Inspection visit
Inspection
13 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 13 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based on employee file review, policy review, and staff interviews, it was determined that the facility failed to
conduct timely, complete, and accurate background investigations for four of five employee files reviewed
(Employee 7, 8, 9, and 11).
Residents Affected - Some
Findings include:
Review of facility policy, titled Hiring, last reviewed August 16, 2024, revealed section 10 stated, Where
appropriate, background investigations may be conducted on persons making application for employment
with this facility and on current employees as per regulatory guidelines.
Review of Employee 7's personnel file revealed that Employee 7 was hired by the facility on August 19,
2024.
Review of Employee 7's application submitted to the facility revealed that Employee indicated, Yes, to the
question of, Have you ever been convicted of a felony or misdemeanor? Employee 7 did not have anything
recorded in the section below the question which stated, If yes, please explain.
Review of Employee 7's personnel file revealed the facility completed a criminal background check through
the Pennsylvania State Police on August 27, 2024.
Review of the criminal background check revealed the facility failed to submit the Employee's correct name
and the correct date of birth . Further, the submission did not include Employee 7's social security number.
Review of Employee 8's personnel file revealed Employee 8's hire date was August 25, 2024. Review of
Employee 8's personnel file revealed the facility did not conduct a criminal background check upon hire.
Employee 8's personnel file contained a criminal background check completed on December 20, 2021.
Review of Employee 9's personnel record revealed that Employee 9 was hired on August 16, 2024. Review
of Employee 9's personnel record revealed the facility did not conduct a criminal background check upon
hire. Employee 9's personnel record contained a criminal background check that was completed on
February 7, 2024.
Review of Employee 11's personnel file revealed Employee 11's hire date was July 16, 2024. Review of
Employee 11's personnel file revealed the facility did not conduct a criminal background check upon hire.
Review of Employee 11's personnel file revealed a criminal background check completed on January 23,
2024.
(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 11
Event ID:
395142
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
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 0607
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Further review of Employee 11's personnel record also revealed the facility did not verify that Employee
11's Registered Nurse license was unencumbered (active, with no professional or legal restrictions placed
upon the license). Review of Employee 11's personnel record revealed a license verification conducted on
January 23, 2024.
During a staff interview on October 16, 2024, Director of Nursing (DON) confirmed that the person who
would be responsible for alerting the facility to any criminal convictions or actions taken against a
professional license would be the employee.
During a staff interview on October 17, 2024, at approximately 11:15 AM, DON confirmed that the facility
should conduct criminal background checks and professional license verifications upon hire at the facility.
28 Pa code 201.18(b)(1)(3) Management
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 2 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, and staff interviews, it was determined that the facility failed to
provide the highest practical well-being by not following physician orders for two of 23 residents reviewed
(Residents 22 and 72).
Residents Affected - Some
Findings include:
Review of Resident 22's clinical record revealed diagnoses that included chronic kidney disease (CKD loss
of the ability of the kidneys to remove waste and concentrate urine) and congestive heart failure (CHF
when your heart muscle doesn't pump blood as well as it should).
Review of Resident 22's physician orders revealed an order for Fiasp FlexTouch Subcutaneous Solution
Pen-injector 100 Unit/milliliter (Insulin Aspart with Niacinamide) Inject as per sliding scale: If 140-180 = 2;
181-240 = 4; 241-300 = 6; 301-350 = 8; 351-400 = 10; if greater than 400 administer 10 units and call
physician, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic
polyneuropathy, with an order date of April 29, 2024.
Review of Resident 22's July 2024 Medication Administration Record (MAR) revealed on July 1, 2024, at
12:00 PM, Resident 22's blood sugar level was 229, and it was marked that Resident 22 received no units
of insulin at that time.
Review of Resident 22's August 2024 MAR revealed on August 14, 2024, at 8:00 AM, Resident 22 had a
blood sugar level of 140, and it was marked that Resident 22 received no units of insulin at that time.
