Inspection visit

Health inspectionOctober 11, 2024

JULIA RIBAUDO EXTENDED CARE CENTERCMS #3954937 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policies, investigative reports, and staff interviews, it was determined the facility failed to ensure that two residents out of 21 sampled (Residents 35 and 64) were free from abuse perpetrated by another resident (Resident 76). Findings include: A facility policy titled Pennsylvania Resident Abuse Section: Abuse, Neglect, and Exploitation, last reviewed by the facility on December 15, 2023, revealed the facility will not tolerate abuse by anyone. Abuse is defined as the willful infliction of injury, intimidation, or punishment, resulting in physical harm, pain, or mental anguish. The policy indicates that physical abuse includes hitting, slapping, punching, and kicking. Verbal abuse is defined as the use of language that willfully includes disparaging and derogatory terms directed at residents or their families, regardless of the resident's age, ability to comprehend, or disability. Furthermore, the policy states that willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury. A review of clinical records, facility investigations, and incident reports indicated that Resident 76 abused Resident 64 on August 14, 2024, when he grabbed Resident 64's chin, shook her face, and told her to shut the f*%k up. Additionally, Resident 76 also abused Resident 35 on September 17, 2024, when he wrapped his arms around her from behind, resulting in faint bruising around Resident 35's neck. A clinical record review revealed that Resident 76 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities) and unspecified psychosis (symptoms that affect a person's cognition and cause detachment from reality). A review of a quarterly Minimum Data Set (MDS) assessment (MDS is a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 18, 2024, revealed that Resident 76 is severely cognitively impaired, with a BIMS score of 00 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0-7 indicates severe cognitive impairment). A clinical record review revealed that Resident 64 was admitted to the facility on [DATE], with (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 14 Event ID: 395493 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0600 diagnoses that include dementia. Level of Harm - Minimal harm or potential for actual harm A review of a quarterly MDS assessment dated [DATE], revealed that Resident 64 is severely cognitively impaired, with a BIMS score of 00. Residents Affected - Few A clinical record review revealed that Resident 35 was admitted to the facility on [DATE], with diagnoses that included dementia and panic disorder (an anxiety disorder where a person experiences sudden and repeated panic attacks-intense periods of fear or discomfort). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 35 is severely cognitively impaired, with a BIMS score of 3. A clinical record review revealed that Resident 76 has a history of behavioral symptoms, including physically and verbally abusive behaviors towards staff and involvement in a resident-to-resident altercation initiated on June 5, 2024. Goals in place indicate that Resident 76 will not threaten, scream, or curse at other residents, visitors, or staff, and will refrain from physical and verbal abuse towards others. A review of progress note documentation revealed that Resident 76 had known physical and verbal aggressive behaviors. A progress note dated July 29, 2024, at 7:48 AM, revealed that Resident 76 had an unprovoked verbal outburst towards staff. A progress note dated July 30, 2024, at 5:54 AM, revealed that Resident 76 had several verbal outbursts during the night. The note indicated he snapped, cursed, and yelled at staff, attempted to enter other residents' rooms, and kicked the nursing station gate. A facility incident and investigation report dated August 14, 2024, revealed that at 10:40 PM, Resident 76 was observed walking up to Resident 64, leaning down in front of her, grabbing her by the chin, shaking her face, and stating, shut the f*%k up. Staff intervened and separated the residents. The report indicates that both residents were assessed and no issues were noted. A witness statement provided by Employee 2, Nurse Aide (NA), revealed that on August 14, 2024, she heard Resident 64 yelling loudly and becoming agitated. She indicated that Resident 76 grabbed Resident 64 by the chin, shook her face, and told her to shut the f*%k up. Employee 2, NA, further indicated that while she moved Resident 64 away from Resident 76, they started slapping at each other. Further review of progress note documentation revealed that Resident 76's physical and verbal aggression continued following the resident-to-resident incident on August 14, 2024. A progress note dated August 22, 2024, at 6:25 PM, revealed that Resident 76 was yelling at other residents and attempting to grab them. A progress note dated August 25, 2024, at 5:14 PM, revealed that Resident 76 was grabbing other residents' meal trays at dinner, being nasty, and yelling. After multiple attempts, staff were able to redirect him. A progress note dated August 25, 2024, at 9:39 PM, revealed that when Resident 76 was