her and if
Resident R1 needs something to come get me. I know he's messing around down there because I place
the foley in a certain way to keep it from rubbing her skin and when I change her the next time, the catheter
is in a different place than I left it, and the brief is ripped. Husband also messes with her G tube.
Interview on 3/26/25, at 10:16 a.m. NA Employee E6 indicated Husband creeps me out. Seems like every
time he's here her briefs are always ripped. It's been like that for years. We're always telling him to stop
touching her, but he denies doing it. Nobody ever saw him actually doing it. One day he asked to look at her
rectum. He's gotten stranger as of late. He was at the desk, and we asked him why do you have that ripped
glove on your hand, Husband replied because I'm touching stuff. We told him he can't touch her and to stop
touching her because she can't speak for herself. We have had the thought he may be doing something to
her, but we had no proof only suspicion. We've talked to our nurses about it. It's looked over as normal
behavior. He made me uncomfortable he's very weird and we hate when he walks in the facility. He just
stares at everyone and other residents.
Interview on 3/26/25, at 11:14 a.m. Licensed Practical Nurse (LPN) Employee E7 indicated she works
Resident R1's floor every Monday, Wednesday, and Friday. Was hired last July almost a year ago. I thought
he was just an overly loving husband, but he always wanted more even if we explained things to him. He
was always wearing that glove and asking for a glass of water. He'd say he wears the glove because he
doesn't want to get Resident R1 sick. We had to make him leave during care for privacy. There are three
other female residents in that room. When he leaves, we'll go check on her to see if he was messing with
her and/or her equipment. The catheter would generally be rearranged every time he visited.
Telephonic interview on 3/26/25, at 1:52 p.m. LPN Employee E4 indicated the husband come in at 11:00
a.m. and stays until dinnertime. He asks the same questions. This has gone for years. Almost every time
he's here the brief is torn. We'll go in and they change her before he arrives at 11:00 a.m. He'll arrive and
say there's something in her catheter. He'll say she needs changed and her brief will be dislodged usually
on the right side he sits on the left side. We've (nursing staff) told the DON's, Assistant DON's and
Administrators have talked with him about messing around with her brief. I don't know if he's messing with
her catheter. It made me uncomfortable that he messes with her brief and I've spoken with him, and he
denies it every time. He'll tell the aides the same thing. Always had gloves on. If he's down messing around
with her or whatever he's doing for the brief to become dislodged he's not pulling her privacy curtain. I have
thought he's doing inappropriate things; me and the girls have felt this way a long while. We reported it to
the DON. Back then we had a different DON that came up and spoke to him. The old DON spoke with him
because the NA's would be upset that he was doing something inappropriate. I think that's a suspicious
behavior because there's no reason for his hands to down there or messing with her brief. We told her what
we were going to do to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 5 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
check her and Resident R1 was pushing us away like. We don't know how long this could have been going
on because nobody ever witnessed it before 3/17/25.
Interview on 3/27/25, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that
the facility failed to recognize and report timely suspicions of sexual abuse for one of three residents
(Resident R1) until it was actually witnessed by a staff member.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code 201.18 (e)(1) Management.
28 Pa. Code 201.29 (a)(c)Resident Rights.
28 Pa. Code 211.12 (d)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 6 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
clinical record and facility document review and staff interview, it was determined that the facility failed to
provide the necessary services and failed to make certain appropriate treatment, and services for dementia
were provided to ensure safety for one of three residents (Resident R1).
Residents Affected - Few
Findings include:
Review of the facility Dementia-Clinical Protocol policy last reviewed 3/4/25, indicated for an individual with
a confirmed dementia diagnosis, the interdisciplinary team will identify a resident-care centered care plan
to maximize remaining function and quality of life.
Review of the facility Visitation policy dated 3/4/25, indicated incidents of any visitors' disruptive behavior
are documented in the resident's record. Some visitations may be subject to reasonable clinical and safety
restrictions that protect the health, security, and/or rights of the facility's residents.
Review of the admission record indicated Resident R1 admitted to the facility on [DATE].