Review of Resident 22's October 2024 MAR revealed on October 13, 2024, at 8:00 AM, Resident 22 had a
blood sugar level of 269, and it was marked they Resident 22 received no units of insulin at that time.
During an interview with the Nursing Home Administrator and Director of Nursing (DON) on October 17,
2024, at 11:30 AM, they revealed that Resident 22 is care planned for refusing medications, but they would
have expected it to have been marked as a refusal on the MARs if Resident 22 had refused insulin during
the days listed above.
Review of Resident 72's clinical record revealed diagnoses that included hypertension (elevated/high blood
pressure) and peripheral vascular disease (disease of the arteries that decreases circulation of blood in the
extremities of the body).
Review of Resident 72's clinical record revealed that on July 11, 2024, Resident 72 was examined by
consultative dental services.
Review of the consultation sheet revealed the dentist documented that Resident 72 had an abscess at the
site of an extracted tooth with pus drainage (sign of infection). As a result of the findings, the dentist
prescribed clindamycin (an antibiotic medication used to treat infections) 300 milligrams (mg - metric unit of
measure) two tablets stat (medical term used to indicate the medication or treatment should be provided
right away), then one tablet (equal to 300 mg) four times a day until 29 pills were used.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 3 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident 72's interdisciplinary progress notes revealed that on July 12, 2024, at 4:41 PM, DON
documented, [Resident 72] was seen by dentist on [July 11, 2024] for tooth pain at #6 retained root. Dentist
identified an abscess with pus exudate in addition to the pain. Antibiotic order for loading dose followed by
QID admin x7days .
Review of Resident 72's medication administration record revealed that Resident 72 did not receive the
initial dose of 600 mg of clindamycin.
Review of progress note entered on July 12, 2024, at 10:09 PM, by Employee 19 revealed it stated, The
medication [Clindamycin] is on order, spoke with pharmacy they stated the medication [should] arrive by
morning.
Review of Resident 72's clinical record revealed that Resident 72 did not receive the initial dose of
clindamycin 600 mg. Further, Resident 72 was not started on clindamycin 300 mg four times a day until July
13, 2024, at 6:00 PM.
During a staff interview on October 17, 2024, at approximately 11:15 AM, DON revealed that the
consultative dental service did not provide the consultation sheet with the order until July 12, 2024; at which
time, the order was transcribed. However, the facility did not have clindamycin available at that time and
would need the medication delivered from the pharmacy. DON confirmed that there was no documented
evidence that Resident 72 received the initial dose of clindamycin 600 mg. Further, since it was not
available at the time of administration, an administration prompt in the electronic medication administration
record did not occur again.
During the staff interview, DON stated that stat orders are expected to be provided in a time frame no less
than four hours.
Review of Resident 72's clinical record revealed that on July 16, 2024, Resident 72 was scheduled for an
appointment with an oral surgeon on September 18, 2024, at 3:15 PM.
Review of Resident 72's progress notes revealed that on July 31, 2024, at 8:50 AM, Employee 6
documented, [Employee 6] spoke with [oral surgeon's office staff] she updated this RN that resident will be
having teeth extractions on [August 8, 2024] at 10am .[Oral surgeon office staff] advised [Resident 72's]
Apixaban needs to be placed on hold 5 days prior to procedure .[Certified Registered Nurse Practitioner]
gave [verbal order] to place Apixaban on hold.
Review of Resident 72's clinical record revealed that staff did not hold Resident 72's Apixaban order for five
days leading up to the procedure and, as a result, Resident 72 was unable to have the procedure when
planned.
During a staff interview on October 17, 2024, at approximately 11:15 AM, DON revealed that Resident 72
was sent to the hospital on August 2, 2024, and returned August 3, 2024, and, upon returning, staff did not
continue the hold order for Resident 72's Apixaban.
During the staff interview, the DON revealed that staff should have continued the hold order for Resident
72's Apixaban upon returning to the facility on August 3, 2024.
