The Pinnacle at Plymouth Meeting.

“Resident did not receive required assistance with shower as indicated in their assessment and support plan.”

“Staff member spoke to resident in a nasty tone with profanity, stating they could not provide shower while performing double-briefing during toileting assistance. Resident reported feeling treated disrespectfully.”

“A sign posted on resident's door specified the resident's medication regimen including blood pressure thresholds for medication administration, violating the resident's privacy regarding medical information visible to visitors and other residents.”

“Resident did not receive required toileting assistance as specified in assessment and support plan. Resident rang call bell at 8:45 AM and 7:36 PM and waited over 45 minutes for toileting assistance due to lack of available direct care staffing.”

“Resident's PureWick urine collection incontinence equipment was soiled and not clean, causing a strong urine odor. Staff is responsible for care and maintenance of the device per the resident's support plan.”

“A resident prescribed a medication with a systolic blood pressure parameter was administered the medication when the resident's blood pressure fell outside the prescriber's established parameters on multiple occasions.”

“A resident was admitted to the Secured Dementia Care Unit, but the written cognitive preadmission screening was not completed within the required 72 hours prior to admission.”

“Prescription medications, OTC medications, and other medical items were not kept in locked containers as required.”

“The home failed to report a resident's hospital admission due to change in health status to the Department within 24 hours as required.”

“A resident's wine bottles were found empty in their room when family members had brought full bottles for the resident, raising concerns of potential staff consumption or misappropriation of resident property.”

“Degree deodorant and Zinc oxide cream, both labeled as poisonous materials, were unlocked, unattended, and accessible to residents in bathroom cabinets and areas. Not all residents were assessed as capable of safely recognizing and using these materials.”

“Feces was observed smeared on the back of a resident's toilet, indicating unsanitary conditions were not maintained.”

“There was no toilet paper available for the toilet in a resident's bathroom.”

“The back exit door by the kitchen could not open more than two inches because the door to the fenced area containing dumpsters was blocking the exit, creating an obstruction of egress routes.”

“A resident requiring toileting and peri-care assistance waited 18 minutes and 53 seconds for call-bell response. Additionally, another resident requiring bathing assistance waited approximately 30 minutes when the assigned caregiver was in a meeting and the covering staff member had misplaced their pager.”

“Staff member spoke to resident in a demeaning tone, acted dismissively about the resident's request for scissors to change bandages, and criticized the resident. The following day, the staff member refused to discuss the conflict and later avoided the resident in the hallway, causing the resident (diagnosed with major depressive disorder) to feel disrespected and dismissed.”

“A resident's medical evaluation did not include health status as required by the regulation.”

“Staff person A was hired but did not complete required training on the emergency medical plan within 40 scheduled working hours of hire.”

“A resident fell in the Garden House hallway at approximately 6:00 pm. Staff person A initially reported that one resident had pushed another, but this allegation of abuse was not reported by the home until 11:30 pm, a delay of approximately 5.5 hours.”

“A resident allegedly pushed another resident to the floor in the Garden House hallway. The home did not perform a timely assessment of the resident following the fall, and the resident's support plan was not updated to reflect needs related to potential physical aggression until after the incident.”

“The home does not have a system to safeguard resident laundry from loss. Residents reported waiting over three days for personal belongings to be returned, with some items going missing. Clean clothing must be returned within 24 hours after laundering.”

“A laptop computer with resident information was left unlocked, unattended, and accessible on top of the medication cart on the 2nd floor, violating confidentiality requirements.”

“A resident did not receive required assistance to and from meals and activities as indicated in their assessment and support plan following breakfast.”

“One resident pushed another resident against a wall. The facility failed to review transfer documents and progress notes indicating the aggressive resident had a prior history of abuse and aggression toward staff before or at the point of admission.”

“Direct care staff person A did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required.”

“Multiple residents experienced excessive call bell response times ranging from 58 minutes to 15 hours 31 minutes, indicating insufficient staffing to meet resident needs as specified in support plans.”

“Staff person A completed their 40th scheduled work hour by February 2025 but did not complete required orientation training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions.”

“A controlled substance accountability log containing resident medical information was unlocked, unattended, and accessible on top of the 4th floor medication cart, violating resident record confidentiality requirements.”

“A resident did not receive required assistance with peri-care and disposing of used incontinent products during the 7 AM to 3 PM shift as indicated in the resident's assessment and support plan.”

“A staff person employed by a subcontracted staffing agency had a background check that was completed over 1 year prior to being hired to work at the facility.”

“The administrator's list of staff persons does not include substitute and contracted agency staff persons, as required.”

“A staff person whose first day of work was during the inspection period did not receive required orientation on evacuation procedures, staff duties and responsibilities during fire drills and emergency evacuation, and the designated meeting place in the event of an actual fire. This is a repeat violation.”

