Health inspection·January 23, 2025

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on review of facility policies and written menus, as well as observations and staff and resident interviews, it was determined that the facility failed to ensure that dietary staff served the planned portion sizes and had condiments available per resident preference. Findings include: A facility policy related to menus, dated January 20, 2025, indicated that menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. Menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal. If a food group is missing from a resident's daily diet, the resident is provided an alternative means of meeting his or her nutritional needs. The facility's written menu for the breakfast meal on January 23, 2025, revealed that the residents were to receive two pancakes each, six ounces of breakfast grits, two slices of bacon, a single banana, six ounces of juice, eight ounces of whole or two-percent milk, and six ounces of coffee or hot tea. During an interview with Resident 5 on January 23, 2025, at 8:39 a.m. the resident was delivered his breakfast tray and stated that he was supposed to have more; that's it; the rest must have gone into the atmosphere. The resident's tray ticket revealed that he was to receive ground sausage with gravy, six ounces of breakfast grits, two pancakes, a single banana, six ounces of juice, eight ounces of whole milk, and six ounces of coffee or tea. Observations at that time revealed that Resident 5 had received a single pancake with syrup, ground sausage without gravy, and a glass of milk. He stated, that might be enough to hold me for an hour. During an interview with Resident 6 on January 23, 2025, at 8:47 a.m. the resident revealed that he received one pancake with syrup, two slices of bacon, and a glass of milk for breakfast. The resident's tray ticket revealed that he was to receive two slices of bacon, six ounces of breakfast grits, two pancakes, a single banana, six ounces of juice, eight ounces of whole milk, and six ounces of coffee. The resident indicated that he usually gets a small glass of orange juice and usually gets coffee but that generally comes before or after breakfast. He stated that he gets hungry sometimes. During an interview with Resident 7 on January 23, 2025, at 9:16 a.m., the resident revealed that she received one pancake with syrup, two slices of bacon, oatmeal, a glass of juice, and a glass of milk for breakfast. She indicated that she did not receive a banana and does not receive snacks. (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 3 Event ID: 395439 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 01/23/2025 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)