Pine Run Health Center

Based on policy review, observation, and staff interview, it was determined that the facility failed to properly store food and maintain sanitary conditions in the dietary department and in two of three country kitchens. (Second and Third floors) Findings include:Observations during the tour of the dietary department and in the country kitchen on the second floor on March 10, 2026, at 10:25 a.m., revealed the following:In the Emergency Food Storage section, there was one box of six large cans of green beans that was expired on December 25, 2025, nine cans of corned beef that were labeled with a use by date of July 1, 2025, four large boxes of oatmeal that were labeled with a use by date of September 8, 2025, four large boxes of apple juice dated use by date of December 9, 2025, two large boxes of cranberry juice that were labeled with a use by date of October 16, 2025, six large cans of tomatoes labeled with a use by date of June 17, 2025, and six large cans of fruit cocktail that were noted to be expired on May 28, 2025.In the country kitchen on the second floor, there was a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, group interview, resident interviews, and review of electronic call bell logs, it was determined that the facility failed to answer call bells in a timely manner to provide care and services respectful of each resident's dignity and preferences to promote the quality of life for six of 18 sampled residents. (Residents 3, 6, 56, 68, 83, 96)Findings include:Review of the facility policy entitled Call Bell Response, dated January 5, 2026, revealed that all nursing personnel must be aware of call lights/alerts at all times, and answer bell/alert promptly. During an interview on March 11, 2026, at 1:17 p.m., the Administrator stated that staff were expected to respond to call bells in less than 20 minutes. Clinical record review revealed that Resident 3 had diagnoses that included chronic kidney disease and recovery from recent digestive system surgery. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident was able to communicate his needs to staff and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to implement physicians' orders for six of 21 sampled residents. (Residents 3, 11, 29, 37, 42, and 56) Findings include: Clinical record review revealed that Resident 3 had diagnoses that included hypotension (low blood pressure) and chronic kidney disease. A physician's order dated February 26, 2026, directed staff to administer 5 milligrams (mg) of a blood pressure medication (midodrine) two times daily. The physician ordered that staff was not to administer the medication if the resident's systolic blood pressure (SBP, the first measurement of blood pressure when the heart beats and the pressure is at its highest) was higher than 130 millimeters of mercury (mm/Hg). Review of Resident 3's Medication Administration Record (MAR) for February and March 2026, revealed that the staff withheld the medication once in February, when Resident 2's blood pressure was below 130mm/Hg and administered midodrine once in March, when Resident's 3's SBP was higher than 130 mm/Hg. Clinical record review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interview, it was determined that the facility failed to provide restorative nursing services to improve or maintain walking mobility on a consistent basis for one of 21 sampled residents. (Resident 4) Findings include:Clinical record review revealed that Resident 4 had diagnoses that included Alzheimer's disease, generalized muscle weakness, and difficulty in walking. The Minimum Data Set assessment dated [DATE], indicated that the resident was cognitively impaired and required limited assistance from staff for activities of daily living. On February 10, 2026, the physical therapist had recommended a Restorative Nursing Program (RNP) for walking with a rolling walker for ambulation up to 200 feet. In an interview on March 12, 2026, at 12:37 p.m., the Director of Therapy stated the program consisted of Resident 4 using a front wheeled walker to go to and from the dining room for each meal and that it was to maintain his mobility status. There was a lack of documentation to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, clinical record review, staff interview, and review of facility policy it was determined that the facility failed to store respiratory equipment appropriately for one of three sampled residents who received oxygen therapy. (Resident 42) Findings include: Review of the facility policy entitled, Oxygen Protocol, dated January 5, 2026, revealed that oxygen cannulas and masks were to be changed weekly and labeled with the date. When oxygen tubing was not in use it was to be kept in a plastic bag. Staff were to place a new bag with the resident's name and date on the side of the concentrator or portable oxygen tank weekly to hold the tubing. Clinical record review revealed that Resident 42 had diagnoses that included chronic obstructive pulmonary disease and respiratory failure. On September 5, 2025, the physician ordered that staff administer oxygen therapy via nasal cannula (a tube with two prongs where each prong is inserted into each nostril of the nose) at a rate of two liters per minute at bedtime. On September 5, 2025, the physician ordered for staff to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the physician acknowledged the pharmacist's recommendations for two of 21 sampled residents. (Residents 9 and 37)Findings include: Clinical record review revealed that on September 14, 2025, the consultant pharmacist made a recommendation to review and assess the orders for Resident 9's Celexa and Remeron. On November 17, 2025, the consultant pharmacist made a recommendation to evaluate and adjust the dose of Tylenol. There was no documented evidence that the attending physician had acknowledged or acted upon these recommendations. Clinical record review revealed that on December 24, 2025, the consultant pharmacist made recommendations to evaluate Resident 37's seroquel for a dose reduction and to consider adding a stimulant laxative such as Senna to this resident's regiment to prevent constipation. On January 13, 2026, the consultant pharmacist again made recommendations to evaluate Resident 37's seroquel. There was no