Pennsylvania Department of Health
PLEASANT RIDGE MANOR- WEST
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

PLEASANT RIDGE MANOR- WEST
Inspection Results For:

There are 137 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


PLEASANT RIDGE MANOR- WEST - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey and an Abbreviated Complaint Survey completed on June 5, 2026, it was determined that Pleasant Ridge Manor West was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.\~
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Plan of Correction:

483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.

Observations:

Based on review of clinical records, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, and staff interview, it was determined that the facility failed to ensure that a quarterly Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), was completed within the required time frame for one of 37 residents reviewed (Resident R46).

Findings include:

The Long-Term Care Facility RAI 3.0 User's Manual, which provides instructions and guidelines for completing required MDS assessments, dated October 2024, indicated that the assessment reference date (ARD- the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 calendar days after the ARD of the most recent assessment of any type.

Resident R46's clinical record revealed an admission date of 2/12/24, with diagnoses that included Dementia (loss of cognitive functioning affecting a person's memory and behaviors), Transient Ischemic Attack ( TIA occurs when there is a brief interruption of blood flow to a part of the brain, leading to symptoms similar to those of a stroke that are temporary, typically lasting only a few minutes to a maximum of 24-hours), and Peripheral Vascular Disease (A common condition characterized by narrowed arteries that reduce blood flow to the limbs, primarily the legs, leading to symptoms like leg pain and cramping).

Resident R46's clinical record revealed an annual MDS Assessment with an ARD of 1/15/26. The next MDS assessment completed had an ARD of 5/21/26, 34 days past the required 92 calendar days.

During an interview on 6/4/26, at 10:40 a.m. Registered Nurse Assessment Coordinator confirmed that Resident R46's quarterly MDS ARD was past the required 92-days from his/her last MDS ARD.

28 Pa. Code 211.5(f) (ix) Medical records

Plan of Correction - To be completed: 07/31/2026

Preparation and/or evaluation of the following Plan set forth in these documents does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the Statement of Deficiency. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of federal and state law.

R46's Quarterly Minimum Data Sets was completed on 5/21/26. R46's previous Annual Minimum data sets was completed on 1/15/26. There was nothing that needed to be done at the time as the missed minimum data sets was noted and an minimum data sets was found. R46's next minimum data sets is scheduled for 8/20/26.

Utilization Review Director audited all residents minimum data set assessments to be sure there were no missed assessments. Any missed assessments had an minimum data sets initiated, completed and submitted to the Internet Quality Improvement and Evaluation System.

Education was provided by the Utilization Review Director to all minimum data sets staff on the required timeframe regarding minimum data sets assessments on 6/18/26.

The Utilization Review Licensed Practical Nurse/ Designee will run a weekly report to ensure assessments are timely. The Utilization Review Director/designee will be responsible to monitor these reports weekly and correct any inaccuracies.

Results of the reports will be shared with the Quality Assurance committee at our monthly meeting.

Completion date: 7/31/26

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.

Observations:

Based on review of clinical records and Minimum Data Set (MDS - federally mandated standardized assessment conducted at specific intervals to plan resident care), and staff interviews it was determined that the facility failed to ensure that MDS assessments accurately reflected the status of two of 36 residents reviewed (Residents R5 and R213).

Findings include:

Resident R5's clinical record revealed an admission date of 4/10/17, with diagnoses that included Malignant Neoplasm of Pancreatic Duct (Cancerous tumor that originates in the cells lining the ducts of the pancreas [a large gland behind the stomach which secretes digestive enzymes into the intestines]), Chronic Obstructive Pulmonary Disease (COPD a condition that prevents airflow to the lungs resulting in difficulty breathing), and Diabetes (a health condition caused by the body's inability to produce enough insulin).

Resident R5's physician's orders dated 11/24/25, revealed an order that the resident was admitted under Hospice Services with admitting diagnosis of Malignant Neoplasm of the Pancreatic Duct.

Resident R5's quarterly MDS with an Assessment Reference date (ARD) of 4/30/26, MDS Section O Special Treatments, Procedures, and Programs O0110 K1 "Hospice Care" was coded as "No."

During an interview on 6/4/26, at 11:58 a.m. Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident R5's 4/30/26 quarterly MDS was coded incorrectly and should have been coded "Yes" that he/she was receiving hospice services.

Resident R213's clinical record revealed an admission date of 11/21/25, with diagnoses that included difficulty swallowing, kidney disease, dementia, and adult failure to thrive [syndrome of progressive physical, cognitive, and functional decline, often marked by weight loss, poor nutrition, decreased appetite, and inactivity].

Resident R213's physician's orders dated 12/3/25, revealed an order to admit to Hospice services.

