Inspection Reports for The Garden at Pine Run Health Center
777 FERRY ROAD,, PA, 18901
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
73% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 29
Capacity: 40
Deficiencies: 10
Jul 29, 2025
Visit Reason
The inspection was an unannounced full renewal inspection conducted on 07/29/2025, including an incident review and follow-up on plan of correction submissions.
Findings
Multiple deficiencies were identified related to record confidentiality, staff training, trash receptacle use, food labeling, emergency procedure submissions, fire drill evacuation, medication storage, and labeling. All deficiencies had accepted plans of correction with completion dates and were reported as implemented by 09/17/2025.
Deficiencies (10)
| Description |
|---|
| Narcotics logs were left out on top of medication carts, violating confidentiality. |
| Direct care staff did not receive required infection control and hygiene training during the 2024 training year. |
| Direct care staff did not receive required annual training in fire safety, emergency preparedness, and Older Adult Protective Services Act. |
| Trash can in the memory care kitchenette was uncovered and not in use. |
| Unlabeled and undated plate of breakfast food found in kitchenette refrigerator. |
| Written emergency procedures had not been submitted to the local emergency management agency since 02/09/2024. |
| During fire drill, only 13 of 29 residents evacuated to a designated meeting place away from the building or within a fire-safe area. |
| Medication cards had punctured blister foil exposing medication to contamination. |
| A tube of antifungal cream in medication cart was not labeled with resident's name. |
| Glucometer for Resident #4 was not calibrated to the correct date and time. |
Report Facts
License Capacity: 40
Residents Served: 29
Current Hospice Residents: 1
Residents Age 60 or Older: 29
Residents with Mobility Need: 29
Total Daily Staff: 58
Waking Staff: 44
Inspection Report
Complaint Investigation
Census: 33
Capacity: 40
Deficiencies: 0
Nov 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial licensing inspection.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Complaint Details
The inspection was triggered by a complaint or incident, but no deficiencies or substantiated issues were found.
Report Facts
Total Daily Staff: 66
Waking Staff: 50
License Capacity: 40
Residents Served: 33
Residents 60 Years of Age or Older: 33
Residents with Mobility Need: 33
Inspection Report
Renewal
Census: 37
Capacity: 40
Deficiencies: 5
Sep 25, 2024
Visit Reason
The inspection was conducted as a renewal review of THE GARDEN AT PINE RUN HEALTH CENTER to verify compliance with licensing requirements and to assess the submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including issues with refunding charges after a resident's death, locking poisonous materials, posting emergency telephone numbers, notifying the fire department of changes, and maintaining current prescriptions. All deficiencies had plans of correction accepted and were implemented by December 2, 2024.
Deficiencies (5)
| Description |
|---|
| Failure to refund remainder of previously paid charges after death of a resident under 60 years of age within 30 days. |
| Poisonous materials (toothpaste) were unlocked, unattended, and accessible to residents in room #507. |
| No emergency telephone numbers posted on or by the telephone in room #507. |
| Failure to notify local fire department in writing of address, bedroom locations, and evacuation assistance after change in ownership. |
| Discontinued prescription medications were found in the medication cart for resident #2. |
Report Facts
License Capacity: 40
Residents Served: 37
Current Hospice Residents: 2
Residents Age 60 or Older: 37
Residents with Mobility Need: 37
Inspection Report
Monitoring
Census: 30
Capacity: 40
Deficiencies: 1
Feb 21, 2024
Visit Reason
The inspection was a monitoring visit conducted on 02/21/2024 to review the facility's compliance and verify the implementation of a submitted plan of correction.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. A specific deficiency related to medication labeling was addressed and corrected.
Deficiencies (1)
| Description |
|---|
| Resident's prescription medication labeling did not include a direction change sticker on the pharmacy label for PRN medications, leading to improper medication administration documentation. |
Report Facts
License Capacity: 40
Residents Served: 30
Total Daily Staff: 60
Waking Staff: 45
Inspection Report
Monitoring
Census: 29
Capacity: 40
Deficiencies: 8
Dec 28, 2023
Visit Reason
The inspection was an unannounced partial monitoring visit conducted by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing on 12/28/2023 to review compliance and follow-up on a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies related to sanitary conditions, medication management, documentation accuracy, and support plan signatures. The submitted plan of correction was accepted and fully implemented as of 04/09/2024, with ongoing audits and staff re-education planned to maintain compliance.
Deficiencies (8)
| Description |
|---|
| Strong odor of urine in hallways and dried feces on a resident's toilet seat indicating unsanitary conditions. |
| Discontinued medication was found in the home's medication cart. |
| Over-the-counter medication package was not labeled with the resident's name. |
| Controlled substance log was not completed properly during medication pass and discrepancies in glucometer readings documentation. |
| Medication administration record inaccurately stated the purpose of a medication. |
| Medication administration documentation errors including missing signatures and incomplete controlled substance logs. |
| Medications were not administered as prescribed on multiple occasions. |
| Resident participated in support plan development but did not sign; no notation of refusal or inability to sign was documented. |
Report Facts
License Capacity: 40
Residents Served: 29
Total Daily Staff: 58
Waking Staff: 44
Number of Residents 60 Years or Older: 29
Number of Residents with Mobility Need: 29
Inspection Report
Renewal
Census: 34
Capacity: 40
Deficiencies: 0
Aug 18, 2023
Visit Reason
The inspection was conducted as a renewal visit and due to a change in legal entity for the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 34
License Capacity: 40
Current Residents in Hospice: 1
Total Daily Staff: 68
Waking Staff: 51
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