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/26/25,
indicated the diagnoses of (a general term for loss of memory, language, problem solving and other
thinking abilities that are severe enough to interfere with daily life), multiple sclerosis (MS - immune system
eats away at protective covering of nerve cells), anxiety disorder (a group of mental illnesses that cause
constant fear and worry and are characterized by sudden feelings of worry, fear, and restlessness), and
neurogenic bladder (lack of bladder control due to a brain, spinal cord or nerve problem).
-Section C0500 indicated a Brief Interview for Mental Status (BIMS - is a screening test that aides in
detecting cognitive impairment) score of four. The distribution indicated zero to seven as severe cognitive
impairment.
Review of Resident R1's current care plan indicated the resident has impaired cognitive function and
impaired thought processes related to dementia. Monitor, document, and report to physician any changes
in cognitive function. Meet with her to discuss any issues and provide psychosocial support as needed.
Review of Resident R1's progress notes indicated the following:
-On 11/26/24, at 4:52 p.m. spoke with Resident R1's husband in great length regarding wounds and that
they are now healed. Husband is not understanding. It was explained in a different approach, and he stated
he understood. Ten minutes later questioning everything that we just spoke about. Showed pictures of the
healed wound and husband still did not understand.
-On 12/20/24, at 6:38 a.m. husband visits almost every day.
-On 12/20/24, at 2:07 p.m. RN was called to unit due to husband took off G- tube (a small flexible tube
surgically inserted through the abdomen and stomach wall to deliver nutrition, fluids, and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 7 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
medications directly into the stomach) dressing and kept messing with Foley catheter (a thin flexible tube
inserted into the urethra to drain urine from the bladder). Husband was educated on not removing dressing
and placing foley close to the patient.
-12/27/24, at 6:08 p.m. indicated resident last seen on 11/26/24, and a lot of time in psychosocial
support/care coordination with Resident R1's husband. Resident has history of worsening mood which is at
least partially attributable to Resident R1's MS, but also aggravated by her husband who seems to be
overly-involved.
-On 3/4/25, at 10:37 a.m. Resident R1 was in bed asleep however, her husband readily began to pour out
his heart and told me multiple different stories, reported he was working in his house, his knee buckled up
and he fell down 15 stairs he had broken a lot of bones and was hospitalized for three weeks, also admitted
that he was very upset that his wife hasn't been making any progress, that at this point it just seems like
she is never going to get better.
-On 3/4/25, at 1:44 p.m. Resident R1's husband came to the nursing station and asked if he could have a
glass of water to give Resident R1 because she was coughing. He stated that he thought she had been
cleared to have thin liquids. It was explained to him that there have not been any changes in her thickened
liquid status with pleasure trays.
-On 3/10/25, at 11:33 p.m. Resident R1's spouse was in to visit on 3-11 shift.
-On 3/17/25, at 5:57 p.m. indicated social service was made aware that Confidential Employee (CE) E1
witnessed Resident R1's husband inappropriately touching the resident's genital area. Social Service (SS)
Employee E2 and Director of Nursing (DON) asked Resident R1's husband to leave the facility. DON asked
Resident R1 if her husband was touching her inappropriately. Resident responded, YES. DON asked
resident if she wanted her husband's visitation to continue. Resident responded, No. SS Employee E2
repeated the series of questions with Resident R1 and received the same answers. The DON and SS
Employee E2 later repeated the series of questions for a third time with Resident R1 and received the same
answers.
Interview on 3/26/25, at 9:59 a.m. Nurse Aide (NA) Employee E3 indicated being employed as a NA for
over five years and has cared for Resident R1 for a very long time. NA Employee E3 confirmed that CE
Employee E1 reported to her and Licensed Practical Nurse (LPN) Employee E4 that Resident R1's
husband was touching her vaginal area inappropriately. Indicated I've had suspicion before. Sometimes the
husband asks to see her rectum. Numerous times the brief is ripped, he always wears a glove only on one
hand. I frequently have to tell him to stop touching her and if Resident R1 needs something to come get
me. I know he's messing around down there because I place the foley in a certain way to keep it from
rubbing her skin and when I change her the next time, the catheter is in a different place than I left it, and
the brief is ripped. Husband also messes with her G tube.