documented evidence that the attending physician had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure that a licensed practical nurse (LPN) maintained professional standards of quality care in following the established policies and procedures of the facility set forth in the Pennsylvania Code Title 49 Professional and Vocational standards for one of three sampled residents who were at risk for falls. (Resident 1)Findings include: Review of Pennsylvania Code Title 49, Chapter 21, Subchapter B. Practical Nurses, revealed guidelines which included that an LPN shall follow the written, established policies and procedures of the facility. Review of the facility policy entitled, Falls Management Program, last reviewed January 2025, revealed that when a resident sustained a fall, an examination by a licensed nurse was completed and a Registered Nurse (RN) must assess the resident post fall and document on the accident/incident report.Clinical record review revealed that Resident 1 had diagnoses that included orthostatic hypotension,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interview, and review of facility policy, it was determined that the facility failed to safely administer medications for one of 14 sampled residents. (Resident 2)Findings include: Review of the facility policy entitled, Medications, Administration (Self), last reviewed January 2025, revealed that a written physician's order for self-administration of medications and bedside storage was obtained and kept in the resident's medical record.Clinical record review revealed that Resident 2 had diagnoses that included muscle wasting, dysphagia, need for assistance with personal care, and hearing loss. Review of the resident's self-administration of medications assessment dated [DATE], revealed that she required assistance storing medications in a secured location, administering oral medications, naming medications and prescribed use, and she was not approved to self- administer her own medications. On November 10, 2025, at 11:10 a.m., Resident 2 was observed in her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy review and observation, it was determined that the facility failed to follow policies and procedures to prevent the spread of infection on the nursing unit. (Fourth floor) Findings include: Review of the facility policy entitled, Hand Hygiene, last reviewed January 2025, revealed that staff was to sanitize or wash their hands before and after each procedure or task and after handling resident belongings. On November 10, 2025, at 11:50 a.m., nurse aide (NA) 2 was observed exiting Resident 3's room carrying linens with ungloved bare hands. NA 2 disposed of the linens into the dirty linen receptacle. NA 2 did not perform hand hygiene after this task and proceeded to enter Resident 4's room without performing hand hygiene. NA 2 touched Resident 4's belongings, obtained clean linens from the clean linen cart, re-entered then exited Resident 4's room again, and did not perform hand hygiene at any time during the observation.28 Pa. Code 211.10(b)(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to store food under sanitary conditions in the kitchen. Findings include: Observation of the kitchen on March 19, 2024, at 11:50 a.m. revealed the following: The bottom row of shelves in the reach-in freezer were missing. Multiple food items were stored on the bottom floor of the freezer. There was a box of raw chicken cheesesteak meat that was open, other food items were stored on top of the box. There was an open bag of French fries that was not dated. The slicer handle was broken. There was a muffin tin and round cake pan stored on top of a transformer. There were two muffin tins on the floor between the storage shelf and the transformer. There was water leaking from the nozzle of a hose behind the kettle while food was being cooked. There was an accumulation of debris under the stovetop and grille. There was cocktail sauce with a use-by date of March 15, 2024, and blue cheese dressing with a use-by date of March 16, 2024, in the walk-in refrigerator. There was a container of popcorn with a use-by date of January…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and observation, it was determined that the facility failed to ensure that dignity was maintained for two of 18 sampled residents. (Residents 45, 222) Findings include: Clinical record review revealed that Resident 45 had diagnoses that included stroke, hemiplegia to the left side, depression, and muscle weakness. Review of the care plan revealed that the resident preferred activities that identified with his prior lifestyle and staff were to include the resident's preferences in rendering care and services. On March 19, 2024, at 1:33 p.m., Resident 45 was observed in bed. The white board on the wall in his room displayed March 11, 2024, and identified an assigned nurse and nurse aide for that date. During the observation, the resident stated that he preferred the white board to be updated daily with accurate and current information and he does not recall the last time staff updated the board. Observations on March 20, 2024, at 11:52 a.m., and March 21, 2024, at 11:20 a.m., revealed that the resident's white board still displayed March 11, 2024, with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented for one of 18 sampled residents. (Resident 15) Findings include: Clinical record review revealed that Resident 15 had diagnoses that included pleural effusion, dysphagia (difficulty swallowing), and lymphedema. Review of the care plan revealed that Resident 15 was at risk for dehydration and weight changes and staff were to monitor weights and report changes to the physician. On November 17, 2023, the physician ordered for the resident to be weighed daily. There was no evidence that weights were obtained on March 4, 7, 9, and 17, 2024. On January 19, 2024, there was an order for staff to notify the physician of a two pound (lb.) weight gain or loss in one day or a five lb. weight change in one week. Review of the resident's weight record revealed that she experienced weight changes of greater than two pounds in one day on the following dates: A loss of 3.6 lbs. from January 31, 2024, through February 1, 2024. A gain of 3.6 lbs. from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.