Inspection·March 6, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policies and clinical records, and staff interview, it was determined the facility failed to provide care in accordance with professional standards for care of a gastrostomy tube (G-tube-a surgically placed rubber tube placed into the stomach to deliver nutrition, water, and medications) for one of six residents reviewed. (Resident R1) Residents Affected - Few Findings include: Review of facility policy entitled Administering medications via enteral feeding tube dated 1/2023, revealed, a slow gentle push with a piston syringe of water may only be done if medication will not flow in by gravity. Review of facility policy entitled Irrigation of feeding tubes dated 1/2023, revealed feeding tubes will be flushed with adequate amount of water to prevent formula residue from adhering to the tube causing a clogged tube. Review of Resident R1's clinical record revealed an admission date of 1/22/20, with diagnoses that included dysphagia (a condition that causes a person to not be able to swallow), diabetes (condition of improper blood sugar control), and Gastro Esophageal Reflux (acid reflux or heart burn). Review of Resident R1's clinical record revealed a nurse's progress note dated 2/20/24, that indicated Resident R1 was sent to the emergency room for evaluation due to a foreign object stuck in his/her G-tube. Review of a transfer form dated 2/20/24, indicated reason for transfer to emergency room was, G-tube clogged, and something stuck in it. Resident R1 was transferred to the emergency room on 2/20/24, at 9:00 p.m. Review of emergency department provider note dated 2/20/24, revealed on Resident R1's arrival to the emergency room his/her G-tube was removed and replaced with a new G-tube and a tip of a broken off Q-tip was felt in the G-tube that was removed. Review of Nurse Practitioner post emergency room documentation dated 2/22/24, indicated that Resident R1 was sent to hospital on 2/20/24, due to a foreign object that was inserted into Resident R1's G-tube which became lodged in the G-tube. During an interview on 3/05/24, at 2:50 p.m. the Director of Nursing confirmed that a foreign object should never be placed in a G-tube. He/she also confirmed that a foreign object should never be used to unclog a G-tube. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 395361 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pleasant Ridge Manor East/West 8300 West Ridge Road Girard, PA 16417 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)