Pennsylvania Department of Health
THE PINES AT PHILADELPHIA REHABILITATIONANDHEALTHCARE CENTER
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 41 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.


THE PINES AT PHILADELPHIA REHABILITATIONANDHEALTHCARE CENTER - 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 July 21, 2025, it was determined that The Pines At Philadelphia Rehabilitation and Healthcare Center was not in compliance with the requirements of 42 CFR 483.73.

Plan of Correction:

403.748(a), 416.54(a), 418.113(a), 441.184(a), 482.15(a), 483.475(a), 483.73(a), 484.102(a), 485.542(a), 485.625(a), 485.68(a), 485.727(a), 485.920(a), 486.360(a), 491.12(a), 494.62(a) STANDARD Develop EP Plan, Review and Update Annually:

This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.

§403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a).

The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements:

(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following:

* [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach.

* [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually.

* [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years.

.

Observations:
Name: - Component: -- - Tag: 0004

Based on documentation review and interview, it was determined the facility failed to ensure Emergency Preparedness Plan policies and procedures were reviewed and updated at least annually, affecting the entire facility.

Findings include:
Document review on July 21, 2025, at 8:30 a.m., revealed the Facility's Emergency Preparedness Plan had not been reviewed and updated at least annually.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 09/19/2025

1 There was no negative outcome due to Emergency Preparedness plan not being completely reviewed and revised annually.
2 All patient have potential to be harmed by this deficiency
3 The facility immediately initiated the revision of the emergency preparedness binder including but not limited to policies and procedures related to medical records during transfer, emergency evacuation, Active shooter.
4 The Administrator, Maintenance director, or designee will audit binder to ensure that all required updates and revisions are up to date quarterly X4 to ensure all policies are included. The findings will be reported to the QAPI committee on a quarterly basis X2.

403.748(a)(3), 416.54(a)(3), 418.113(a)(3), 441.184(a)(3), 482.15(a)(3), 483.475(a)(3), 483.73(a)(3), 484.102(a)(3), 485.542(a)(3), 485.625(a)(3), 485.68(a)(3), 485.727(a)(3), 485.920(a)(3), 491.12(a)(3), 494.62(a)(3) STANDARD EP Program Patient Population:

§403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3).

[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:]

(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.**

*[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following:
(3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

*NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.]

Observations:
Name: - Component: -- - Tag: 0007

Based on document review and interview, it was determined the facility failed to ensure policies and procedures were in place addressing patient population, including, but not limited to, persons at-risk; the type of services the facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans, affecting the entire facility.

Findings include:
Document review on July 21, 2025, at 8:30 a.m., revealed the Facility's Emergency Preparedness Plan did include policies and procedures that addressed persons at-risk, affecting the entire facility.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to Policies and Procedures addressing persons at-risk. Plan not included in policy binder.
2. All residence have potential harm from this deficiency.
3. The facility immediately initiated the revision of policies and procedures addressing persons at risk at all levels of care. As well a succession plan has been initiated immediately. This updated documentation of the policy and procedures will be included in the binder.
4. The maintenance director, or qualified designee will audit the plan to ensure that all any required updates and revisions are documented. quarterly X4 and annually thereafter, to ensure all policies are included. The findings will be reported to the QAPI committee on a quarterly basis X2.

403.748(b), 416.54(b), 418.113(b), 441.184(b), 482.15(b), 483.475(b), 483.73(b), 484.102(b), 485.542(b), 485.625(b), 485.68(b), 485.727(b), 485.920(b), 486.360(b), 491.12(b), 494.62(b) STANDARD Development of EP Policies and Procedures:

This is a less serious (but not lowest level) 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 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.

§403.748(b), §416.54(b), §418.113(b), §441.184(b), §460.84(b), §482.15(b), §483.73(b), §483.475(b), §484.102(b), §485.68(b), §485.542(b), §485.625(b), §485.727(b), §485.920(b), §486.360(b), §491.12(b), §494.62(b).

(b) Policies and procedures. [Facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years.

*[For LTC facilities at §483.73(b):] Policies and procedures. The LTC facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least annually.

*Additional Requirements for PACE and ESRD Facilities:

*[For PACE at §460.84(b):] Policies and procedures. The PACE organization must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must address management of medical and nonmedical emergencies, including, but not limited to: Fire; equipment, power, or water failure; care-related emergencies; and natural disasters likely to threaten the health or safety of the participants, staff, or the public. The policies and procedures must be reviewed and updated at least every 2 years.

*[For ESRD Facilities at §494.62(b):] Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. These emergencies include, but are not limited to, fire, equipment or power failures, care-related emergencies, water supply interruption, and natural disasters likely to occur in the facility's geographic area.

Observations:
Name: - Component: -- - Tag: 0013

Based on documentation review and interview, it was determined the facility failed to ensure emergency preparedness policies and procedures, based on the emergency plan, risk assessment and communication plan, were updated at least annually, affecting the entire facility.

Findings include:
Document review on July 21, 2025, at 8:30 a.m., revealed the facility's emergency preparedness policies and procedures including the emergency plan, risk assessment, and communication plan had not been updated at least annually.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 a.m., confirmed the documentation had not been updated.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to the facility not documenting revision and review to EP policies and procedures annually.
2. All residents have potential harm from this deficiency
3. The facility immediately initiated revision of its Emergency plan, risk assesment, and communication plan to ensure it is up to date.
4. The Maintenance Director or qualified designee will audit binder to ensure that all required updates and revisions are documented, quarterly X4 to ensure all policies and procedures are up to date. The findings will be reported to the QAPI committee on a quarterly basis X2.

403.748(b)(2), 416.54(b)(1), 418.113(b)(6)(ii) and (v), 441.184(b)(2), 482.15(b)(2), 483.475(b)(2), 483.73(b)(2), 485.542(b)(2), 485.625(b)(2), 485.920(b)(1), 486.360(b)(1), 494.62(b)(1) STANDARD Procedures for Tracking of Staff and Patients:

§403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility's] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location.

*[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF's, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF's, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location.

*[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures.
(ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance.
(v) A system to track the location of hospice employees' on-duty and sheltered patients in the hospice's care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location.

*[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance.

*[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

*[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients.

Observations:
Name: - Component: -- - Tag: 0018

Based on documentation review and interview, it was determined the facility failed to develop Emergency Plan policies and procedures that included a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location if on-duty staff and sheltered patients are relocated during an emergency, affecting the entire facility.

Findings include:
Document review on July 21, 2025, at 8: 30 a.m., revealed the Facility's Emergency Preparedness Plan did not include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location if on-duty staff and sheltered patients are relocated during an emergency.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to the Emergency Preparedness Plan not including policy to track the location of on-duty staff and sheltered patients in the event of major transferring of patients
2. All residence have potential harm by this deficiency.
3. The facility immediately initiated the development and revision of its Emergency Preparedness policy and plan to ensure it accurately reflects procedure for tracking the location of on-duty staff and sheltered patients in the event of an emergency transfer
4. The Maintenance or qualified designee will audit binder to ensure that all required updates and revisions are documented quarterly X4 and annually thereafter, to ensure patient and staff tracking is included in the emergency plan. The findings will be reported to the QAPI committee on a quarterly basis X2.

403.748(b)(5), 416.54(b)(4), 418.113(b)(3), 441.184(b)(5), 482.15(b)(5), 483.475(b)(5), 483.73(b)(5), 484.102(b)(4), 485.542(b)(5), 485.625(b)(5), 485.68(b)(3), 485.727(b)(3), 485.920(b)(4), 486.360(b)(2), 491.12(b)(3), 494.62(b)(4) STANDARD Policies/Procedures for Medical Documentation:

§403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4).

[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:]

[(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

*[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following:
(i) Preserves patient information.
(ii) Protects confidentiality of patient information.
(iii) Secures and maintains the availability of records.

*[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records.

Observations:
Name: - Component: -- - Tag: 0023

Based on documentation review and interview, it was determined the facility failed to develop Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records, affecting the entire facility.

Findings include:
Document review on July 21, 2025, at 8:30 a.m., revealed facility failed to develop Emergency Plan policies and procedures that included a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to the facility failing to have an emergency plan for all medical records in the event of an emergency
2. All residence have potential harm by this deficiency.
3. The facility immediately initiated the development and revision of its Emergency Preparedness policy and plan to include the safety and security of all records in the event of an emergency.
4. The department heads, and, or qualified designee will audit binder to ensure that policy and procedure include safety and security to all records in the event of an emergency quarterly X4,. The findings will be reported to the QAPI committee on a quarterly basis X2.

403.748(d)(2), 416.54(d)(2), 418.113(d)(2), 441.184(d)(2), 482.15(d)(2), 483.475(d)(2), 483.73(d)(2), 484.102(d)(2), 485.542(d)(2), 485.625(d)(2), 485.68(d)(2), 485.727(d)(2), 485.920(d)(2), 486.360(d)(2), 491.12(d)(2), 494.62(d)(2) STANDARD EP Testing Requirements:

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).

*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:

(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:

(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.

*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.

(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.

*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.

*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.

*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.

*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.

*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.

*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.

*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.

Observations:
Name: - Component: -- - Tag: 0039

Based on document review and interview, it was determined the facility failed to conduct the Emergency Plan's required annual-full scale exercise or accepted substitution and the required additional exercise or accepted substitution, affecting the entire facility.

Findings include:
Document review on July 21, 2025, at 8:30 a.m., revealed the facility failed to conduct an annual full-scale exercise or accepted substitution and an additional exercise or accepted substitution within the previous 12 months.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the documentation was not available.

Plan of Correction - To be completed: 09/19/2025

. There was no negative outcome due to the facility not exercising a full scale table top drill with the community or excepted substitution within the past 12 months
2. all patients have potential harm from this deficiency
3. The facility immediately educated Maintenance Director on the importance and requirement of these drills.
- facility began discussions on a table top community exercise to be held.
4. The Maintenance, or qualified designee will audit binder to ensure that all required drills have been conducted and documentation is updated quarterly X4 to ensure community table top excersize is within 12 months. The findings will be reported to the QAPI committee on a quarterly basis X2.

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

Facility ID# 12800200
Component 01
Healthcare Building

Based on a Medicare/Medicaid Recertification Survey completed on July 21, 2025, it was determined that The Pines at Philadelphia Rehabilitation and Healthcare Center was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 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, it was determined the facility failed to ensure exit doors did not require excessive force to open, affecting one of ten exits within the facility.

Findings Include:
Observation on July 21, 2021, at 10:35 a.m., revealed the occupancy connecting corridor vestibule right side exit discharge door required excessive force to open, affecting one of ten exits within the facility.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the door required excessive force to open.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to the connecting corridor vestibule right side exit door that required excessive force to open.
2. All residents have potential to be harmed by this deficiency.
3. The facility immediate plan of action Maintenance contact Fire safety vendor to schedule a service appointment for the door.
- conduct audit of all facility doors to ensure none of the doors require excessive force to open.
4. The Maintenance director or designee will audit all exit doors weekly X4 and monthly X2, thereafter, to ensure all doors open without exceeding maximum allowed force. The findings will be reported to the QAPI committee on a quarterly basis X2.

NFPA 101 STANDARD Discharge from Exits:

Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface.
18.2.7, 19.2.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0271

Based on observation and interview, it was determined the facility failed ensure that exit discharges to the public way were accessible, affecting six of ten exits within the facility.

Findings include:
Observation on July 21, 2025, between 10:00 a.m. and 12:00 p.m., revealed all direct discharge exits in the following areas failed to provide a level, hard packed all-weather travel surface to the public way.
a)Patient Corridor Wing B
b)Sunny Conference Room (plan I.D. therapeutic dinning 148)
c)Exit discharge near main kitchen (plan I.D. landscape courtyard)
d)Small Gym exit (plan I.D. activity room 255)
e)Main Dining Room exit (plan I.D. landscape courtyard)
f)Connecting Corridor left discharge exit within the vestibule
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the uneven egress surfaces.

Plan of Correction - To be completed: 09/19/2025

1. There was no negative outcome due to the facility failing to maintain exits with hard packed all weather travel surface to the public way
2. All residents have the potential to be affected by the deficient practice.
3. As per conversation with local field office on 8/7/2025 The facility immediately audited all exit surfaces to ensure hard packed level surface can be maitained
- Immediately the facility discussed designating specific walkways outside the exits which will be monitored and maintained during all seasons including rain and snow to ensure hard packed level surfaces
4. The Maintenance Director or designee will audit all Exits for hard packed level surfaces weekly x4 and at all seasonal changes to ensure exit surfaces are hard packed, level and no additional adjustments need to be made The findings will be reported to the QAPI committee on a quarterly basis X4.

NFPA 101 STANDARD Exit Signage:

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 the observation and interview, it was determined the facility failed to maintain provide proper directional signage in accordance with NFPA 101, affecting two of five smoke zones.
Findings Include:
Observations on July 21, 2025, between 10:00 a.m. and 12:00 p.m. revealed missing directional signage in the following areas impeding proper timely egress:
a) Rehab exam room office near patient rehab kitchen failed to provide visible directional signage leading to direct egress;
b) Main nursing station connecting A, B, and C wings failed to provide accurate directional signage, and ensure visible signage ensuring direct egress travel.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the missing and inaccurate directional egress signage.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to missing directional signage. All maintenance and environmental services staff were educated by the Maintenance Supervisor.
2. All residents have the potential to be harmed by this deficiency.
3. The facility immediate plan of action Maintenance Director scheduled a service appointment with contracted Fire and safety vendor to complete all necessary directional adjustments.
4. The Maintenance director or designee will audit all exit signs weekly X4 and monthly X2, thereafter, to ensure all exit signage has appropriate display. The findings will be reported to the QAPI committee on a quarterly basis X2.

NFPA 101 STANDARD Portable Fire Extinguishers:

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined the facility failed to ensure portable fire extinguishers are spaced in accordance with NFPA not to exceed seventy-five feet, affecting one of five smoke zones within the facility.
Findings include:
Observation on July 21, 2025, at 10:40 a.m., connection corridor to occupancy separation exceeded the maximum travel distance per the NFPA maximum travel distance to extinguisher rule.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the excessive spacing.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to the portable fire extinguisher not being spaced in the required distance.

2. All residence has the potential risk by the deficiency.

3. The facility immediate plan of action contacted the fire protection vendor to inspect and service all portable fire extinguishers in the facility, to ensured that all required portable extinguishers are mounted at the correct height and distance, properly labeled and accessible

- Education provided to maintenance director on proper distances for fire extinguishers.
4. The Maintenance director or designee will audit facility to ensure spaces do not exceed Maximum travel distances without fire extinguishers. weekly X4 and monthly X2, thereafter, to ensure all portable extinguisher are mounted and properly distanced in all fire zones. The findings will be reported to the QAPI committee on a quarterly basis X2.

NFPA 101 STANDARD Corridor - Doors:

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to ensure corridor doors resisted the passage of smoke, affecting one on of five smoke zones within the facility.
Findings include:
Observation on July 21, 2025, at 11:05 a.m., revealed the self-closing hardware of the right-side door entering the small gym failed to operate allowing for positive latching ensuring smoke tight integrity.
Exit interview with the Head Nurse, Maintenance Director, Maintenance Representative and Administrator on July 21, 2025, at 12:30 p.m., confirmed the inoperable self-closing hardware.

Plan of Correction - To be completed: 09/01/2025

1. There was no negative outcome due to hardware broken on self closing door.
2. All Residents have potential to be harmed by this deficiency
3. The Maintenance director immediately reached out for repairs
Audit was completed on all self closing doors hardware to ensure functionality
4. Maintenance director, or designee will audit all facility self closing doors weekly x4 monthly x2 quarterly X4 and annually thereafter, to ensure all hardware is functioning properly. The findings will be reported to the QAPI committee on a quarterly basis X2.

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