Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 The Pines At Philadelphia Rehab And Healthcare Ctr during CMS and state inspections, most recent first.
Failure to Address Toileting and Continence Needs: A resident with BPH, prostate CA, dementia, hearing impairment, and back pain was not provided an individualized continence care plan despite needing assistance with toileting, hygiene, and transfers. Staff observed him unclothed with fecal matter on his body and toilet, and interviews showed delayed call bell response, prolonged time on the toilet, and instructions for him to clean himself even though he could not do so independently. The DON and Administrator confirmed that individualized toileting preferences and continence interventions had not been implemented.
The facility did not report two separate incidents involving allegations of neglect and misappropriation: one where a resident's money was taken and another where a resident's biliary drain was forcibly removed during care, resulting in hospital transfer. In both cases, the facility conducted internal investigations but failed to notify the appropriate authorities as required.
A resident with chronic pain and other medical conditions did not receive scheduled doses of prescribed Xtampza ER for pain management due to a delay in pharmacy delivery. Despite a physician's order and facility policy requiring timely medication administration, the medication was not available or given as ordered, and the resident reported significant pain. The DON confirmed the delay and missed doses.
The facility failed to provide necessary grooming services for three residents, resulting in inadequate personal hygiene. A resident with mobility issues was observed with long facial hair and nails, expressing a desire for grooming. Another resident had not received a scheduled shower, and a third resident, dependent on assistance due to a stroke, also lacked grooming. These deficiencies were confirmed by staff.
The facility did not evaluate the competencies of three agency nursing staff members, including a registered nurse and a nursing aide, as required by its policy. Despite the facility's commitment to ongoing staff training and competency validation, these employees were not assessed for their skills or oriented to the facility's practices, as confirmed by interviews with the HR Director and DON.
Two residents with intact cognition were unaware of the arbitration agreements they signed upon admission. The facility's Admissions Director failed to educate them about their 30-day revocation rights, and the agreement improperly limited revocation to 10 days.
A resident with a diagnosis of anxiety did not receive necessary behavioral health care in an LTC facility. Despite documented anxiety and depression, the facility failed to implement interventions to address the resident's daytime anxiety. The resident experienced increased anxiety due to roommate changes, leading to trichotillomania, but no coping strategies were developed. Interviews confirmed the lack of interventions or documentation to manage the resident's anxiety.
The facility failed to store food according to professional standards, with unlabeled and expired items found in the refrigerator, freezer, and a resident's room. Observations included expired ketchup, unlabeled cheeses, and improperly labeled meats and spices. A resident had opened food items in their room without proper labeling or refrigeration.
The facility did not ensure complete and accurate physician orders for two residents. One resident's order for ProSource Nocarb lacked the route of administration, while another's order for Vancomycin HCL did not specify the appropriate diagnosis, only listing the drug class as IV ABT. These issues were confirmed by the DON during interviews.
A resident with multiple diagnoses, including dementia and a history of falling, experienced an unwitnessed fall and subsequent hip fracture. The facility failed to conduct a thorough investigation, did not interview key staff, and did not review camera footage. Pain management documentation was also incomplete.
Failure to Address Resident Toileting and Continence Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to assist a resident in maintaining bowel and bladder continence to the extent possible. The resident had diagnoses including benign prostatic hyperplasia, prostate cancer, unspecified dementia with a BIMS score of 9, low back pain, and thyrotoxicosis. The resident also had moderate hearing difficulty, and the record incorrectly indicated that he did not use a hearing aid or other hearing appliance. He was prescribed Lasix 20 mg, which increases urine production. The comprehensive care plan, last reviewed on April 29, 2026, did not include goals or interventions related to bowel or bladder continence, toileting assistance, scheduled toileting, continence management, or staff assistance needed to maintain continence. The care plan focused on transfer assistance and mobility, but did not address the resident’s toileting needs, his preference for using a cup rather than a standard male urinal, or behaviors affecting continence care. The DON confirmed that the resident did not have a care plan addressing toileting preferences, refusal behaviors, toileting assistance, or individualized continence management strategies. During observation on May 26, 2026, the resident was found lying sideways in bed unclothed and without bed linens, with fecal matter on his buttocks and side. Fecal matter was also observed on the toilet, and the toilet remained visibly soiled minutes later. A CNA entered and stated the resident had finished a bowel movement and wanted help getting dressed and transferred to his chair. An LPN present during the observation stated she was unsure where the assigned CNA was or why the resident had been left unclothed, without linens, and with fecal matter remaining on him. In interviews, the resident and his daughter reported that staff often did not respond promptly to call bell requests, that he was left on the toilet for extended periods, and that he could not perform toileting hygiene independently. The resident also reported that staff gave him wet paper towels and told him to clean himself despite his inability to do so. The DON and Administrator later confirmed that individualized interventions to address the resident’s toileting needs and preferences had not been implemented.
