Health inspection·December 18, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that food was served under sanitary conditions, and by failing to properly label and date refrigerated and frozen foods. Findings include: The facility's policy regarding food labeling and dating, dated February 23, 2024, revealed that leftovers and open foods shall be clearly labeled with the date the food item is to be discarded. Food items to be labeled and dated included items prepared in house and food items that are opened and stored for later use. The facility's policy for cleaning standards, dated February 23, 2024, revealed that food contact surfaces, non-food contact surfaces, equipment, pans, and utensils must be kept clean at all times. This includes but not limited to free of grease deposits, food residue, dust, and other soil accumulation/debris. Observations in the facility's kitchen on December 18, 2024, at 8:44 a.m. revealed that in the dry storage area there was a plastic storage container labeled breadcrumbs maple syrup that was not dated and two bags of pasta noodles that were opened and undated. There were also five packs of hot dog buns, one pack of rolls, three bags of tortilla shells, and four loaves of bread with no labels or dates. Four large cans of tomato soup and 11 cans of cream of mushroom soup were not clearly labeled with a discard date. Observations in the walk-in cooler on December 18, 2024, at 8:47 a.m. revealed a plastic container labeled chicken noodle soup and a plastic container labeled gravy, both with a discard date of December 12 written on the label. A glass jar containing beets was labeled with a discard date of December 5, and a plastic container of crushed pineapple was labeled with a discard date of December 13. There was a medium-size plastic container of wilting lettuce left open to air and undated. Two sealed bags of chopped lettuce had use-by dates of December 15. Two packages of frozen loin-style meat that were not labeled or dated was observed thawing on a shelf next to a metal container covered in plastic wrap labeled shredded pork and a metal container covered in plastic wrap labeled pork gravy. Observations in the walk-in freezer on December 18, 2024, at 8:49 a.m. revealed debris scattered on the floor including two containers resembling pudding cups on the floor under a shelf. Observations of a portable drink cooler on December 18, 2024, at 8:49 a.m. revealed three trays of chocolate milk pre-poured into plastic cups, one tray of white milk pre-poured into plastic cups, one tray of orange juice pre-poured into plastic cups, and three trays of other juices pre-poured into plastic cups. There were no labels or discard dates on any cup or tray containing the milk and juice. There were also three small refrigerators under a table along the wall that contained one tray of chocolate milk pre-poured into plastic cups and one tray of juice pre-poured into plastic cups that were not labeled or dated. Observations of the work/prep space in the kitchen on December 18, 2024, at 8:50 a.m. revealed a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395439 If continuation sheet Page 2 of 3 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 395439 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Ridge Senior Living at Johnstown 807 Goucher Street Johnstown, PA 15905 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stainless-steel table with an open drawer containing utensils. The bottom of the drawer was scattered with a brown substance and had a black/dark brown clump of unknown substance making contact with the utensils. The stainless-steel prep table containing a sink that was behind the tray line area had two drawers in it. The drawer on the left side had an accumulation of crumbs and debris in it and the drawer on the right side was lined with brown pieces of paper taped together. Three stainless-steel table tops, as well as the front and sides of the stainless-steel cooler, appeared streaked or spotted with unknown substances. A plastic container containing sugar and a plastic container containing flour were observed under the table along the back wall of the kitchen. Both containers were streaked and spotted with an unknown substance and the sugar container had a white scoop sitting in the sugar. The deep fryer had a significant amount of grease build up on both sides of it as well as on the floor underneath it. The stove beside the deep fryer and the oven beside the stove were splattered with markings appearing to be food or grease splatters. A personal protective mask and a paper towel were observed on the floor behind the ice machine. Interview with the Dietary Manager at the time of the observations confirmed that the food items in the dry storage area were not labeled and dated per facility policy; the chicken noodle soup, gravy, beets, crushed pineapple, and lettuce in the walk-in cooler were past the identified discard date and should have been removed; and the frozen meat in the walk-in cooler should not have been thawing next to prepared foods. The interview also confirmed that milk and juices poured in cups to be placed on residents' meal trays should have been dated and labeled, and that the stainless steel appliances, tabletops, drawers, stove, oven, deep fryer, and floor under the deep fryer did not appear to be free of grease deposits, food residue, dust, and other soil accumulation/debris. Interview with the Dietary Manager on December 18, 2024, at 12:38 p.m. revealed that the dietary staff are responsible for cleaning and sanitizing the kitchen and that the dietary staff were to have lists of daily cleaning tasks that were to be completed; however, those tasks were not being completed by the dietary staff. 28 Pa. Code 211.6(f) Dietary services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395439 If continuation sheet Page 3 of 3