Inspection·April 4, 2023

F 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm Based on review of facility financial records and clinical records, as well as staff interviews, it was determined that the facility failed to convey and provide a final accounting of a resident's funds upon discharge from the facility within 30 days as required for seven of seven residents reviewed (Residents 1, 2, 3, 4, 5, 6, 7). Residents Affected - Some Findings include: Physician orders for Resident 1 dated July 22, 2022, indicated that he was discharged to home. A check request form, dated December 20, 2022, revealed that a check was requested in the amount of $398.00 for a refund that was due to Resident 1, as a result of overpayment. The refund to Resident 1 was paid on December 27, 2022 (158 days after being discharged ). A nursing note for Resident 2, dated July 15, 2022, at 7:35 p.m. revealed that the resident ceased to breath and her family member was notified. A facility e-mail, dated December 27, 2022, revealed that a refund for Resident 2 was late and needed paid as soon as possible. A check request form, dated January 12, 2023 revealed that a check was requested in the amount of $1665.30 for a refund that was due to Resident 2's family, as a result of overpayment. As of April 4, 2023, there was no documented evidence that Resident 2's refund was paid out to the resident's family. Interview with the Business Office Manager on April 4, 2023, at 9:01 a.m. revealed that Resident 2 was the only resident refund that had not been paid. She indicated that she was having a hard time getting it paid and that it should have been paid by August 15, 2022. Physician's orders for Resident 3, dated October 20, 2022, indicated that he ceased to breath. A check request form, dated December 21, 2022, revealed that a check was requested in the amount of $648.40 for a refund that was due to Resident 3's family, as a result of overpayment. The refund to Resident 3's family was paid on December 27, 2022 (68 days after being discharged ). Physician orders for Resident 4, dated November 7, 2022, indicated that he ceased to breath. A check request form, dated December 20, 2022, revealed that a check was requested in the amount of $957.00 for a refund that was due to Resident 4's family, as a result of overpayment. The refund to Resident 4's family was paid on December 27, 2022 (52 days after being discharged ). A nursing note for Resident 5, dated October 21, 2022, at 11:52 p.m. revealed that the resident ceased to breathe and her family member was at bedside. A check request form, dated December 20, 2022, (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 2 Event ID: 395652 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 395652 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ridgeview Healthcare and Rehabilitation Center 30 Fourth Avenue Curwensville, PA 16833 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)