Pennsylvania Department of Health
PINECREST MANOR
Building Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 58 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


PINECREST MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on January 21, 2026, at Pinecrest Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID #010902
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on January 21, 2026, it was determined that Pinecrest Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type II (000), unprotected, non-combustible building, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Building Rehabilitation:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following:
* Requirements of Chapter 18 and 19
* Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2-hour fire resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2-hour fire resistance rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0111

Based on observation and interview, the facility failed to maintain building rehabilitation requirements on one of one building component.

Findings include:

Observation on January 21, 2026, 10:19 a.m., revealed the facility changed the use of the basement therapy side room by converting it into a storage room. The side room is open to patients receiving therapeutic care. Storage in the room included combustible items, such as soiled utility carts, storage totes, and pool noodles. A washing machine and dryer were in use in the room as well. This room was not designed to be a hazardous room. Plans were submitted to State Plan Review and approved, with drawing number H-24-0775 created. Work had not started at the time of this survey, and an occupancy has yet to be granted by the Division of Life Safety.

Interview with the maintenance supervisor, on January 21, 2026, at 10:19 a.m., confirmed the above deficiency existed at the time of the survey.

Plan of Correction - To be completed: 03/20/2026

1. KTH Architects will be consulted for plan review to covert this room in therapy to a storage area. A quote was obtained for a fire door and ordered for installation to separate the storage area from the therapy room.
2. Corrective action date is March 20, 2.026
3. All therapy employees will be educated about the installation of the door and to not keep combustible materials in the storage area.
4. Audits will be completed quarterly by the Director of Maintenance or his designee on all fire doors to ensure they meet regulation. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.

NFPA 101 STANDARD Means of Egress Requirements - Other:

Means of Egress Requirements - Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of Egress requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
18.2, 19.2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0200

Based on observation and interview, the facility failed to maintain emergency evacuation diagrams for one of one building component.

Findings include:

Observation on January 21, 2026, at 11:02 a.m., revealed the evacuation diagrams throughout the facility did not display a prominent viewer's location.

Reference: NFPA 170-11.2.4 and 11.3.2

Interview with the maintenance supervisor on January 21, 2026, at 11:02 a.m., confirmed the evacuation diagram deficiency.

Plan of Correction - To be completed: 03/20/2026

1. All evacuation diagrams will be updated to contain a notation showing the prominent viewer's location.
2. Correction action date will be April 20, 2026.
3. All employees will be reeducated on evacuation diagrams.
1. Audits will be completed quarterly by the Director of Maintenance or his designee on all evacuation diagrams to ensure they meet regulation. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.

NFPA 101 STANDARD Exit Signage:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0293

Based on observation and interview, the facility failed to maintain exit signs for two of over twenty exit signs.

Findings include:

Observation on January 21, 2026, at 10:48 a.m., revealed the A-B corridor had missing exit signage, breaking continuity at the A-B nurse station and the right of the dining room door.

Interview with the maintenance director on January 21, 2026, at 10:48 a.m., confirmed the deficiency at the time of the survey.

Plan of Correction - To be completed: 03/20/2026

1. An exit sign will be placed in the corridor of A&B neighborhood.
2. Corrective action date will be March 20, 2026.
3. All maintenance employees will be reeducated on exit signage and the regulations.
4. Audit will be completed monthly by the Director of Maintenance or his designee on exit signs to ensure they meet regulations.
5. All results will be reported at the Quarterly Quality Assurance Performance Improvement Committee.

NFPA 101 STANDARD Cooking Facilities:

Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation and interview, the facility failed to maintain cooking equipment in one of one kitchen.

Findings include:

Observation and interview on January 21, 2026, at 10:45 a.m., revealed the kitchen staff were uncertain of the location and operation of the hood fire suppression system's manual activation.

Interview with the maintenance supervisor on January 21, 2026, at 10:45 a.m., confirmed the kitchen cooking equipment deficiency.

Plan of Correction - To be completed: 03/20/2026

1. The employee interviewed regarding the location and operation of the kitchen hood suppression system was educated at the time of the survey.
2. Corrective Action date will be March 20, 2026.
3. All dietary employees will be reeducated on the location and operation of the kitchen hood suppression system.
4. The Dietary manager or her designee will complete monthly audits asking employees the location and operation of the kitchen hood suppression system. These audits will be completed monthly for 3 months and then quarterly thereafter. The results will be reported at the Quarterly Quality Assurance Performance Improvement Committee.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Subdivision of Building Spaces - Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0372

Based on observation and interview, the facility failed to maintain smoke barrier walls to resist the passage of smoke in four of over twenty rooms.

Findings include:

Observation on January 21, 2026, between 10:22 a.m. and 11:06 a.m., revealed the following smoke barrier deficiencies:

A. (10:22 a.m.) Basement electrical room had unsealed penetrations around an electrical conduit that would allow the passage of smoke;
B. (11:47 a.m.) Basement storage room had unsealed penetrations around an electrical conduit that would allow the passage of smoke;
C. (10:47 a.m.) Main floor dining room storage room had unsealed penetrations around an electrical conduit and piping that would allow the passage of smoke;
D. (11:06 a.m.) Main floor D-wing housekeeping room had unsealed penetrations around a dryer venting pipe and other pipes that would allow the passage of smoke.

Interview with the maintenance supervisor on January 21, 2026, at 11:06 a.m., confirmed the smoke barrier deficiencies.

Plan of Correction - To be completed: 03/20/2026

1. All unsealed penetrations identified during the survey will be fixed.
2. Corrective action date will be April 20, 2026.
3. All employees will be reeducated on unsealed penetrations and the regulations and if identified to place a maintenance order in to be fixed.
4. Audits will be completed quarterly by the Director of Maintenance or his designee to ensure that there are no unsealed penetrations. Results of these audits will be reported to the Quarterly Quality Assurance Performance Improvement Committee.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement