Inspection Reports for Pine Manor Home
2165 NEW HOLLAND PIKE,, LANCASTER, PA, 17601
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
134% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
55% occupied
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 17
Capacity: 31
Deficiencies: 0
Apr 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial inspections on 04/08/2025 and 04/18/2025.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint, but no deficiencies or regulatory citations were found, indicating no substantiated issues.
Report Facts
License Capacity: 31
Residents Served: 17
Resident Support Staff: 0
Total Daily Staff: 17
Waking Staff: 13
Residents Receiving Supplemental Security Income: 9
Residents Age 60 or Older: 15
Residents Diagnosed with Mental Illness: 5
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Inspection Report
Renewal
Census: 18
Capacity: 31
Deficiencies: 13
Nov 6, 2024
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 11/06/2024 to review compliance with licensing requirements.
Findings
The inspection found multiple deficiencies including issues with criminal background checks, annual training hours, sanitary conditions, surfaces, hot water temperature, lighting, emergency preparedness, fire extinguisher inspections, medical evaluations, medication storage, prescription currency, training records, and additional resident assessments. Plans of correction were accepted and implemented by 12/18/2024.
Deficiencies (13)
| Description |
|---|
| Criminal background check was not requested timely for a staff member. |
| Administrator completed only 20.5 hours of required annual training. |
| Brown-colored smears and splatter on bathroom walls; grab bar wrapped in duct tape and not cleanable. |
| Accumulation of dust on overhead vents and ceiling tiles with water damage. |
| Hot water temperature exceeded 120°F in bathroom and kitchenette. |
| Residents in lower level room lacked operable lamps within reach at bedside. |
| Administrators did not have a copy of or were not familiar with local emergency preparedness plan. |
| Fire extinguishers had not been inspected or approved since October 2023. |
| Residents admitted did not have medical evaluations completed within required timeframes. |
| Prescription medications and syringes were unlocked and accessible in resident bedroom. |
| Discontinued medication (Mupirocin ointment) was found in resident's room. |
| Medication administration training record lacked date, trainer name, and documentation of completion. |
| Resident's previous assessment and support plan was not completed annually as required. |
Report Facts
License Capacity: 31
Residents Served: 18
Staffing Hours: 18
Waking Staff: 14
Supplemental Security Income Recipients: 9
Residents 60 Years or Older: 16
Residents Diagnosed with Mental Illness: 3
Hot Water Temperature: 127
Hot Water Temperature: 124
Inspection Report
Follow-Up
Census: 16
Capacity: 31
Deficiencies: 2
Apr 25, 2024
Visit Reason
The inspection was a follow-up review conducted on 04/25/2024 to verify the implementation of the submitted plan of correction related to prior deficiencies.
Findings
The submitted plan of correction was determined to be fully implemented, and continued compliance must be maintained. Two specific deficiencies were addressed: failure to submit an incident report within 24 hours and incomplete documentation in the resident support plan regarding medical needs.
Deficiencies (2)
| Description |
|---|
| Failure to submit an incident report to the Department within 24 hours after a resident was transported to the emergency room due to stomach pain and vomiting. |
| Resident's support plan did not document how the need for assistance with eating/swallowing would be met. |
Report Facts
License Capacity: 31
Residents Served: 16
Total Daily Staff: 16
Waking Staff: 12
Residents Receiving Supplemental Security Income: 10
Residents Age 60 or Older: 14
Residents Diagnosed with Mental Illness: 1
Inspection Report
Renewal
Census: 18
Capacity: 31
Deficiencies: 11
Nov 15, 2023
Visit Reason
The inspection was an unannounced full renewal inspection with an incident review conducted on 11/15/2023.
Findings
The inspection identified multiple deficiencies including failure to post required regulations, staff qualification issues, lack of CPR/First Aid certification for staff, incomplete emergency telephone postings, inadequate first aid kit supplies, unlabeled soap bars, insufficient emergency water supply, overdue fire drills during sleeping hours, incomplete resident medical evaluations, improper calibration of glucometers, and missing recent resident photographs. Plans of correction were accepted and implemented by early January 2024.
Deficiencies (11)
| Description |
|---|
| A copy of the Chapter 2600 regulations was not posted in a conspicuous and public place in the home. |
| Direct care staff person A does not have a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| At least one staff person present was not certified in both CPR and First Aid during night shifts. |
| The personal care home complaint hotline was not included on the emergency telephone number list near telephones. |
| The first aid kit did not contain scissors, adhesive tape, and antiseptic. |
| Unlabeled used bars of soap were found in showers in the basement and main floor bathrooms. |
| The home did not maintain the required 3-day supply of emergency drinking water and lacked a contract with a local bottled water supplier. |
| Fire drills during sleeping hours were not conducted every six months as required. |
| Resident medical evaluations were incomplete, missing key elements such as height, diagnoses addendum, immunization history, body positioning, health status, cognitive functioning, dietary restrictions, and medical professional license number. |
| The glucometer for Resident #1 was not calibrated to the correct date and time, and discrepancies were found between glucometer readings and Medication Administration Records. |
| Resident #1's record did not include a photograph that is no more than 2 years old. |
Report Facts
License Capacity: 31
Residents Served: 18
Total Daily Staff: 18
Waking Staff: 14
Supplemental Security Income Recipients: 10
Residents Age 60 or Older: 16
Residents Diagnosed with Mental Illness: 4
Residents Diagnosed with Intellectual Disability: 0
Residents with Mobility Need: 0
Residents with Physical Disability: 0
Emergency Drinking Water Required: 48
Emergency Drinking Water Available: 42
Inspection Report
Renewal
Census: 15
Capacity: 31
Deficiencies: 15
Sep 22, 2022
Visit Reason
The inspection was conducted as a renewal inspection of the Pine Manor Home facility to assess compliance with licensing requirements.