redirected, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 2 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0600 he balled his fist and made a movement as though he was going to punch a nurse aide. Level of Harm - Minimal harm or potential for actual harm A progress note dated August 29, 2024, at 10:42 PM, revealed that Resident 76 was sitting in another resident's doorway, yelling at that resident. Residents Affected - Few A progress note dated September 7, 2024, at 9:07 PM, revealed that Resident 76 was extremely agitated and attempted to barricade himself in the room of a female resident. He was not redirectable by several staff members and was verbally and physically aggressive toward staff. A progress note dated September 11, 2024, at 3:27 PM, revealed that Resident 76 was confused and could become belligerent at times, needing a lot of redirection. The note indicated that he could become nasty at times and was not always redirectable. A progress note dated September 17, 2024, at 7:14 PM, revealed that Resident 76 was walking around the facility and hit a nurse aide in the chest. A progress note dated September 17, 2024, at 10:19 PM, revealed that Resident 76 was standing at the nurses' station when she heard Resident 35 arguing with him. The note indicates that Resident 76 bear-hugged and subsequently grabbed Resident 35 by the throat. Resident 76 remained agitated and easily provoked when redirection was attempted. A facility investigation and incident report dated September 17, 2024, revealed that Resident 76 put his arms around Resident 35, and while staff were approaching, he placed his hands around her neck. A witness statement dated September 17, 2024, revealed that Employee 3, NA, observed Resident 76 behind Resident 35 with his arms around her. Employee 3, NA, indicated that she yelled for him to let go of her. Employee 3, NA, reported that Resident 35 said he had choked her. The residents were separated, and Employee 3, NA, stayed with Resident 76. A Focused Head-to-Toe Observation form dated September 18, 2024, at 8:54 AM, revealed that Resident 35 was assessed following the resident-to-resident incident on September 17, 2024. The document indicates that there were faint bruises noted on Resident 35's neck, though the resident was not experiencing any pain. A social service note dated September 17, 2024, at 11:12 PM, revealed that Resident 35 was okay and, according to staff, did not appear to be in any distress. Social services will continue to monitor her, provide emotional support as needed, and a psychological services referral was made. A progress note dated September 23, 2024, at 11:00 AM, revealed that Resident 76 was evaluated post-incident without further issues or behaviors. The note indicated that Resident 76 receives external psychological/psychiatric services and a medication review is in progress. Interventions and precautions are in place and updated in the resident's care plan. A social service note dated September 24, 2024, at 4:19 PM, revealed that Resident 35 does not appear to be in any distress from the incident and shows no signs of being afraid. Social services provided emotional support, and psychological consultation will continue as needed. The facility failed to prevent the physical abuse of Residents 35 and 64 perpetrated by Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 3 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0600 76, which resulted in a grab of the face and hands wrapped around the neck. Level of Harm - Minimal harm or potential for actual harm During an interview on October 11, 2024, at approximately 10:00 AM, the Director of Nursing (DON) confirmed that it is the facility's responsibility to ensure residents are free from resident-to-resident abuse. The DON confirmed it is the facility's responsibility to ensure that Resident 76 does not verbally, physically, or emotionally abuse other residents. Residents Affected - Few The facility was aware of the physically aggressive behavior of Resident 76 but failed to demonstrate sufficient supervisory measures of this resident to monitor his whereabouts to prevent the physical abuse of other residents. 28 Pa. Code 201.14 (a) Responsibility of licensee 28 Pa. Code 201.18(e)(1) Management 28 Pa. Code 201.29(a) Resident Rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 4 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0623 Level of Harm - Potential for minimal harm Residents Affected - Some Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and facility-initiated transfer notices and a staff interview, it was determined the facility failed to provide written notices of facility-initiated hospital transfers of residents, with the reasons for the move in writing, to one out of 21 residents reviewed (Resident 53). Findings include: Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A review of the clinical record revealed that Resident 53 required to be transferred to the hospital on August 5, 2024, and was readmitted to the facility on [DATE]. A review of the facility provided Immediate Discharge/Transfer Notice revealed the resident required an immediate transfer/discharge to an acute care facility on August 5, 2024, because the resident's urgent medical needs cannot be met in the facility there was no medical reason for the transfer provided on this form. Interview with the Nursing Home Administrator on October 11, 2024, at approximately 1:30 PM confirmed that the facility failed to provide transfer information including the reason for the move in writing to both the resident and/or resident representative. 