42 CFR 483.25 Quality of care
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 4 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
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 0684
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 5 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
Based on observations, facility policy review, manufacturer label review, and staff interview, it was
determined that the facility failed to provide appropriate care and services to residents receiving tube
feedings for one of three residents with tube feedings reviewed (Resident 19).
Findings include:
Review of facility policy, Enteral Nutrition, revised November 2018, failed to reveal any expectation for
labeling an enteral nutrition bottle with the time or date that it was open and placed into use.
Review of Resident 19's clinical record revealed diagnoses of abnormal weight loss (unintentional weight
loss or weight loss without trying) and feeding difficulties (difficulties eating, chewing, or swallowing).
Observation of Resident 19 on October 15, 2024, at 10:14 AM, revealed that the Resident was lying in bed.
Beside the Resident's bed was a pole with tube feeding hanging. The tube feeding container was not
labeled with the time or date that the tube feeding was opened, or when the administration began.
Observation of Resident 19 on October 16, 2024, at 9:52 AM, revealed that the Resident was lying in bed.
Beside the Resident's bed was a pole with tube feeding hanging. The tube feeding container was not
labeled with the time or date that the tube feeding was opened, or when the administration began.
Review of current physician orders for Resident 19 on October 15, 2024, revealed a current order for
Resident 19 to receive enteral feeding, Jevity 1.5 cal (type of enteral feeding) at 60 ml/hr from 6:00 PM until
6:00 AM.
Review of product information for Jevity 1.5 cal, last updated November 9, 2022, revealed, once opened,
the product may be used for up to 48 hours after initial connection when clean techniques is used.
Otherwise, it should be discarded after no more than 24 hours.
Interview with the Director of Nursing at 12:35 PM, revealed the facility does not have a separate policy that
speaks to the labeling and dating of enteral nutrition, but the expectation would be that the nurse would
date the bottle when it is placed into use.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 6 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
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 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on facility document review and staff interviews, it was determined that the facility failed to complete
a performance review for nurse aide staff at least once every 12 months for five of five employees reviewed
(Employees 1, 2, 3, 4, and 5).
Residents Affected - Some
Findings Include:
Review of select facility documentation revealed that Employee 1 was hired on November 16, 1999;
Employee 2 was hired on January 4, 2019; Employee 3 was hired on March 27, 2007; Employee 4 was
hired on September 12, 2011; and Employee 5 was hired on May 1, 2006.
On October 16, 2024, at approximately 8:45 AM, the surveyor was provided with performance evaluations
for Employees 2, 3, and 5. Review of the performance evaluations revealed they were all dated as being
completed on October 15, 2024. No performance evaluations were provided for Employees 1 and 4.
On October 16, 2024, at 11:05 AM, the Director of Nursing (DON) stated that the facility has been working
on updating the performance evaluations because of the recent change in ownership and they were
starting staff with a clean slate.
In a follow-up interview with the DON on October 16, 2024, at 11:14 AM, she confirmed that there were no
performance evaluations completed prior to October 15, 2024.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.19(2) Personnel policies and procedures
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 7 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, policy review, and staff interviews, it was determined that the facility failed to ensure
drugs are stored in locked compartments and only accessible by authorized personnel for two of three
resident areas observed (100 Hall and 200 Hall).
Findings Include:
Review of facility provided policy, Disposal of Medications and Medication-Related Supplies, effective July
1, 2023, revealed, all discontinued and unused medications may be disposed of by the facility, and
medications to returned to the pharmacy should be secured until the time of pick-up.
An observation on October 15, 2024, at 10:11 AM revealed a round, white object on the floor in a resident's
room in the 100 Hall.
An immediate interview with Employee 6 (Registered Nurse), confirmed the round, white object to be a
medication (pill) and stated she would attempt to determine the type of medication.
An additional interview with Employee 6 on October 15, 2024, at 12:44 PM, revealed she was unable to
determine the name or origin of the medication.
