Pine Run Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Doylestown, Pennsylvania.
- Location
- 777 Ferry Road, Doylestown, Pennsylvania 18901
- CMS Provider Number
- 395366
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Pine Run Health Center during CMS and state inspections, most recent first.
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.
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.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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