28 Pa. Code 201.29 (a)(c.3)(2) Resident rights FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 5 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, and staff interview, it was determined the facility failed to provide appropriate treatment and services to restore normal bowel function for one out of 21 residents sampled (Resident 75). Findings include: A review of facility policy titled Continence Management Program, last reviewed by the facility on December 15, 2023, revealed the facility will ensure a plan designed to manage incontinence is developed according to the resident's needs and capabilities. The policy indicates residents should be considered for a bowel incontinence program for those who require limited to extensive assistance in toilet use or who could benefit from a prompted or scheduled toileting plan. The license nurse will complete a new continence evaluation once they identify a pattern. The licensed nurse will develop a toileting plan, determining the approaches needed to achieve the goals. A clinical record review revealed Resident 75 was admitted to the facility on [DATE], with diagnoses that include cellulitis (infection of the skin) and morbid obesity (a condition where a person is extremely overweight characterized by a body mass index of 40 or higher). A review of an admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated July 22, 2024 revealed that Resident 75 is cognitively intact with a BIMS score of 13 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact). An Elimination-Continence and Retraining/Scheduled Toileting and Decision/Determination observation form dated July 17, 2024, at 11:38 PM indicated Resident 75 was reviewed for appropriateness for continence and retraining schedule. However, several areas of the form were not completed. The assessment indicates the resident is unable to walk to the bathroom and is completely aware of his toileting needs. The assessment indicated Resident 75 has no problems with communication or mental status. There was no documented evidence indicating the resident would benefit from a bowel incontinence schedule or determination for continence or retraining. The initial MDS assessment, Section H Bladder and Bowel, dated July 22, 2024, indicated Resident 75 is frequently incontinent of bowels (i.e. the resident was observed with two or more episodes of bowel incontinence). A care plan dated July 25, 2024, indicated Resident 75 has a problem with incontinence and experiences occasional incontinence with the bowel and bladder. Interventions developed to assist the resident indicate offering toileting after meals. A review of Resident 75's bowel tracking from his admission on [DATE], through October 9, 2024, revealed the resident experienced bowel incontinence on 96 occasions. Further review of the clinical record revealed there was no documented evidence the facility assessed Resident 75 to determine the appropriateness of a bowel management program. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 6 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0690 Level of Harm - Minimal harm or potential for actual harm During an interview on October 11, 2024, at approximately 9:30 AM, the Director of Nursing (DON) confirmed the facility failed to assess Resident 75 after identifying he is frequently incontinent of bowels or develop and implement interventions to minimize episodes of his incontinence or prevent his bowel incontinence. The DON confirmed that it is the facility's responsibility to ensure residents receive appropriate treatment and services are provided to restore normal bowel function. Residents Affected - Some 28 Pa. Code 211.12(d)(1)(5) Nursing services 28 Pa. Code 211.10(c) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 7 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select facility policy, observation, and staff interview, it was determined the facility failed to implement procedures to maintain records of controlled drugs and ensure accurate drug administration for one out of the 21 residents sampled (Resident 75) and failed to store drugs in a safe manner for one out of the 21 residents sampled (Resident 39). Findings include: A facility policy titled Long Term Care Facility Pharmacy Services and Procedures Manual 5.4 Inventory Control of Controlled Substance, last reviewed by the facility on December 15, 2023, revealed the facility should maintain separate individual controlled substance records on all Schedule II medications and any medication with a potential for abuse or diversion. The policy also indicates the facility should regularly check inventory records to reconcile inventory. The facility should regularly reconcile current inventory to the controlled medication declining inventory record and the resident's medication administration record. A facility policy titled Long Term