Heritage Ridge Senior Living at Johnstown

In the surveyor’s words

From the most serious findings on record at Heritage Ridge Senior Living at Johnstown, in the surveyor’s own words.

• Immediate jeopardy, patternF600Apr 14, 2026

  Based on a review of facility policies, clinical records, grievances, and resident and staff interviews, it was determined that the facility failed to promptly take measures necessary to protect residents from sexual abuse after abuse was identified for four of 15 residents reviewed (Residents 1, 6, 7, 14). This failure placed the residents in immediate jeopardy due to the actual sexual abuse that already occurred, as well as the potential for further sexual abuse to occur. Findings include:Review of the facility's abuse policy, dated August 21, 2025, revealed that each resident has the right to be free from abuse.A comprehensive Medicare 5-day Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated December 16, 2025,… […]

• Actual harm, isolatedF607Apr 14, 2026

  Based on review of facility policies, personnel files, clinical records, and grievances filed by residents, as well as resident, family and staff interviews, it was determined that the facility failed to implement its abuse policy by not immediately protecting residents who were at risk of sexual abuse, which led to three more residents being sexually abused by a staff member for four of 15 residents reviewed (Residents 1, 6, 7, 14). Findings include:The facility's policy regarding abuse, dated August 21, 2025, indicated that any employee whose conduct gives rise to a reasonable suspicion of resident abuse may be immediately removed from the floor, and where appropriate suspended without pay pending an investigation and that facility staff were to investigate all possible incidents of… […]

• Actual harm, isolatedF610Apr 14, 2026

  Based on review of policies, clinical records, family member interview, resident interviews, and staff interviews, it was determined that the facility failed to complete thorough investigations of incidents to rule out sexual abuse, which led to three more residents being sexually abused by a staff member for four of 15 residents reviewed (Residents 1, 6, 7, 14). Findings include:The facility's policy regarding abuse, neglect, exploitation or misappropriation - reporting and investigating, dated August 21, 2025, revealed that all allegations were thoroughly investigated and that the employee who was accused of resident abuse would be placed on leave with no resident contact until the investigation is complete.A review of Nurse Aide 1's personnel file revealed that he completed facility… […]

• Actual harm, isolatedF600Aug 5, 2024

  Based on review of policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of three residents reviewed (Resident 3), resulting in a large laceration that required surgical intervention and repair. Findings include: The facility's policy regarding abuse and neglect, dated February 23, 2024, indicated that the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. […]

• No harm, potential for more than minimal, patternF835Apr 14, 2026

  Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of abuse.Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free of abuse.Findings include:The current job description for the NHA indicated that the primary purpose of this position was to direct the day to day functions of the… […]