Health inspection·April 17, 2025

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete a thorough investigation for an incident that occurred for one of four residents reviewed (Resident 2). Residents Affected - Few Findings include: A facility policy for incident and accident reports, dated January 20, 2025, revealed that the accidents or incidents involving residents, employees, visitors and vendors, occurring on our premises shall be investigated and reported to the administrator. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 3, 2025, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had a diagnosis of dementia. Interview with the Social Worker on April 17, 2025, at 10:35 a.m. revealed an incident in March 2025 when Resident 2's spouse came to the facility, took Resident 2 out of the building, and attempted to put her in his vehicle to take her home. He made threats towards staff and the police were called. A Social Service note for Resident 2, dated March 20, 2025, at 4:27 p.m., revealed that the social worker had a conversation with Resident 2's daughter to provide an update regarding the resident's spouse attempting to take the resident from the facility. The Social Worker explained that the resident was unable to stand to get herself into the car and spouse became extremely frustrated with Resident 2 and with facility staff while they were attempting to explain the concern for her safety. The situation was de-escalated with police presence; however, the police did have to contact crisis related to a comment made by the spouse to the officer. Crisis did talk with resident's spouse and felt that he was okay to go home once he calmed down. The social worker explained that resident was safe and remained at the facility. The daughter voiced understanding and stated that she felt that the safest place for the resident was to remain at the facility. Interview with the Director of Nursing April 17, 2025, at 12:15 p.m. revealed that she was not aware that an investigation needed to be completed when a family member of a resident was involved. Interview with the Nursing Home Administrator on April 17, 2025, at 12:30 p.m. revealed that he signed a document that Resident 2's spouse was no longer permitted on the property following the incident on March 20, 2025, and that he was not aware that an investigation needed to be completed. 28 Pa. Code 201.18(e)(1) Management. Page 1 of 2 395439 395439 04/17/2025 Heritage Ridge Senior Living at Johnstown 807 Goucher Street Johnstown, PA 15905

F 0610 28 Pa. Code 211.10(d) Resident Care Policies. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code 211.12(d)(5) Nursing Services. Residents Affected - Few 395439 Page 2 of 2