INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted July 20, 2022, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint 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.
|
Plan of Correction
|
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
|
Observations
Based on a physical plant inspection conducted during a complaint investigation on July 20, 2022, the facility failed to maintain furnishings in a state of good repair. The following was observed during the investigation:
In House B, the living room/lounge area had two torn/damaged black loveseats and a torn/damaged black chair.
In House C, the living room had a torn/damaged black couch and loveseat.
In House D, broken floor tiles were observed on the first floor in the kitchen/laundry area and in the half bathroom.
In Community Building H, the game room had discolored ceiling tile from a possible leak and a torn/damaged black loveseat. The TV room had a torn/damaged black chair.
This was discussed with facility staff during the investigation.
|
Plan of Correction
On 7/31/22, the damaged furniture was removed from B House, C House,and H Building and new furniture was added.
New floor tiles were replaced in D House laundry/kitchen area and downstairs half bathroom on 8/5/2022.
Ceiling tile in H building was replaced on 8/5/2022.
Risk committee with monitor physical plant areas of concern during monthly walk thru's and submit maintenance tickets for needed repairs monthly.
Executive Director will ensure maintenance tickets are completed in required time frames.
|
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.
|
Observations
Based on a physical plant inspection conducted during a complaint investigation on July 20, 2022, the facility failed to maintain each client bedroom in good repair.
The following was observed in House B: The client bedroom B-5 had a hole in the wall, client bedroom B-6 had paint torn off the wall above bed 6B, and client bedroom B-7-B had a large hole in the wall.
This was discussed with facility staff during the investigation.
|
Plan of Correction
Maintenance fixed holes on 8/01/2022 in B5 and B7. B5, B6, and B7 will be repainted by 8/31/2022.
Risk committee and maintenance will monitor rooms monthly to ensure no new holes. Maintenance will monitor for any rooms needing new paint. Maintenane tickets will be submitted as needed. |
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.
|
Observations
Based on a physical plant inspection conducted during a complaint investigation on July 20, 2022, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
During the investigation, House D was observed to have multiple broken floor tiles in the half bathroom on the first floor.
This was discussed with facility staff during the investigation.
|
Plan of Correction
on 8/5/2022 floor tiles were replaces in the laundry/kitchen area and the half bathroom downstairs in D House.
Risk committee/Maintenance will monitor physial plant issues/concerns during monthly inspections. Maintenance tickets will be submitted for any issues needing addressed. |