INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 28-29, 2026, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site investigation, Pyramid Healthcare Inc. Pine Ridge was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation:
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Plan of Correction
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on July 29, 2026, the facility failed to keep the grounds clean, safe, sanitary, and in good repair at all times for the safety and well-being of residents, employees and visitors.
Building B was observed to have multiple stained ceiling tiles in the area where the refrigerators and freezers are as well as in the kitchen area. A light cover was cracked with pieces broken off in the kitchen area. Room # 7-A has a hole in the wall by the door. There was a desk chair inside the dry food storage area with ripped and worn off pleather-like material. There are two cement pads that are crumbling and broken. One is on the left side of the building when facing the front door and one in the front of the building, causing a tripping hazard.
Building C was observed to have chipped paint and cracked corner siding trim with sharp edges on the outside of the first-floor entrance. Rooms 8,10, and 11 have holes in the walls. By the exit closest to the upstairs lounge, the wall has a black mold-like substance, and the plaster is chipping off. The bottom panel of siding is broken on the left side of the building.
Building E was observed to have paint bubbling and chipping on the walls behind and beside the toilet in the bathroom upstairs.
Building F was observed to have a ceiling light that was not working and had a cracked plastic cover hanging down from the light. Also, there is a missing bottom windowpane on the right side of the building. The area where the windowpane is missing is boarded up.
Building H was observed to have a hole in the wall behind the door in the bathroom. The lounge with the TV has a chair with a seat that is ripped. On the outside, the bottom panel of siding is broken and the second to bottom panel of siding has a hole. These panels are on the left side of the building.
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Plan of Correction
Maintenance will replace all stained ceiling tiles and replace the light cover by August 31, 2026. The desk chair in dry storage was removed and replaced on August 1, 2026. Maintenance will repair all drywall damage and repaint all facility rooms by September 30, 2026.
Building C- outside entrance railing caps and siding will be replaced by September 1, 2026. The chipped paint on front of the building will be scraped and repainted by 9/01/26.
Building E- bubbling paint will be repaired and repainted by September 1, 2026.
Building F- light cover and window will be replaced by September 1, 2026.
Building H- the hole behind the door was repaired on 8/01/26. The chair with a rip was removed and replaced on 8/01/26. The piece of siding will be replaced by 9/01/26.
Outside B House- cement pads will be drilled and removed by 8/31/26 by the maintenance department.
ED and risk committee will ensure completion of the above tasks within completion dates, while conducting the monthly facility walkthroughs in August and September 2026.
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705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on July 29, 2026, the facility failed to have a bed with a fire-retardant mattress in good repair.
Room # 6, located in building B, was observed to have two mattresses with ripped fire-retardant material.
Room # 8 and room # 10, located in building C, were each observed to have one mattress with ripped fire-retardant material.
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Plan of Correction
The facility will ensure all mattress's are within good standings during monthly facility inspections. Any mattress's will tears/rips will be replaced immediately. The mattress's in room #6, #8, and #10 have been ordered to be replaced. They will be replaced by 8/10/2026.
Risk committee (ED, Maintenance, BHT Supervisor) will add mattress's to their monthly checklist to be monitored when completing facility walk throughs. Any mattresses not within good condition will be replaced. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on July 29, 2026, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
The bathroom in room # 3, located in building B, was observed to have a black, mold-like substance in the shower.
The upstairs bathroom in building C was observed to have a black mold-like substance in the shower and on the wall behind the shower, near the baseboard.
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Plan of Correction
Housekeeping was addressed on 8/02/26 regarding cleanliness of the restrooms. Staff also addressed proper restroom maintenance with clients as part of their daily work therapy. The facilities risk team (ED, Maintenance, and BHT Supervisor) will monitor cleanliness during facility walk throughs on a monthly basis. Any additional concerns will be addressed immediately with housekeeping.
All bathrooms noted will be deep cleaned on 8/8/26; showers will be cleaned and disinfected. Maintenance will remove old caulking and replace with new. ED developed a housekeeping checklist that will be completed daily to ensure ongoing compliance. This was implemented to begin 8/10/26. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection conducted on July 29, 2026, the facility failed to store all food items off the floor.
A box with coffee K-cups was observed on the floor in Executive Director ' s office of building A.
There was a box of chocolate pudding, and a box of strawberry kiwi flavored water observed on the floor inside the dry food storage area located in building B.
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Plan of Correction
All food items will be stored properly on shelves and not on the floor. This will be monitored monthly during facility walk through inspections for compliance. Any issues will be documented and addressed by the facilities risk management team. All items were removed from the floor and placed properly on shelves on 8/1/26. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection conducted on July 29, 2026, the facility failed to be free of an insect infestation.
The first-floor bathroom on the right, located in building C, was observed to have ants crawling on multiple walls.
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Plan of Correction
Ehrlich pest control provides monthly routine maintenance. They will provide additional services for treating ants in the restroom of C house, this will occur during their next scheduled appointment on August 14, 2026. Housekeeping/maintenance will continue to monitor daily to ensure there is no further infestation. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide documentation of medication being provided as prescribed by a physician in one of four records reviewed.
Client # 2 was admitted on May 6, 2026, and discharged on June 1, 2026. The client was prescribed a medication and the prescription stated that one tablet was to be taken daily at bedtime. The medication administration record showed that the medication was not given as prescribed on May 19-21, 2026, and May 26-28, 2026.
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Plan of Correction
Medical was addressed on 8/4/26 during staffing regarding medications. Medical staff will review MARs daily to ensure medications have been provided as prescribed. Any missed medications will be reviewed with the client. Medical will ensure all medications are refilled within required time frames and ensure all medications are available. Medical will review dosing history's during monthly chart audits in the EMAR to ensure medications are given as prescribed. |