An interview with the Director of Nursing (DON) on October 16, 2024, at 12:45 PM, confirmed she had
knowledge of the medication found on the floor in a resident room in the 100 Hall.
Observation of the 200-hall nursing station on October 16, 2024, at 12:30 PM, revealed one round white pill
with 210 inscribed on it. The pill was identified as Amlodipine (blood pressure medication) 5 mg tablet.
Interview with Employee 13 (Registered Nurse Supervisor) on October 16, 2024, at 12:30 PM, revealed
that a nurse had just been there wasting medication and must have dropped it.
Interview with the DON on October 17, 2024, at 1:35 PM, revealed an expectation that the facility policy
would have been followed and the medication would be secured.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 8 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, facility policy review, clinical record review, and resident and staff interviews, it was
determined that the facility failed to maintain a safe and sanitary environment that supports infection
prevention and control for seven of 25 residents reviewed (Residents 40, 49, 60, 66, 80, 83, and 86); and
failed to maintain an accurate data collection system of infection surveillance from January 2024 through
August 2024.
Residents Affected - Some
Findings Include:
Review of facility policy, titled Enhanced Barrier Precautions, with a revision date of March 2024, revealed
Enhanced barrier precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant
organisms (MDROs) to residents.
Further review of the policy revealed:
2.
EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident
care activities when contact precautions do not otherwise apply.
5.
EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or
indwelling medical devices regardless of MDRO colonization.
a.
Wounds generally include chronic wounds (i.e., pressure ulcers, diabetic foot ulcers, venous stasis ulcers,
and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears.
b.
Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies.
Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs.
6.
EBPs remain in place for the duration of the resident's stay or until resolution of the wound or
discontinuation of the indwelling medical device that places them at increased risk.
Review of facility policy, titled Coronavirus Disease (COVID-19) - Using Personal Protective Equipment,
revised May 2023, revealed, when caring for a resident with suspected or confirmed SARS-CoV-2 infection,
personnel who enter the room of the resident will adhere to standard precautions and use a NIOSH
(National Institute for Occupational Safety and Health)-approved N95 mask or equivalent or higher-level
respirator, gown, gloves, and eye protection.
Observation of Resident 40 on October 15, 2024, at 11:34 AM, revealed Resident 40 with an indwelling
catheter. Observation of Resident 40's room revealed no signage on the door indicating that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 9 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Resident 40 was receiving EBP.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident 49's clinical record revealed that Resident 49 received tube feeding through a G-tube
and that Resident 49 has a pressure ulcer (a skin injury caused by prolonged pressure on a specific area of
the body) to the left heel.
Residents Affected - Some
Observation of Resident 49's room on October 15, 2024, at 11:26 AM, revealed no signage on the door
indicating that Resident 49 was receiving EBP.
During an interview with the Director of Nursing (DON) on October 17, 2024, at 10:10 AM, she stated that
the aforementioned residents should be on EBP.
Review of Resident 60's clinical record revealed diagnoses that include COVID-19 (Respiratory virus).
Observation of Resident 60's room door on October 15, 2024, at 12:20 PM, revealed a sign that said,
Quarantine Room: Gloves, gown, N95, face shield when entering room.
Observation of Employee 12 on October 15, 2024, at 12:20 PM, revealed him walking into Resident 60's
room to serve Resident 60 lunch, wearing only an surgical mask and disposable gown for PPE. When
Employee 12 was finished in the room, he exited the room and hung his used disposable gown on the PPE
cabinet located in the hallway outside of Resident 60's room.
Review of Resident 60's clinical record revealed that Resident 60 had received a positive COVID-19 test on
October 10, 2024, at 8:51 PM.
Review of Resident 60's care plan on October 16, 2024, at 12:30 PM, revealed a care plan for Resident 60
is positive for COVID-19, with an intervention of maintain standard and transmission-based precautions,
with a date initiated of October 11, 2024.
