Pennsylvania Department of Health
PLEASANT RIDGE MANOR- WEST
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 55 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:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on June 9, 2026, at Pleasant Ridge Manor-West, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0000

Facility ID #311002
Component 03
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on June 9, 2026, it was determined that Pleasant Ridge Manor-West was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a three-story, Type II (222), fire resistive building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD General Requirements - Other:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

General Requirements - Other
List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0100

Based on document review and interview, the facility failed to maintain Pennsylvania Act 48 regulations for one of one policy for carbon monoxide detectors.

Findings include:

1. Document review on June 9, 2026, at 11:47 a.m., revealed the facility lacked a documented carbon monoxide detector policy.

Interview with the facilities manager on June 9, 2026, at 11:47 a.m., confirmed the carbon monoxide detector policy was unavailable at the time of the survey.

2. Document review on June 9, 2026, at 9:25 a.m., revealed the facility failed to provide a set of accurate, portable floor plans. The Division of Safety Inspection is requiring that all facilities under its jurisdiction provide a portable, accurate floor plan on-site, to be used during the Life Safety Code Survey.

The Life Safety Code Floor Plan shall include the following:

a. Smoke barrier walls (outside wall to outside wall);
b. Fire barrier walls (1-2 hour walls);
c. Horizontal exits;
d. Rated rooms (storage rooms, soiled utility rooms, designated medical gas rooms) will be clearly designated. It is the facility's responsibility to have all rated rooms indicated on its Life Safety Code Floor Plan;
e. Required exits should be clearly noted;
f. Shaft walls.

The facility also had corridor access to a shaft exceeding one building level with a 20-minute fire-rated door installed.

Interview with the maintenance supervisor on June 6, 2026, at 9:25 a.m., confirmed the Life Safety Code Floor Plan provided during the survey failed to accurately contain the listed items.

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.

1. The Maintenance department has developed a preventative maintenance program for maintenance of the Carbon Monoxide policy. The current policy will be added to the Pleasant Ridge Manor Life Safety Compliance book.

A monthly Quality Assurance Monitor is completed by the Maintenance Supervisor to assure that the current Carbon Monoxide policy was added to the Life Safety Compliance Book and it's location is confirmed by the Director of Environmental Services.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion Date: June 26, 2026

2. Pleasant Ridge Manor has adopted an updated set of prints of the facility. These print shall be portable with the following information.
a. Smoke barrier walls
b. Fire barrier walls
c. Horizontal exits
d. Fire rating on rooms
e. Required exits and Shaft walls

The prints will be monitored by the Maintenance Supervisor and/or designee.

Completion date: July 31, 2026

3. Pleasant Ridge Manor will have the 20 minute fire rated door at Unit H crawl space access replaced with a 90 minute steel door. This new door will be matched with a door closer.

The door will be checked monthly for closer with our Door Latch preventative maintenance.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion date: July 31, 2026

NFPA 101 STANDARD Egress Doors:

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.

Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0222

Based on observation and interview, the facility failed to maintain egress door requirements for two of over ten egress doors.

Findings include:

Observation on June 9, 2026, at 11:10 a.m., revealed the clinic doors had two-step locking arrangements installed that required special knowledge to open and egress in the event of an emergency.

Interview with the maintenance technician on June 9, 2026, at 11:10 a.m., confirmed the egress door deficiency.

Plan of Correction - To be completed: 06/15/2026

The Maintenance Department has a monthly preventative Maintenance that checks the doors for latching and ease of operation, checking for locking mechanisms on our doors will be added to our door latch preventative maintenance.

The Clinic door hardware on both doors have been replaced with Lever lock door hardware that release the door in one motion. An assessment of the rest of the facility has been completed to assure there is no other antiquated door hardware in the facility.

A monthly Quality Assurance monitor is completed by the Maintenance Department to assure the doors do not have a twostep locking arrangement on them.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion date: June 15, 2026

NFPA 101 STANDARD Discharge from Exits:

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0271

Based on observation and interview, the facility failed to maintain exit discharge requirements for two of over ten emergency exits.

Findings include:

Observation on June 9, 2026, between 10:38 a.m. and 10:43 a.m., revealed the following emergency exits required significant force to open, possibly delaying exit in the event of an emergency:

A. (10:38 a.m.) Emergency exit by room K17;
B. (10:43 a.m.) Emergency exit by room J16.

Interview with the maintenance technician on June 9, 2026, at 11:46 a.m., confirmed the exit doors were difficult to open.

Plan of Correction - To be completed: 06/10/2026

The Maintenance Department has a monthly Preventative Maintenance Program that checks the doors for latching and ease of operation in the entire facility.

The exit doors near J16 and K17 have been adjusted for ease of operation and latching properties.

A monthly Quality Assurance Monitor is completed by the Maintenance staff to assure the door operates properly.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion date: June 10, 2026

NFPA 101 STANDARD Exit Signage:

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit signs for four of over thirty exit signs.

Findings include:

1. Observation on June 9, 2026, between 9:30 a.m. and 11:45 a.m., revealed exit directions were lacking throughout common gathering areas in the facility.

Interview with the maintenance technician on June 9, 2026, at 11:45 a.m., confirmed the exit sign deficiencies.

