INITIAL COMMENTS
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This report is a result of an on-site follow-up investigation to an Incident Report conducted on September 1, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site follow-up, the incident which occured at Pyramid Healthcare Inc. Pine Ridge Manor was handled appropriately however; additional findings were identified on-site. Therefore, the facility 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 inspection:
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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 the physical plant inspection that was conducted on September 1, 2016, the facility failed to ensure that the facility was clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. It was observed in the B-House that electrical conduit which shielded a live electrical wire was falling off the wall below the staircase to the second floor.These findings were reviewed with facility staff during the incident follow-up investigation.
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Plan of Correction
September 1, 2016 the maintenance department came in immediately after the inspection and fixed the electrical conduit. The adhesive broke loose due to the high humidity. The conduit was refastened and secured by maintenance. The risk team will continue to conduct regular checks throughout the facility to ensure there are no safety issues. If there is an area of concern, maintenance will be contacted immediately to repair the problem.
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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 that was conducted on September 1, 2016, the facility failed to provide toilet paper at each toilet at all times.It was observed that there was no toilet paper in the bathrooms in the Recreation Center, B-House and C-House. These findings were reviewed with facility staff during the incident follow-up investigation.
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Plan of Correction
Staff will check all bathrooms daily during 1st, 2nd, and 3rd shift when doing rounds throughout the facility, to ensure that they are fully stocked with necessary supplies. |
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 the physical plant inspection that was conducted on September 1, 2016, the facility failed to store all food items off the floor It was observed that food items were stored directly on the floor in the facility pantry. These findings were reviewed with facility staff during the incident follow-up investigation.
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Plan of Correction
All items in the storage unit have been placed on proper shelving that was installed. Lifeskill's coordinator will monitor the dry storage and kitchen to ensure that all items remain off the floor and kept on the proper shelving. |