Care Facility Pharmacy Services and Procedures Manual 6.0 General Dose Preparation and Mediation Administration, last reviewed by the facility on December 15, 2023, revealed that during medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to documenting the administration of controlled substances in accordance with applicable law. The policy also indicates that following medication administration, facility staff should take all measures required by facility policy and applicable law, including, but not limited to, the following: Document necessary medication administration information (e.g., when medications are opened, when medications are given) on appropriate forms. A clinical record review revealed Resident 75 was admitted to the facility on [DATE], with diagnoses that include cellulitis (infection of the skin) and neuropathy (a nerve problem that can cause pain, numbness, tingling, swelling, or muscle weakness in different parts of the body). A physician's order for Resident 75 to receive OXYcodone-acetaminophen 10mg - 325mg (Oxycodone is in a schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) was initiated on July 21, 2024, and discontinued on July 29, 2024, with instructions to administer one tablet every four hours for severe pain. A physician's order for Resident 75 to receive OXYcodone-acetaminophen 10mg - 325mg initiated on July 29, 2024, and discontinued on August 26, 2024, with instructions to administer one tablet every six hours for moderate to severe pain. A physician's order for Resident 75 to receive OXYcodone-acetaminophen 10mg - 325mg initiated on August 26, 2024, with instructions to administer one tablet every eight hours for moderate to severe pain. A review of facility clinical records revealed the facility utilizes a Controlled Medication Utilization Record to track, monitor, and reconcile each controlled medication, such as OXYcodone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 8 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of facility clinical records revealed the facility tracks medication administration for each resident by way of the Medication Administration Record (MAR). The MAR indicates the medication administered, time and date of administration, staff administering the medication, pain prior to the administration of medication, and clinical rationale for the administration of medication. A comparison of Resident 75's Controlled Medication Utilization Record with Resident 75's Medication Administration Record (MAR) from July 22, 2024, through October 9, 2024, revealed 19 entries indicating OXYcodone-acetaminophen 10mg - 325mg was utilized according to Resident 75's Controlled Medication Utilization Record. However, there was no documented evidence in Resident 75's MAR indicating the medication was administered. The following is a list of the dates where there is a discrepancy in Resident 75's Controlled Medication Utilization Record and MAR: July 25, 2024, at 6:00 AM July 29, 2024, at 6:00 PM July 30, 2024, at 8:30 AM August 1, 2024, at 12:30 AM August 3, 2024, at 2:30 PM August 8, 2024, at 5:30 AM August 8, 2024, at 9:30 AM August 9, 2024, at 11:00 PM August 11, 2024, at 12:30 AM August 13, 2024, at 5:30 AM August 16, 2024, at 8:00 AM August 19, 2024, at 9:30 AM August 22, 2024, at 9:40 PM August 23, 2024, at 5:45 AM August 23, 2024, at 7:00 PM August 28, 2024, at 9:45 PM August 30, 2024, at 2:40 PM September 2, 2024, at 5:30 AM September 19, 2024, at 12:00 AM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 9 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0755 Level of Harm - Minimal harm or potential for actual harm During an interview on October 11, 2024, at approximately 10:00 AM, the Director of Nursing (DON) was unable to explain the discrepancies between Resident 75's Medication Administration Record and Resident 75's Controlled Medication Utilization Record. The DON confirmed the facility failed to implement effective procedures to reconcile Resident 75's controlled substance medications (OXYcodone-acetaminophen 10mg - 325mg). Residents Affected - Some A facility policy titled Long Term Care Facility Pharmacy Services and Procedures Manual 5.3 Storage and Expiration Dating of Medications and Biologicals, last reviewed by the facility on December 15, 2023, revealed the facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. The policy also indicates the facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. A clinical record review revealed Resident 39 was admitted to the facility on [DATE], with diagnoses that include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs). A physician's order for midodrine 10 mg tablet (midodrine is used to treat sudden decreases in blood pressure through the constriction of blood vessels) for end stage renal disease initiated on April 6, 2024, with instructions to administer one tablet three times daily and to hold the medication if blood pressure is greater than 120 mmHg. During an observation on October 10, 2024, at 10:16 AM, two medication packs of midodrine 10 mg were observed in Resident 39's dialysis communication binder in the D Hall nursing station. The first medication packet was observed with four tablets remaining, and another medication pack was observed with 30 tablets. The dialysis communication binder is a tool that travels with the resident to an external hospice and indicates pertinent clinical resident information. During an interview at the same time as the observation, Employee 4, Registered Nurse (RN), indicated that the medication should not be stored in the dialysis communication binder or left in the nursing station. Employee 4, RN, indicated that medication should be secured in areas approved for appropriate medication storage. During an interview on October 11, 2024, at approximately 10:00 AM, the Director of Nursing (DON) confirmed it is the facility's responsibility to ensure medications are properly stored and secured. The DON confirmed that Resident 39's midodrine 10 mg should not be left in the dialysis communication binder in the nursing station. 28 Pa Code 211.5(f)(xi) Medical records 28 Pa Code 211.9(a)(1)(k) Pharmacy services. 28 Pa Code 211.12 (d)(1)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 10 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide adaptive dining equipment as required and prescribed for one resident out of 21 sampled (Resident 52). Residents Affected - Few Findings include: A review of the clinical record revealed that Resident 52 was admitted to the facility on [DATE], with diagnoses to include early onset Alzheimer's disease (a progressive brain disease that destroys memory and other important mental functions) diagnosed before the age of 65, protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health), and oropharyngeal dysphagia (swallowing problems occurring in the mouth and/or throat). Review of a Speech Therapy Discharge summary dated [DATE], revealed that Resident 52 was not able to self-control the rate and amount of food and liquids presented to him at meals. The resident was provided with a maroon spoon (an adaptive spoon with a narrow, shallow bowl) to decrease the size of the bolus (semi-solid mass of food) and provided with a small sip Provale cup (2 handled spout cup with a separate chamber inside which delivers specific volume in each mouthful. This prevents over-delivery of fluids and promotes safer swallowing) to decrease the risk of aspiration (when food or liquid enter a person's airways and eventually the lungs) and choking. Review of a current physician order dated April 5, 2024, revealed an order for the use of a maroon spoon and a 2 handled spout cup on all meal trays for food/liquid presentations. One-to-one nursing supervision for all food intake to provide assistance and cues to slow the rate and amount of food/liquid intake. Observation of the lunch meal on October 8, 2024, at 12:06 PM revealed that the above resident, with physician orders for the maroon spoon and 2 handled spout cup, was seated in the dining room and served his lunch meal with a white plastic spoon, a regular carton of milk and a regular plastic juice cup with a foil pull-back lid. The resident did not receive the maroon spoon or 2 handled spout cup as ordered. Observation of the lunch meal of October 9, 2024, at 12:28 PM revealed the resident was seated on a sofa by the nurses station with his lunch on a table tray positioned in front of him. His lunch meal was served with a stainless-steel spoon and a regular plastic juice cup with a foil pull-back lid with a straw inserted through the top of the foil. The resident did not receive the maroon spoon, or the 2 handled spout cup as ordered. The resident was being supervised by Employee 1 (Director of Rehab). Interview with Employee 1 on October 9, 2024, at 12:30 PM confirmed the maroon spoon and Provale cup were not being utilized at the time of the meal observation and that the facility failed to provide the resident with the prescribed adaptive eating/drinking equipment as ordered by the physician and required to prevent aspiration and choking. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 11 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on staff interview and review of professional literature, the facility's assessment, facility provided documentation, and review of the medical, psychiatric, and mental health conditions of the resident census, it was determined that the facility failed to conduct and document a facility-wide assessment, using evidence-based methods, which identified the specific resources necessary to care for its specific resident population. Findings include: Review of the Centers for Medicare and Medicaid Services Memorandum, Revised Guidance for Long-Term Care Facility Assessment Requirements (QSO-24-13-NH) dated June 18, 2024, revealed that the facility assessment must include an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide. Continued review revealed, The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served. Review of the Facility Assessment, last reviewed by the facility on July 26, 2024, failed to accurately identify the specific needs and services required by the various subsets and characteristics of the resident population. Review of the facility's Resident Matrix (list of all residents in the facility), dated October 8, 2024, revealed a total census of 86 residents. Of the 86 residents, the Matrix identified 30 residents with an Alzheimer's