2. Observation on June 9, 2026, at 12:03 p.m., revealed the first floor southeast stairwell emergency exit required a person descend the stairs to reach the exit discharge. Exit stairs that continue beyond the level of the exit discharge must be interrupted at the exit discharge level by an effective means.

Interview with the maintenance technician on June 9, 2026, at 12:03 p.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 06/26/2026

1. The Pleasant Ridge Manor Maintenance department has a monthly preventative Maintenance Program that checks lighting of all exit signs and stairwell lighting to ensure the continuity of direction to those in an emergency situation.

It has been brought to our attention that we have inadequate exit lighting signage in our common gathering areas. After an audit of the facility, Maintenance has determined that we need to upgrade eight gathering areas.

A monthly Assurance Monitor is completed by the Maintenance staff to assure that the exit and stairwell light and signage is correct and operational. The additional signage will be added to our current Exit and Stairwell light preventative maintenance.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion Date: June 26, 2026

2. A self closing fire gate has been constructed and installed in the southeast stairwell near the operator, to guide any person descending down the steps in an emergency situation. This will guide them through the emergency exit.

The additional fire gate will be added to our current Exit and Stairwell light preventative maintenance.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion date: June 16, 2026

NFPA 101 STANDARD Sprinkler System - Installation:

Spinkler System - Installation
2012 EXISTING
Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0351

Based on observation and interview, the facility failed to maintain sprinkler installation requirements in one of over five smoke compartments.

Findings include:

Observation on June 9, 2026, at 1:00 p.m., revealed the main dining room closet lacked visible sprinkler head coverage.

Interview with the maintenance technician on June 9, 2026, at 1:00 p.m., confirmed the lack of a visible sprinkler head in the closet at the time of the survey.

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

The Maintenance Department has a semiannual Fire System Visual Program that inspects all sprinkler heads escutcheons and fire system devices in the facility.

It was brought to our attention that our Resident Dining Room Closet was missed when our sprinkler system was installed by Allied Fire Systems. We have contacted Allied Fire Systems to install a sprinkler head in the Resident Dining Room closet. This sprinkler head will be added to our Fire System Visual Program.

A semiannual Assurance monitor is completed by the Maintenance staff to assure the fire head is unobstructed.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion Date: July 31, 2026

NFPA 101 STANDARD Corridor - Doors:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0363

Based on observation and interview, the facility failed to maintain corridor doors for one of over thirty doors.

Findings include:

Observation on June 9, 2026, at 10:35 a.m., revealed the employee break room in unit K had the latch taped over, preventing the door from latching.

Interview with the maintenance technician on June 9, 2026, at 10:35 a.m., confirmed the door latch was taped over and removed it during the survey.

Plan of Correction - To be completed: 06/10/2026

The Pleasant Ridge Manor Maintenance Department has a monthly Preventative Maintenance program that checks all doors for latching and ease of operation.

The tape from the employee breakroom door in Unit K was removed and the numerical door lock was repaired to bring the door back to normal operation.

A monthly Quality Assurance monitor is completed by the maintenance staff to assure that the doors work properly.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion Date: June 10, 2026

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0372

Based on observation and interview, the facility failed to maintain smoke barrier walls on two of two building levels.

Findings include:

Observation on June 9, 2026, between 10:00 a.m. and 10:46 a.m., revealed the following locations had large openings in the drywall, allowing the passage of smoke:

A. (10:00 a.m.) Basement men's restroom;
B. (10:46 a.m.) First floor large dining room closet.

Interview with the maintenance technician on June 9, 2026, at 10:46 a.m., confirmed the opening in the drywall.

Plan of Correction - To be completed: 06/18/2026

Pleasant Ridge Manor Maintenance department has a semiannual penetration survey preventative maintenance that checks for penetrations in the ceiling and walls throughout the building.

The penetrations in the basement men's restroom and in the Residents Dining Room closet have been repaired. A semiannual Assurance monitor is completed by the Maintenance staff to assure there are no penetrations open in the ceiling, walls, and floors.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion Date: June 18, 2026

NFPA 101 STANDARD Gas Equipment - Cylinder and Container Storag:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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.

Gas Equipment - Cylinder and Container Storage
Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3.
>300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Observations:
Name: PLEASANT RIDGE MANOR -- WEST - Component: 03 - Tag: 0923

Based on observation and interview, the facility failed to meet oxygen equipment and cylinder requirements in one of one main oxygen storage room.

Findings include:

Observation on June 9, 2026, at 11:22 a.m., revealed the oxygen room near the garage lacked dedicated continuous mechanical ventilation to prevent oxygen from accumulating and creating a fire hazard.

Interview with the maintenance technician on June 9, 2026, at 11:22 a.m., confirmed the oxygen room lacked ventilation.

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

Pleasant Ridge Manor Maintenance Department has a daily assessment of water and air temps which includes an oxygen storage inspection.

The Maintenance department will install an 18", 3746cfm exhaust fan to install in our oxygen storage room. The exhaust fan will run continuously.

The facility will submit a narrative/plan to life safety plan review outlining the scope of work for the installation of the exhaust fan.

A daily assurance monitor is completed by the Maintenance staff to assure the exhauster and oxygen storage room is working and in proper order.

It will be monitored by the Maintenance Supervisor and/or designee.

Completion date: July 31, 2026

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement