Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Run Health Center during CMS and state inspections, most recent first.
Food Storage and Hair Restraint Deficiencies in Dietary Areas: Surveyors found expired and improperly dated food items in the Emergency Food Storage area and the second-floor country kitchen, including milk past its use-by date and an undated container of grape tomatoes. The Dining Services Assistant Director confirmed the items should have been removed. In addition, during lunch service in the third-floor country kitchen, a Dietary Employee was observed serving and plating food with hair and facial hair not covered as required by facility policy.
Delayed Call Bell Response: Staff did not answer call bells promptly for six sampled residents, despite a facility expectation of response in less than 20 minutes. Residents with conditions including CKD, CHF, diabetes, heart disease, and recovery from recent surgeries reported or experienced prolonged waits, and a device activity report showed 87 call bell responses over 20 minutes, including waits of 96, 125, 38, 93, 130, and 109 minutes.
Failure to follow physician orders affected multiple residents. Orders for BP meds were not followed for residents with hypotension and HTN, including giving meds when BP was outside ordered parameters and withholding meds when criteria were met. A resident with HF and kidney disease was not weighed as ordered, and two residents with dementia and DM did not receive ordered constipation treatments despite no recorded BMs. The DON confirmed there was no documented evidence that one resident was weighed as ordered.
A resident with Alzheimer's disease, generalized muscle weakness, and difficulty walking was recommended for an RNP for ambulation with a rolling walker to maintain mobility. The program was described as walking to and from the dining room for meals, but documentation did not show the resident was offered restorative ambulation on 8 of 30 days, and the NHA confirmed there was no evidence it was provided daily.
Improper Storage of Oxygen Tubing: A resident with COPD and respiratory failure had physician-ordered oxygen via nasal cannula, but surveyors observed multiple sets of tubing that were not dated and were not stored in the attached storage bags when not in use. The DON confirmed the cannula and tubing should have been dated and bagged when not in use.
The facility failed to ensure the physician acknowledged the consultant pharmacist’s medication regimen review recommendations for two residents. For one resident, the pharmacist recommended review of Celexa and Remeron and later evaluation of Tylenol dosing; for another resident, the pharmacist recommended evaluating Seroquel for dose reduction and considering Senna for constipation prevention, then repeated the Seroquel recommendation. There was no documented evidence the attending physician acknowledged or acted on these recommendations, and the DON confirmed the recommendations were not addressed.
Failure to provide required transfer notices: The facility did not give written notice of appeal rights and the Office of the State LTC Ombudsman contact information to six sampled residents and/or their representatives when they were transferred to the hospital after changes in condition. Clinical record review showed no documentation that the required information was provided, and the Administrator confirmed the omission in interview.
A resident with multiple medical conditions experienced a fall, and an LPN placed the resident back into a chair without an RN assessment, contrary to facility policy. The RN supervisor was notified but did not assess the resident, and there was no documentation of an RN assessment. The Director of Nursing confirmed that the required RN assessment did not occur.
A resident with multiple care needs, including assistance with medication management, was found with a cup of medications at her bedside without a physician's order for self-administration. Staff confirmed the medications were left for the resident, and the DON verified that no order was in place for self-administration.
A nurse aide was observed handling soiled linens and entering another resident's room without performing required hand hygiene, in violation of facility policy. The aide touched resident belongings and obtained clean linens without sanitizing or washing hands before or after these tasks.
The facility failed to store food under sanitary conditions, with issues including missing freezer shelves, improperly stored and dated food items, broken equipment, water leakage, debris accumulation, and expired food items.
The facility failed to maintain the dignity of two residents. One resident's white board was not updated daily as preferred, and another resident's foley catheter bag was left uncovered in a common area. The Director of Nursing confirmed these deficiencies.
The facility failed to implement physician's orders for a resident with pleural effusion, dysphagia, and lymphedema. Weights were not obtained on several dates, and the physician was not notified of significant weight changes. This was confirmed by the DON.
The facility failed to provide written notification to two residents and their representatives upon transfer to the hospital after a change in condition. Clinical records lacked documentation of written information regarding the transfers, which was confirmed by the Assistant Administrator.
Food Storage and Hair Restraint Deficiencies in Dietary Areas
Penalty
Summary
The facility failed to properly store food and maintain sanitary conditions in the dietary department and in two of three country kitchens. During a tour of the dietary department and the second-floor country kitchen, surveyors found expired and improperly dated food items in the Emergency Food Storage area, including green beans, corned beef, oatmeal, apple juice, cranberry juice, tomatoes, and fruit cocktail with use-by dates ranging from May 28, 2025, through December 25, 2025. In the second-floor country kitchen, surveyors also observed a half-gallon of milk with a use-by date of March 7, 2026, and a container of grape tomatoes that was not dated. During interview, the Dining Services Assistant Director confirmed that the expired foods should have been removed from the Emergency Food Storage area and the second-floor country kitchen and were not. Review of the facility policy, Uniform Standards, dated March 1, 2026, showed that all staff were to cover all hair with a hair and/or beard restraint in all food service areas. During lunch meal service in the third-floor country kitchen, Dietary Employee 1 was observed serving and plating food with hair and facial hair that were not covered.
Delayed Call Bell Response
Penalty
Summary
The facility failed to answer call bells in a timely manner to provide care and services respectful of each resident’s dignity and preferences for six of 18 sampled residents. The facility policy titled Call Bell Response stated that all nursing personnel must be aware of call lights/alerts at all times and answer bells promptly, and the Administrator stated staff were expected to respond in less than 20 minutes. Clinical record review showed that the affected residents had diagnoses including chronic kidney disease, congestive heart failure, diabetes, heart disease, and recovery from recent surgeries involving the digestive system, limb, hip replacement, and spine. Their MDS assessments indicated they were able to communicate their needs and required varying levels of assistance with transfers, toileting, dressing, and other activities of daily living. During a confidential group interview, seven residents reported that it often took 30 minutes or more for staff to answer call bells and provide assistance. Review of the Device Activity Report for the six sampled residents from February 10, 2026, through March 10, 2026, showed 87 instances when call bell response time exceeded 20 minutes. Specific examples included waits of 96 minutes, 125 minutes, 38 minutes, 93 minutes, 130 minutes, and 109 minutes for the six residents. The Administrator confirmed that these residents waited longer than the expected response time of 20 minutes.
Failure to Follow Physician Orders for Medications, Weights, and Bowel Regimens
Penalty
Summary
The facility failed to implement physician orders for six sampled residents. Resident 3 had hypotension and chronic kidney disease, and a February 26, 2026 order directed staff to give midodrine 5 mg twice daily unless systolic blood pressure was above 130 mm/Hg. The MAR showed the medication was withheld once when blood pressure was below the ordered limit and given once when systolic blood pressure was above 130 mm/Hg. Resident 56 had hypertension and chronic kidney disease, with orders for PRN furosemide with potassium chloride when systolic blood pressure was greater than 160 mm/Hg, PRN hydrochlorothiazide when systolic blood pressure was greater than 160 mm/Hg, and hydralazine 25 mg twice daily unless systolic blood pressure was below 130 mm/Hg. The MAR showed medications were withheld when blood pressure met the criteria for administration and hydralazine was given once when systolic blood pressure was below 130 mm/Hg. Resident 11 had heart failure and kidney disease, and an order required weights every Monday and Thursday with notification for specified weight gain; the record showed no evidence of weights on February 5 and March 5, 2026. Resident 29 had hypertension and was ordered hydralazine twice daily as needed for blood pressure above 160/90, but the MAR showed it was administered multiple times when blood pressure was below those parameters. Resident 37 and Resident 42, both with dementia and diabetes, had bowel regimen orders for milk of magnesia, Dulcolax suppository, and Fleet saline enema when no bowel movement occurred for several days; bowel tracking showed periods with no recorded bowel movements, and the MAR showed the ordered constipation medications were not provided. The DON confirmed nursing was to follow physician orders and that there was no documented evidence Resident 11 was weighed as ordered.