Findings
The inspection identified multiple deficiencies including failure to post required documents, uncovered trash receptacles, unsecured thermostat with exposed wires, incomplete first aid kit, lack of chairs and operable lamps in resident bedrooms, improper food storage, insufficient emergency water supply, missing emergency procedures posting, lack of recent fire safety inspection and fire drills, medication storage and documentation errors, and missing recent resident photographs. All deficiencies had plans of correction accepted and were reported as implemented by the administrator.
Deficiencies (15)
| Description |
|---|
| Chapter 2600 regulations were not posted in a conspicuous and public place in the home. |
| There was a full, uncovered trash can in the bathroom of a shared bedroom, located in the basement. |
| An unsecured old thermostat with exposed wires was located in the hallway of the basement, near the storage room. |
| The first aid kit near the medication cart did not include tweezers, scissors, antiseptic and tape. |
| The bedroom located in basement area of home is occupied by 2 residents; however, there were no chairs in this room. |
| Residents in the shared bedroom, located in basement area of home, do not have access to a source of light that can be turned on/off at bedside. |
| 3 boxes of emergency water were stored on the floor in the storage room, located in the basement. |
| The home had only 18 gallons of emergency drinking water stored, insufficient for the 15 residents requiring 45 gallons. |
| The home’s emergency procedures were not posted in a conspicuous and public place in the home. |
| The home has not had a fire safety inspection/fire drill that was conducted by a fire safety expert. |
| The home has not held a fire drill during sleeping hours within the past 6 months. |
| Errors were observed in Resident 1's medication administration and Medication Administration Record (MAR). |
| Resident 3's medication count discrepancy due to clerical error in documentation. |
| Resident 1's medication administration record (MAR) does not indicate the dosage. |
| Resident records for Resident 1 and 2 do not include a recent photograph. |
Report Facts
License Capacity: 31
Residents Served: 15
Staffing Hours: 15
Waking Staff: 11
Supplemental Security Income: 9
Residents 60 Years or Older: 14
Diagnosed with Mental Illness: 3
Diagnosed with Intellectual Disability: 1
Current Hospice Residents: 0
Emergency Drinking Water Required: 45
Emergency Drinking Water Available: 18
Emergency Drinking Water Purchased: 27
Inspection Report
Original Licensing
Capacity: 31
Deficiencies: 14
May 20, 2021
Visit Reason
The inspection was conducted as part of the initial licensing process for the newly licensed personal care home facility, Pine Manor Home, to assess compliance with applicable regulations.
Findings
The facility was found to be in substantial compliance with regulations, but the inspection was partial due to the home being new and not yet serving four or more residents. Several deficiencies were cited related to safety, maintenance, and documentation, all of which were corrected or had plans of correction submitted.
Deficiencies (14)
| Description |
|---|
| The Care Facility Carbon Monoxide Alarms Standards Act requires an alarm be placed in close proximity to fossil-fuel burning appliances and additional alarms in living areas; the home has only one carbon monoxide alarm in the basement utility room. |
| A boiler is used as the primary heating source but the home did not have a certificate of operation for the boiler. |
| The home does not have a staff contact list. |
| There are 5 holes in the wall inside Bedroom 3. |
| The windows in Bedrooms 9 and 10 do not have shades, blinds, or shutters. |
| There are no grab bars, hand rails or assist bars for the toilet in the main floor staff bathroom, the toilet and shower in the foyer bathroom, and the toilet and shower in the new bathroom on the lower level. |
| The home has only 4 gallons of emergency water. |
| The evacuation diagrams do not include the locations of the fire extinguishers or fire alarm pull signals. |
| The home did not notify the local fire department in writing of the address of the home, location of the bedrooms, and the assistance needed to evacuate in an emergency. |
| A portable space heater was plugged into an electric outlet in a lower level office, temporarily being used as a bedroom for staff. |
| There are no smoke detectors in the hallway housing Bedrooms 1 through 5. |
| There shall be an operable automatic smoke detector located within 15 feet of each bedroom door; the home lacked these detectors. |
| There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic; the home had no fire extinguisher in the attic. |
| Fire extinguishers shall be inspected and approved annually by a fire safety expert; the home's fire extinguishers were last serviced and inspected in March 2020. |
Report Facts
License Capacity: 31
Current Residents: 0
Deficiencies cited: 14
Emergency water gallons: 4
Holes in wall: 5
Inspection date: May 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding licensing inspection results |
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