“The home did not have sufficient hot and cold water in the shower of a resident room. The shower head was broken and leaking water heavily from the sides, causing a complete lack of pressure from the shower head itself.”

“A bottle of OTC/CAM medication belonging to a resident was not labeled with the resident's name; the print on the label had worn away completely.”

“A resident prescribed a PRN medication (two tablets every six hours as needed) did not have the medication available in the home.”

“A violation of 55 Pa Code § 2600.42b was cited during the inspection, with a civil money penalty assessed at $5 per resident per day ($420 total for 84 residents) unless corrected by the mandated correction date.”

“On March 25, 2025, a resident and staff member were involved in an altercation resulting in the resident falling after being pushed by the staff member. Although the staff member reported the incident to another staff member, the allegation of abuse was not reported to the Area Agency on Aging as required.”

“On March 25, 2025, a resident and staff member were involved in an altercation resulting in the resident falling after being pushed by the staff member. Although the staff member reported the incident to another staff member, the allegation of abuse was not reported to the Area Agency on Aging as required.”

“A violation of 55 Pa Code § 2600.42b was cited during the inspection, with a civil money penalty assessed at $5 per resident per day ($420 total for 84 residents) unless corrected by the mandated correction date.”

“A resident's assessment and support plan was not signed by the resident, but the home failed to document a notation regarding the resident's inability or refusal to sign.”

“A resident's most recent medical evaluation does not include section (9) Health Status/Cognitive Functioning, which was left blank.”

“Resident preadmission screening forms do not include a documented determination that the resident's needs can be met by the services provided by the home.”

“A resident participated in the development of their support plan but did not sign the support plan document.”

“Thirty fire extinguishers throughout the facility failed inspection because they exceeded the 6-year manufacturer expiration period and were not approved by a fire safety expert.”

“A resident reported money missing from their purse kept in their bedroom. The home provides locked drawers to safeguard resident property, but the resident was unaware of this option and did not have keys to the drawer.”

“A resident reported that an agency staff person entered their room with a hostile demeanor, refused to provide assistance with toilet paper despite resident's mobility needs, and made the resident feel uncomfortable and intimidated by making dismissive comments in the resident's presence.”

“A direct care staff person did not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry as required for direct care staff qualifications.”

“A staff person whose first day of work was 10/8/24 did not receive required first-day orientation on evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher location and use, smoke detectors and fire alarms, and telephone use for emergency services.”

“A direct care staff person hired on a specified date began providing unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.”

“A self-medicating resident's medication list in their record did not include a current list of all prescription, CAM, and OTC medications, missing specific medications that the resident was taking.”

“Fire drill records do not include the exact time of the drill, the amount of time to evacuate in minutes and seconds, or the exit routes used to evacuate.”

“Staff member C's criminal background check request was not completed until after their date of hire, violating requirements under the Older Adult Protective Services Act.”

“On 05/31/24 from 11:00 PM to 7:00 AM on 06/01/24, approximately 83 residents were present in the home with no staff persons certified in first aid, obstructed airway techniques, and CPR, violating the requirement of at least one staff person for every 50 residents.”

“An unattended, unlocked cleaning cart was found in the hallway of the Memory Care unit containing bottles of industrial bathroom cleaner and glass cleaner with hazard warnings, making poisonous materials accessible to residents unable to safely use them.”

“On 06/03/24 between 9:45 and 10:00 AM, trash cans in the 3rd and 4th floor Men's bathrooms were not covered, violating the requirement that bathroom trash be kept in covered receptacles to prevent insect and rodent penetration.”

“Resident units lacked operable lamps or other sources of lighting that can be turned on by the bedside, violating lighting requirements.”

“On 06/03/24, the temperature in the Memory Care Kitchenette's refrigerator and freezer were 54°F and 50°F respectively (at 10:26 AM) and 58°F and 48°F (at 10:31 AM), exceeding the required maximum temperatures of 40°F for refrigerators and 0°F for freezers.”

“Staff person C does not have a copy of the emergency preparedness plan for the local municipality where the facility is located.”

“The safety inspection tag for the fire extinguisher in the memory care hallway is missing, making it impossible to determine the last inspection date by a fire safety expert.”

“On 06/03/24 between 9:45 and 10:00 AM the trash cans in the 3rd and 4th floor Men's bathrooms were not covered, violating the requirement that trash in kitchens and bathrooms shall be kept in covered receptacles to prevent insect and rodent penetration.”

“Resident units were found without an operable lamp or other source of lighting that can be turned on by bedside, as required by regulation.”

“Staff member C's criminal background check request was not completed until after their date of hire, violating requirements under the Older Adult Protective Services Act.”

“On 05/31/24 from 11:00 PM to 7:00 AM on 06/01/24, approximately 83 residents were present in the home with no staff persons present certified in first aid, obstructed airway techniques, and CPR. At least one staff person for every 50 residents must be trained in these areas at all times.”