Interview on 3/26/25, at 10:12 a.m. Registered Nurse (RN) Employee E5 indicated Husband is odd.
Obsesses over Resident R1 over everything. Area Agency on Aging came out at one point.
Interview on 3/26/25, at 10:16 a.m. NA Employee E6 indicated Husband creeps me out. Seems like every
time he's here her briefs are always ripped. It's been like that for years. We're always telling him to stop
touching her, but he denies doing it. One day he asked to look at her rectum. He's gotten stranger as of
late. He was at the desk, and we asked him why do you have that ripped glove on your hand, Husband
replied because I'm touching stuff. We told him he can't touch her and to stop
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 8 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
touching her because she can't speak for herself. We have had the thought he may be doing something to
her, but we had no proof only suspicion. We've talked to our nurses about it. It's looked over as normal
behavior. He made me uncomfortable he's very weird and we hate when he walks in the facility. He just
stares at everyone and other residents.
Interview on 3/26/25, at 11:14 a.m. Licensed Practical Nurse (LPN) Employee E7 indicated she works
Resident R1's floor every Monday, Wednesday, and Friday. Was hired last July almost a year ago. I thought
he was just an overly loving husband, but he always wanted more even if we explained things to him. He
was always wearing that glove and asking for a glass of water. He'd say he wears the glove because he
doesn't want to get Resident R1 sick. We had to make him leave during care for privacy. There are three
other female residents in that room. When he leaves, we'll go check on her to see if he was messing with
her and/or her equipment. The catheter would generally be rearranged every time he visited.
Telephonic interview on 3/26/25, at 1:52 p.m. LPN Employee E4 indicated the husband came in at 11:00
a.m. and stayed until dinnertime. He asks the same questions. This has gone for years. Almost every time
he's here the brief is torn. We'll go in and they change her before he arrives at 11:00 a.m. He'll arrive and
say there's something in her catheter. He'll say she needs changed and her brief will be dislodged usually
on the right side he sits on the left side. We've (nursing staff) told the DON's, Assistant DON's and
Administrators have talked with him about messing around with her brief. I don't know if he's messing with
her catheter. It made me uncomfortable that he messes with her brief and I've spoken with him, and he
denies it every time. He'll tell the aides the same thing. Always had gloves on. If he's down messing around
with her or whatever he's doing for the brief to become dislodged he's not pulling her privacy curtain. I have
thought he's doing inappropriate things; me and the girls have felt this way a long while. We reported it to
the DON. Back then we had a different DON that came up and spoke to him. The old DON spoke with him
because the NA's would be upset that he was doing something inappropriate. I think that's a suspicious
behavior because there's no reason for his hands to be down there or messing with her brief. We told her
what we were going to do to check her and Resident R1 was pushing us away. We don't know how long this
could have been going on because nobody ever witnessed it before 3/17/25.
Interview on 3/27/25, at 2:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed that
the facility failed to provide the necessary services and failed to make certain appropriate treatment, and
services for dementia were provided to ensure safety for one of three residents (Resident R1).
28 Pa. Code 201.18 (e)(1) Management.
28 Pa. Code 201.29 (a)(c)Resident Rights.
28 Pa. Code 211.12 (d)(5) Nursing Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 9 of 10
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
395011
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Platinum Ridge Ctr for Rehab & Healing
1050 Broadview Boulevard
Brackenridge, PA 15014
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of job descriptions, clinical records, and staff interviews, it was determined that the
Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain
that necessary care and services were provided to residents to prevent sexual abuse.
Residents Affected - Few
Findings include:
Review of CFR §483.70 Administration. A facility must be administered in a manner that enables it to
use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental,
and psychosocial well-being of each resident.
Based on the findings in this report that identified that the facility failed to protect Resident R1 from sexual
abuse and prevent psychosocial and/or physical harm and physical discomfort that resulted in actual harm
for Resident R1. The facility failed to provide fundamental principal that applies to treatment and care
provided to facility residents. The facility failed to ensure that residents receive treatment and care in
accordance with professional standards of practice, facility policies, and resident rights.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (e)(1) Management.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395011
If continuation sheet
Page 10 of 10