or dementia diagnosis. A review of the facility document titled Vital HealthCare Solutions dated October 11, 2024, identified residents currently receiving psychiatry and/or psychology services. Of the 86 residents in the facility, 47 residents were currently identified as receiving psychiatric and/or psychological services. The Facility Assessment presented to the survey team indicated there were no residents with behavioral health needs who would need special treatments and conditions despite the characteristics of the current resident population. The facility assessment failed to accurately reflect the current population in the facility and the behavioral health and dementia care needs of the residents to ensure resident safety. The Facility Assessment failed to include the resources needed, including an evaluation of the overall number of facility staff and the capabilities needed to ensure a sufficient and competent number of qualified staff are available to meet each resident's needs. During an interview on October 11, 2024, at 9:30 AM , the Nursing Home Administrator confirmed that the Facility Assessment did not contain all of the required information. 28 Pa. Code 201.14(a) Responsibility of licensee (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 12 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 0838 28 Pa. Code 201.18 (b)(1)(3)(e)(1)(2) Management Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 13 of 14 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 395493 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Julia Ribaudo Extended Care Center 1404 Golf Park Drive Lake Ariel, PA 18436 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 review of select facility policy, the facility's infection control log and staff interview, it was determined the facility failed to maintain and implement a comprehensive program to monitor and prevent infections in the facility. Residents Affected - Many Findings included: A review of facility policy titled Infection Prevention and Control Program Policy last reviewed by the facility on December 15, 2023, indicated that the facility must maintain an organized, effective facility-wide program designed to systematically prevent, identify, control, and reduce the risk of acquiring and transmitting infections; conduct surveillance of communicable disease and infectious outbreaks; and monitor employee health. A review of the facility's infection control data revealed the facility's infection control program failed to reflect an operational system to monitor and investigate causes of infection and manner of spread. There was no evidence of a system, which enabled the facility to analyze clusters, changes in prevalent organisms, or increases in the rate of infection in a timely manner. A review of facility infection control logs for November 2023 through October 2024 revealed the facility did not have accurate tracking of infections for the months of November 2023 through August 2024. A review of clinical records indicated that Resident 67 was treated for a fungal skin infection in the month of April 2024. Resident 69 was treated for was treated for a urinary tract infection in the month of July 2024. Resident 56 was treated for a c-diff infection in the month of August 2024. An interview with the Director of Nursing (DON) on October 11, 2024, at approximately 10:30 AM revealed the infection control tracking logs could not be located for November 2023 through August 2024. Interview with the Infection Preventionist on October 11, 2024, at approximately 10:45 AM confirmed the facility infection control logs were not complete and failed to maintain a comprehensive program to monitor and prevent infections. The facility failed to demonstrate that its infection control program included, at a minimum, a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, and visitors following accepted standards and guidelines. 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services. 28 Pa. Code 211.10(c)(d) Resident care policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395493 If continuation sheet Page 14 of 14

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Citations

7 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.

0600GeneralS&S Dpotential for harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0623GeneralS&S Bno actual harm
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
0690GeneralS&S Epotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0810GeneralS&S Dpotential for harm
F810 - Assistive devices
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
0838GeneralS&S Fpotential for harm
F838 - Facility assessment
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
0880GeneralS&S Fpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the October 11, 2024 survey of JULIA RIBAUDO EXTENDED CARE CENTER?

This was a inspection survey of JULIA RIBAUDO EXTENDED CARE CENTER on October 11, 2024. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at JULIA RIBAUDO EXTENDED CARE CENTER on October 11, 2024?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."

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.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·October 11, 2024