Failure to Provide Consistent Restorative Ambulation
Penalty
Summary
The facility failed to provide restorative nursing services to maintain or improve walking mobility for one resident. The resident had diagnoses including Alzheimer's disease, generalized muscle weakness, and difficulty walking, and the MDS indicated the resident was cognitively impaired and needed limited assistance with ADLs. A physical therapist recommended a restorative nursing program for walking with a rolling walker for ambulation up to 200 feet. The Director of Therapy stated the program consisted of the resident using a front wheeled walker to go to and from the dining room for each meal to maintain mobility status, but documentation did not support that the resident was offered restorative ambulation on 8 of 30 days. The Nursing Home Administrator confirmed there was no documented evidence that the restorative nursing program was offered daily.
Improper Storage of Oxygen Tubing
Penalty
Summary
The facility failed to store respiratory equipment appropriately for one of three sampled residents receiving oxygen therapy. Resident 42 had diagnoses including chronic obstructive pulmonary disease and respiratory failure. The physician ordered oxygen therapy via nasal cannula at 2 liters per minute at bedtime and also as needed. Facility policy titled Oxygen Protocol, dated January 5, 2026, stated that oxygen cannulas and masks were to be changed weekly and labeled with the date, and that when oxygen tubing was not in use it was to be kept in a plastic bag with a new bag labeled with the resident's name and date placed on the side of the concentrator or portable oxygen tank weekly to hold the tubing. On March 10, 2026, observations showed Resident 42 seated in a wheelchair with a portable oxygen tank in the back pouch and an attached nasal cannula; the oxygen was not in use, and the tubing was not dated and was not stored in the attached storage bag. Later that day, a second set of oxygen tubing attached to the oxygen concentrator in the resident's room was also observed not in use, not dated, and not stored in the attached storage bag. On March 11, 2026, the oxygen tubing attached to the oxygen concentrator was again observed not in use and not stored in the storage bag. During interview, the DON confirmed that the oxygen cannula and tubing should have been dated and placed in a bag when not in use.
Physician Did Not Address Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure that the physician acknowledged the consultant pharmacist’s monthly drug regimen review recommendations for two residents. For Resident 9, the pharmacist recommended review and assessment of the Celexa and Remeron orders on September 14, 2025, and later recommended evaluation and adjustment of the Tylenol dose on November 17, 2025; there was no documented evidence that the attending physician acknowledged or acted on either recommendation. For Resident 37, the pharmacist recommended on December 24, 2025, that Seroquel be evaluated for dose reduction and that a stimulant laxative such as Senna be considered to prevent constipation, and again recommended evaluation of Seroquel on January 13, 2026; there was no documented evidence that the attending physician acknowledged or acted on these recommendations. In an interview on March 12, 2026, at 10:07 a.m., the DON confirmed that the medication review recommendations were not addressed by the physician.
Failure to Provide Required Transfer Notices
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of appeal rights and the contact information for the Office of the State Long-Term Care Ombudsman upon transfer from the facility to the hospital for six of six sampled residents. Clinical record review showed that Resident 2 was transferred on January 28, 2026, Resident 3 on January 13, 2026, Resident 7 on March 9, 2026, Resident 8 on December 13, 2025, Resident 10 on January 17, 2026, February 22, 2026, and March 3, 2026, and Resident 11 on December 27, 2025, all after changes in condition. For each of these residents, there was no documented evidence that the resident, the resident's responsible party, or the legal representative received the required transfer notice containing appeal rights and Ombudsman contact information. During an interview on March 11, 2026, at 1:20 p.m., the Administrator confirmed that the identified residents and/or their representatives were not provided with transfer notices that included the required information.
Failure to Ensure RN Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to adhere to facility policy and state regulations regarding post-fall assessment for a resident with diagnoses including orthostatic hypotension, history of stroke, and glaucoma. After the resident was found on the floor following a fall, the LPN noted the incident and placed the resident back into his chair without an assessment by a registered nurse (RN), as required by the facility's Falls Management Program policy. The RN supervisor was notified, but did not assess the resident, and there was no documentation of an RN assessment in the clinical record or facility documentation. Further review and staff interview confirmed that the LPN did not directly notify the RN supervisor of the fall, and the resident was transferred before an RN assessment was completed. The facility's Director of Nursing acknowledged that the required RN assessment did not occur. This failure to follow established policies and procedures resulted in noncompliance with Pennsylvania Code Title 49 and facility protocols for post-fall care.