“An unattended, unlocked cleaning cart containing industrial-grade poisonous materials (Ecolab Acid Bathroom Cleaner and ZEP Glass Cleaner) was found in the hallway of the Memory Care unit. Not all residents in the unit have been assessed as capable of safely recognizing and using poisons.”

“On 06/03/24 at 10:26 AM the temperature in the Memory Care Kitchenette's refrigerator and freezer were 54 and 50 degrees Fahrenheit respectively; at 10:31 the temperatures were 58 and 48 degrees Fahrenheit. Food requiring refrigeration must be stored at or below 40°F and frozen food at or below 0°F.”

“Staff person C does not have a copy of the emergency preparedness plan for the local municipality where the home is located, which the administrator must have and be familiar with.”

“The safety inspection tag for the fire extinguisher in the memory care hallway is missing, making it impossible to determine when the last inspection by a fire safety expert was conducted. Fire extinguishers must be inspected and approved annually with the inspection date on the extinguisher.”

“The fire drill records for the home do not include the exact time of the fire drill, the amount of time to evacuate in minutes and seconds, or the exit routes used to evacuate, all of which are required documentation.”

“Staff member C's criminal background check request was not completed until after their date of hire, violating requirements under the Older Adult Protective Services Act.”

“On 06/03/24 between 9:45 and 10:00 AM the trash cans in the 3rd and 4th floor Men's bathrooms were not covered, violating the requirement that trash in kitchens and bathrooms shall be kept in covered receptacles to prevent insect and rodent penetration.”

“On 05/31/24 from 11:00 PM to 7:00 AM on 06/01/24, approximately 83 residents were present in the home with no staff persons present certified in first aid, obstructed airway techniques, and CPR. At least one staff person for every 50 residents must be trained in these areas at all times.”

“An unattended, unlocked cleaning cart containing industrial-grade poisonous materials (Ecolab Acid Bathroom Cleaner and ZEP Glass Cleaner) was found in the hallway of the Memory Care unit. Not all residents in the unit have been assessed as capable of safely recognizing and using poisons.”

“Resident units were found without an operable lamp or other source of lighting that can be turned on by bedside, as required by regulation.”

“On 06/03/24 at 10:26 AM the temperature in the Memory Care Kitchenette's refrigerator and freezer were 54 and 50 degrees Fahrenheit respectively; at 10:31 the temperatures were 58 and 48 degrees Fahrenheit. Food requiring refrigeration must be stored at or below 40°F and frozen food at or below 0°F.”

“Staff person C does not have a copy of the emergency preparedness plan for the local municipality where the home is located, which the administrator must have and be familiar with.”

“The safety inspection tag for the fire extinguisher in the memory care hallway is missing, making it impossible to determine when the last inspection by a fire safety expert was conducted. Fire extinguishers must be inspected and approved annually with the inspection date on the extinguisher.”

“The fire drill records for the home do not include the exact time of the fire drill, the amount of time to evacuate in minutes and seconds, or the exit routes used to evacuate, all of which are required documentation.”

“Staff member C's criminal background check request was not completed until after their date of hire, violating requirements under the Older Adult Protective Services Act.”

“On 05/31/24 from 11:00 PM to 7:00 AM on 06/01/24, approximately 83 residents were present in the home with no staff persons present certified in first aid, obstructed airway techniques, and CPR. At least one staff person for every 50 residents must be trained in these areas at all times.”

“An unattended, unlocked cleaning cart containing industrial-grade poisonous materials (Ecolab Acid Bathroom Cleaner and ZEP Glass Cleaner) was found in the hallway of the Memory Care unit. Not all residents in the unit have been assessed as capable of safely recognizing and using poisons.”

“On 06/03/24 between 9:45 and 10:00 AM the trash cans in the 3rd and 4th floor Men's bathrooms were not covered, violating the requirement that trash in kitchens and bathrooms shall be kept in covered receptacles to prevent insect and rodent penetration.”

“Resident units were found without an operable lamp or other source of lighting that can be turned on by bedside, as required by regulation.”

“On 06/03/24 at 10:26 AM the temperature in the Memory Care Kitchenette's refrigerator and freezer were 54 and 50 degrees Fahrenheit respectively; at 10:31 the temperatures were 58 and 48 degrees Fahrenheit. Food requiring refrigeration must be stored at or below 40°F and frozen food at or below 0°F.”

“Staff person C does not have a copy of the emergency preparedness plan for the local municipality where the home is located, which the administrator must have and be familiar with.”

“The safety inspection tag for the fire extinguisher in the memory care hallway is missing, making it impossible to determine when the last inspection by a fire safety expert was conducted. Fire extinguishers must be inspected and approved annually with the inspection date on the extinguisher.”

“The fire drill records for the home do not include the exact time of the fire drill, the amount of time to evacuate in minutes and seconds, or the exit routes used to evacuate, all of which are required documentation.”