Failure to Report Allegations of Neglect and Misappropriation
Penalty
Summary
The facility failed to report allegations of neglect and misappropriation of resident property for two residents, as required by federal and state law. In the first case, a resident reported that money was missing from his nightstand, and although the facility conducted an internal investigation—including reviewing security footage and interviewing staff and residents, ultimately identifying and terminating a perpetrator—the incident was not reported to the appropriate authorities. Facility policy requires that such incidents be reported, but this step was omitted. In the second case, a resident with a history of acute cholecystitis and a biliary drain reported that, during care provided by two staff members, her biliary drain was forcibly removed, resulting in a hospital transfer for replacement of the drain. The resident was cognitively intact at the time of the incident and reported the event to the social services department. Despite the seriousness of the allegation and the resulting harm, the facility did not report the incident as required. Interviews with facility leadership confirmed the failure to report both incidents.
Failure to Timely Administer Prescribed Pain Medication Due to Pharmacy Delay
Penalty
Summary
The facility failed to ensure the timely acquisition and administration of a prescribed pain medication for one resident who was admitted with diagnoses including muscle wasting and atrophy, COPD, and chronic pain syndrome. Despite a physician's order for Xtampza ER, an extended-release oxycodone for pain management, the medication was not administered at the scheduled times from the evening of admission through several subsequent scheduled doses. The resident, who was cognitively intact, reported not receiving the medication and experiencing significant pain, rating it as 8.5 out of 10. Facility policy required pharmacy services to be available 24/7 and for nursing staff to ensure residents have a sufficient supply of prescribed medications, including timely communication with the pharmacy if medications are unavailable. Documentation and interviews confirmed that the resident did not receive the ordered pain medication due to a delay in delivery from the pharmacy, resulting in unmet pain management needs.
Failure to Provide Adequate Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services for three residents, resulting in inadequate personal hygiene. Resident R11, who required substantial assistance with personal hygiene due to a fracture and joint surgery, was observed with long facial hair and nails. The resident expressed a desire to be shaved and have her nails cut, indicating a lack of grooming services. This observation was confirmed by the Director of Nursing. Resident R95, admitted with reduced mobility and chronic obstructive pulmonary disease, required limited assistance with personal care. The resident had long nails and facial hair and had not received a shower since admission, despite being scheduled for showers twice a week. The lack of documentation on whether the shower was provided or refused was confirmed by the Director of Nursing. Similarly, Resident R22, who was dependent on assistance for personal hygiene due to the effects of a stroke, was observed with long nails and facial hair, expressing a desire for grooming. These observations were confirmed by a nursing aide.
Failure to Evaluate Competency of Agency Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the required skills to properly care for residents' needs, as evidenced by the review of personnel files and interviews with staff. Specifically, the facility did not evaluate the competencies of three agency employees, identified as a registered licensed nurse, a nursing aide licensed nurse, and a licensed nurse, who were hired to work at the facility. The facility's policy on staff training emphasizes the importance of ongoing staff training and competency validation, yet these employees were not assessed for their competencies in their specific job duties and responsibilities. Interviews with the Human Resource Director and the Director of Nursing confirmed that these agency staff members were not evaluated for their competencies or oriented to the facility's practices, which is a requirement under the facility's policy and state regulations.
Failure to Ensure Resident Understanding of Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement. This deficiency was identified for two residents, both of whom had a Brief Interview for Mental Status (BIMS) score of 15, indicating they were cognitively intact. Despite this, both residents reported being unaware of the arbitration agreement they signed upon admission. Resident R11, admitted with diagnoses of fracture and orthopedic aftercare, signed the agreement on August 30, 2024, but later stated they had never heard of it and did not understand the procedures. Similarly, Resident R38, who signed the agreement on August 26, 2024, recalled signing something upon admission but did not understand the arbitration procedure. The facility's process for educating residents about the arbitration agreement was inadequate. The Admissions Director, responsible for this education, admitted to not informing residents about their 30-day right to revoke the agreement, as she was unaware of this requirement. The facility's arbitration agreement limited residents to a 10-day revocation period, contrary to the standard 30 days. This oversight in resident education and the improper revocation period contributed to the deficiency identified by the surveyors.