Interview with the DON on October 17, 2024, at 10:38 AM, revealed that the facility policy should have
been followed and appropriate PPE worn.
Observation of Resident 66 on October 15, 2024, at 11:01 AM, revealed the use of an indwelling catheter.
Observation of Resident 66's room door revealed no signage on the door indicating that Resident 66 was
receiving EBP.
Review of Resident 80's clinical record revealed diagnoses included hypertension (elevated/high blood
pressure) and peripheral vascular disease (disease of the arteries that decreases blood circulation in the
extremities).
During a resident interview with Resident 80 on October 15, 2024, at approximately 12:00 PM, it was
observed that Resident 80 had a sutured wound of the face.
Observation of Resident 80's room entrance failed to reveal any indication that Resident 80 was on EBP.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 10 of 11
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
395142
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/17/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Amoroso Healthcare and Rehabilitation Woodridge
3625 North Progress Ave
Harrisburg, PA 17110
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Review of Resident 80's physician orders failed to reveal any orders for Resident 80 to be on EBP.
Level of Harm - Minimal harm
or potential for actual harm
Interview with the DON on October 17, 2024, at 11:30 AM, revealed that the facility policy should have
been followed and Resident 80 should have been on EBP because of his medical conditions.
Residents Affected - Some
Review of Resident 83's clinical record revealed diagnoses included hypertension and congestive heart
failure (CHF disease process that results in decreased ability of the heart to pump blood to the body).
Review of Resident 83's clinical record revealed that Resident 83 had a gastrostomy tube (surgically placed
opening to the stomach through the abdominal tissue) for hydration and medication.
Observation of Resident 83's room entrance failed to reveal any indication that Resident 83 was on EBP.
Review of Resident 83's physician orders failed to reveal any orders for Resident 83 to be on EBP.
Interview with the DON on October 17, 2024, at 11:30 AM, revealed that the facility policy should have
been followed and Resident 83 should have been on EBP because of his medical conditions.
Review of Resident 86's clinical record revealed diagnoses of pressure ulcer of sacral region (ulcer, caused
by pressure, located in the sacral region) and acute kidney failure (AKF a sudden decline in kidney
function).
Observation of Resident 86's room door failed to reveal any signage or any other notification that Resident
86 was on EBP. Further observation of Resident 86 at that time revealed the Resident lying in his bed and
the Resident had an indwelling catheter.
Review of Resident 86's physician orders failed to reveal any orders for Resident 86 to be on EBP.
Review of Resident 86's care plan failed to reveal any plan of care for Resident 86 to be on EBP.
Interview with the DON on October 17, 2024, at 11:00 AM, revealed that the facility policy should have
been followed and Resident 86 should have been on EBP because of his medical conditions.
On October 17, 2024, at 10:08 AM, the DON provided the facility's data collection of infection surveillance
for September 2024. She stated that January 2024 through June 2024 was done electronically under the
facility's prior ownership and, since the new owners took over, she was unable to access the monthly
infection surveillance for January 2024 through June 2024.
In a follow-up correspondence from the DON on October 17, 2024, at 12:52 PM, she stated that, in addition
to not being able to access the infection surveillance for January through June, she was also unable to
locate the monthly infection surveillance for July 2024 and August 2024.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 211.1(a)(c)Reportable diseases
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
395142
If continuation sheet
Page 11 of 11
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Back to topCitations
13 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F607 - The facility must develop and implement written policies and procedures that:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F730 - Regular in-service education
Observe each nurse aide's job performance and give regular training.
- 0133GeneralS&S Epotential for harm
Install a two-hour-resistant firewall separation.
- 0324GeneralS&S Bno actual harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Cno actual harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Bno actual harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the October 17, 2024 survey of AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE?
This was a inspection survey of AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE on October 17, 2024. The surveyor cited 13 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AMOROSO HEALTHCARE AND REHABILITATION WOODRIDGE on October 17, 2024?
Yes, 13 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.