Resident R213's quarterly MDS's with an ARD of 2/19/26, and 5/14/26, MDS Section O Special Treatments, Procedures, and Programs O0110 K1 "Hospice Care" was coded as "No."

During an interview on 6/4/26, at 12:50 p.m. the Nursing Home Administrator confirmed that Resident R213's 2/19/26, and 5/14/26, quarterly MDS's were coded incorrectly and should have been coded "Yes" that he/she was receiving hospice services.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 211.5(f)(ix) Medical records

Plan of Correction - To be completed: 07/31/2026

R5 and R213 Minimum Data Set assessments were corrected and resubmitted on 6/16/26.

An audit was conducted and 6/16/26 of all current hospice residents to ensure Hospice was coded correctly on any minimum data sets completed since initiation of hospice services. All errors were corrected on 6/16/26.

Education was provided by the Utilization Review Director to all minimum data sets staff regarding proper coding of Hospice services on the minimum data sets.

The Utilization Review Director/Designee will be responsible to monitor weekly for accurate coding of Hospice services and results will be reviewed with the Quality Assurance Committee at the monthly meeting.

Additionally, the Utilization Review Director or Designee will review ten percent of all minimum data sets for accuracy on a monthly basis, to ensure all areas are accurate. The report will be reviewed at the monthly Quality Assurance meeting.

Completion Date: 7/31/26

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to maintain accurate and complete documentation for one of 36 residents reviewed (Resident R121).

Findings include:

Review of facility policy dated January 2026, entitled "Administering Medications" revealed "The individual administering the medication initials the resident's MAR (Medication Administration Record) on the appropriate line after giving each medication and before administering the next ones; As required or indicated for a medication, the individual administering the medication records in the resident's medical record: the date and time the medication was administered; the dosage; the route of administration; the injection site; any complaints or symptoms for which the drug was administered; any results achieved and when those results were observed; and the signature and title of the person administering the drug."

Resident R121's clinical record revealed an admission date of 12/1/25, with diagnoses that included Osteomyelitis of the vertebra, sacral and sacrococcygeal region(infection of the bone including the back and pelvis), Chronic Kidney Disease ( a long-term condition in which the kidneys are damaged and gradually lose their ability to function properly over time), and Diabetes (a health condition caused by the body's inability to produce enough insulin).

Review of Resident R121's May 2026 IV (Intravenous) Administration Record revealed the following orders:

Physician's order dated 5/4/26, for Central Line (an IV inserted in a vein near the heart): Document total volume infused per shift every shift related to osteomyelitis of vertebra, sacral, and sacrococcygeal region. Out of 82 opportunities to document completion, 58 were documented as completed and 24 were blank.

Physician's order dated 5/4/26, for Central Line: Flush all unused ports( a device used to deliver IV medications) with 10cc (cubic centimeter) NSS (normal saline solution) in 10cc syringe every shift related to osteomyelitis of vertebra, sacral, and sacrococcygeal region. Out of 82 opportunities to document completion, 58 were documented as completed and 24 were blank.

Physician's order dated 5/4/26, for Central Line: Flush port with 10cc NSS in 10cc syringe before and after medication administration every shift related to osteomyelitis of vertebra, sacral, and sacrococcygeal region. Out of 82 opportunities to document completion, 57 were documented as completed and 25 were blank.

Physician's orders with numerous start and stop dates for the month of May 2026, for Vancomycin HCL Intravenous Solution (an antibiotic administered by IV) for Osteomyelitis. Out of 51 total opportunities to document completion, 34 were documented as completed and 17 were blank.

During an interview on 6/4/26, at 12:10 p.m. the Director of Nursing confirmed that Resident R121's clinical records were incomplete regarding IV documentation.

28 Pa. Code 211.5(f)(ii)(viii) Medical records

28 Pa. Code 211.12(d)(1)(5) Nursing services

Plan of Correction - To be completed: 07/31/2026

R121 is alert and oriented. R121 was interviewed by the Director of Nursing and states no doses of medication or flushes were missed. Nurses were educated on the importance of timely documentation of R121's intravenous medication, flushes, and all documentation related to intravenous therapy.

An audit of residents currently on intravenous therapy was conducted on 6/16/26. All licensed nursing staff will be educated by the Assistant Director of Nursing on the importance of required documentation of intravenous therapy.

Registered Nurse shift report has been edited to include residents with intravenous therapy. Outgoing and incoming Registered Nurse will check at each shift change that all areas of intravenous therapy documentation are complete if ordered.

Director of Nursing or Designee will monitor all Registered Nurse shift reports weekly.

Results of the Registered Nurse shift reports will be forwarded to the Quality Assurance Committee for review at monthly meetings.

Director of Nursing or Designee will be responsible to monitor shift reports to ensure compliance.

Completion Date: 7/31/26

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