Failure to Provide Behavioral Health Care for Resident with Anxiety
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident 38, who was admitted with a diagnosis of anxiety. The resident's social service assessment indicated feelings of depression for a significant period, and subsequent progress notes documented anxiety related to personal issues. Despite these documented concerns, the facility did not implement any interventions to address the resident's anxiety during the day. The only treatment provided was a prescription for Mirtazapine for insomnia, which did not address the resident's daytime anxiety. Interviews with the resident revealed that changes in roommates exacerbated her anxiety, leading to symptoms of trichotillomania. The resident expressed that coloring helped her calm down, yet no interventions were developed to assist her in coping with anxiety. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the absence of any interventions or documentation to manage the resident's anxiety or promote her well-being, resulting in a deficiency in providing necessary behavioral health care.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator, freezer, and resident's room was maintained according to professional standards for food service safety. During an initial tour of the Food Service Department, several deficiencies were observed. In the main walking refrigerator, there was an open ketchup bottle that had expired, two cheeses without labels, and various meats and sausages that were either unlabeled or lacked expiration dates. Additionally, the main freezer contained opened home fries and veggie burgers that were not labeled. At the serving table of the prep line, various spices and sauces were found with only received dates and no expiration dates, and some spices were expired. Furthermore, an interview with a resident revealed that they had opened salsa, nacho cheese, ranch, and two opened pickle jars in their room without proper labeling or refrigeration. A nursing aide confirmed these observations. These findings indicate a failure to adhere to the facility's policy on labeling and dating food items, which requires all fresh and frozen foods to be dated with the date they were received unless they have a purveyor shipping label. The policy also specifies the duration for which certain refrigerated items can be kept once opened.
Incomplete Physician Orders for Two Residents
Penalty
Summary
The facility failed to ensure that physician orders were recorded completely and accurately for two residents. For the first resident, who was admitted with diagnoses including anemia, malnutrition, and dependence on renal dialysis, the physician's order for ProSource Nocarb did not include the route of administration. This omission was confirmed by the Director of Nursing during an interview. For the second resident, admitted with diagnoses including MRSA and long-term use of antibiotics, the physician's order for Vancomycin HCL did not specify the appropriate diagnosis for the medication, only indicating the class of drug as IV ABT. This was also confirmed by the Director of Nursing during an interview. These deficiencies were identified during a clinical record review and staff interviews.
Incomplete Investigation of Resident's Hip Fracture
Penalty
Summary
The facility failed to conduct a complete and thorough investigation regarding a hip fracture for a resident (CL1). The resident, who was admitted with multiple diagnoses including dementia and a history of falling, experienced an unwitnessed fall shortly after admission. Despite initial assessments and pain management attempts, the resident continued to complain of increasing pain over several days, culminating in a diagnosis of a hip fracture after being transferred to a hospital. There was a significant gap in pain management documentation, with no pain assessment or treatment recorded for nearly 12 hours on one of the days leading up to the hospital transfer. The facility's policies on abuse prevention and incident investigation were not followed. The investigation into the resident's injury was incomplete, as key staff members who were on duty during the relevant periods were not interviewed. Additionally, the facility did not review camera footage to determine if the resident had any unwitnessed falls between the initial fall and the hospital transfer. The investigation was left inconclusive as the facility awaited the resident's return from the hospital. Interviews with the Director of Nursing and the Administrator confirmed the deficiencies in the investigation process. The facility did not adhere to its own protocols for investigating injuries of unknown origin, which resulted in a failure to identify the cause of the resident's hip fracture. This lack of thorough investigation and documentation was confirmed by the surveyors, leading to the identification of the deficiency.
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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 Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wesley Enhanced Living Pennypack Park | 0.1 mi | ★★★★★ | 11 | 0 |
| Deer Meadows Rehabilitation Center | 0.2 mi | ★★★★★ | 21 | 0 |
| Transitional Care Unit At Nazareth Hospital | 0.3 mi | ★★★★★ | 0 | 0 |
| Roosevelt Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 24 | 0 |
| Immaculatemarycenter For Rehabilitation&healthcare | 0.9 mi | ★★★★★ | 26 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.