Failure to Safely Administer Medications Without Physician Order
Penalty
Summary
The facility failed to safely administer medications for one resident, as evidenced by clinical record review, observation, and staff interviews. The resident in question had multiple diagnoses, including muscle wasting, dysphagia, a need for assistance with personal care, and hearing loss. According to the resident's assessment, she required help with storing medications securely, administering oral medications, and identifying her medications and their prescribed uses, and she was not approved to self-administer her medications. Despite this, the resident was observed with a cup of medications on her bedside table, and a nurse aide confirmed that these were her morning medications. There was no evidence of a physician's order permitting the resident to self-administer medications, and the Director of Nursing confirmed that such an order did not exist.
Failure to Follow Hand Hygiene Policy on Nursing Unit
Penalty
Summary
A deficiency was identified when a nurse aide failed to follow the facility's hand hygiene policy on the fourth floor nursing unit. The policy, last reviewed in January 2025, requires staff 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., the nurse aide was observed exiting one resident's room carrying linens with bare hands, disposing of them in the dirty linen receptacle, and then entering another resident's room without performing hand hygiene. The nurse aide touched the second resident's belongings, obtained clean linens, and re-entered and exited the room again, all without performing hand hygiene at any point during the observation.
Failure to Store Food Under Sanitary Conditions
Penalty
Summary
The facility failed to store food under sanitary conditions in the kitchen. Observations revealed multiple issues: the bottom row of shelves in the reach-in freezer were missing, leading to food items being stored on the bottom floor of the freezer. An open box of raw chicken cheesesteak meat had other food items stored on top of it, and an open bag of French fries was not dated. The slicer handle was broken, and a muffin tin and round cake pan were stored on top of a transformer. Two muffin tins were found on the floor between the storage shelf and the transformer. Water was 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. Additionally, expired cocktail sauce and blue cheese dressing were found in the walk-in refrigerator, and expired popcorn was found in dry storage. Two trays of croquettes in the walk-in freezer were not completely sealed and were open to air.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of two residents. Resident 45, who had a history of stroke, hemiplegia, depression, and muscle weakness, preferred that his white board be updated daily with accurate and current information. However, observations on three separate days revealed that the white board displayed outdated information from March 11, 2024, despite the resident's preference for daily updates. The resident expressed that he did not recall the last time staff updated the board, indicating a failure to honor his preferences and maintain his dignity. Resident 222, diagnosed with obstructive uropathy and neurogenic bladder, was observed sitting in a wheelchair in the common area with an uncovered foley catheter bag containing urine. This occurred on two separate occasions, with multiple residents and staff present in the area. The Director of Nursing confirmed that the resident's foley catheter was not covered with a dignity bag, further failing to ensure the resident's dignity was maintained.
Failure to Implement Physician's Orders for Weight Monitoring
Penalty
Summary
The facility failed to ensure that physician's orders were implemented for Resident 15, who had diagnoses including pleural effusion, dysphagia, and lymphedema. The care plan required daily weight monitoring and reporting significant weight changes to the physician. However, weights were not obtained on several specified dates, and the physician was not notified of multiple instances where the resident's weight changed by more than two pounds in one day. This was confirmed by the Director of Nursing during an interview.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to notify the resident and the resident's representative(s) in writing upon transfer from the facility for two residents who were transferred to the hospital. Clinical record reviews revealed that Resident 2 was transferred and admitted to the hospital on December 30, 2023, after a change in condition, and Resident 23 was transferred and admitted to the hospital on March 6, 2024, after a change in condition. There was no documentation to support that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers to the hospital. In an interview on March 22, 2024, the Assistant Administrator confirmed that written notice regarding the transfers was not provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Doylestown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Enhanced Living - Doylestown | 2.1 mi | ★★★★★ | 13 | 0 |
| Liberty Pointe Rehabilitation And Healthcare Ctr | 2.5 mi | ★★★★★ | 9 | 0 |
| Heritage Pointe Rehabilitation And Healthcare Ctr | 2.6 mi | ★★★★★ | 5 | 0 |
| Harborview Rehabilitation Care Center At Doylestow | 2.7 mi | ★★★★★ | 8 | 1 |
| Neshaminy Manor Home | 4.4 mi | ★★★★★ | 8 | 0 |
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