Health inspection·July 8, 2025

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure neurological assessments including vital signs and neurological checks were completed following an unwitnessed fall for three of seven residents reviewed (Residents 1, 2, and 6).Findings include:The facility's policy for neurological assessments, dated November 4, 2024, indicated that neurological assessments are indicated upon physician's orders; following an unwitnessed fall; subsequent to a fall or other accident/injury involving head trauma; and when indicated by resident condition. When assessing neurological status, always include frequent vital signs. Perform neurological checks with the frequency as ordered or per fall protocol. The facility's neurological flow sheet indicated that vital signs and neurological checks were to be completed every 15 minutes for one hour, then every 30 minutes for one hour, then every hour for four hours, then every four hours for 24 hours.A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) assessment for Resident 1, dated May 30, 2025, revealed that the resident had mild cognitive impairment, was usually understood and usually able to understand others, required assistance with daily care needs, had two or more falls with no injury since the prior assessment, and had a diagnosis of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A nurse's note for Resident 1, dated May 14, 2025, at 7:25 a.m., revealed that the resident had an unwitnessed fall and had a bleeding abrasion to the left side of his scalp. The resident was sent to the hospital for a computed tomography (CT) scan of the head following a fall with head strike (impact to the head). A nursing note for Resident 1, dated May 14, 2025, at 11:23 a.m. revealed that the resident had returned from the hospital. There was no documented evidence that vital signs and neurological checks were completed per protocol after the resident returned from the hospital.Interview with the Director of Nursing on July 8, 2025, at 3:35 p.m. confirmed that neurological checks should have been completed for Resident 1 related to his unwitnessed fall with head injury. A quarterly MDS assessment for Resident 2, dated June 2, 2025, revealed that the resident was cognitively intact, required assistance with daily care needs, had two or more falls with no injury since the prior assessment and had a diagnosis of Multiple Sclerosis (MS)(chronic disease that affects nerves in the brain and spinal cord).A nurse's note for Resident 2, dated May 28, 2025, at 4:56 a.m., revealed that the resident had an unwitnessed fall. There was no documented evidence that vital signs and neurological checks were completed per protocol after an unwitnessed fall.Interview with the Director of Nursing on July 8, 2025, at 4:56 p.m. confirmed that there was no documented evidence that vital signs and neurological checks were completed per protocol after Resident 2's unwitnessed fall.An admission MDS assessment for Resident 6, dated April 24, 2025, revealed that the resident was cognitively impaired, required assistance with daily care needs, had wandering behaviors, had a bed and chair alarm for safety and had a diagnosis of dementia.A nurse's note for Resident 6, dated June 16, 2025, at 4:45 a.m., revealed that the resident had an Residents Affected - Few (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 07/08/2025 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)