Deficiencies (last 3 years)
Deficiencies (over 3 years)
36.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
187% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
38 residents
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Sep 4, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by allegations of failure to notify resident representatives of changes in condition, failure to timely report and investigate abuse allegations, and concerns about facility equipment and call systems.
Complaint Details
The complaint investigation included allegations that the facility failed to notify resident representatives of changes in condition, failed to timely report and investigate abuse allegations involving sexual abuse and verbal threats, and failed to maintain essential equipment and call systems. The facility was found to have multiple open work orders and delays in addressing these issues.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of condition changes, failure to report and investigate abuse allegations timely, delays in implementing wound care recommendations, inadequate laundry equipment impacting infection control, and malfunctioning resident call systems with call bells not accessible to residents.
Deficiencies (6)
Failure to notify resident's representative of a change in condition for Resident #8.
Failure to timely report suspected abuse and report investigation results to proper authorities for Residents #6, #91, and #107.
Failure to investigate alleged abuse violations for Residents #6, #91, and #107.
Failure to implement wound care recommendations and initiate care upon admission for pressure ulcers for Residents #116 and #131.
Failure to ensure essential laundry equipment was operational, resulting in inadequate laundry processing and potential infection control risks.
Failure to maintain working nurse call systems and ensure call bells were accessible to residents, affecting Residents #19, #11, #54, #5, #14, and #40.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 6
Work orders: 8
Bed capacity: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #18 | Licensed Practical Nurse | Confirmed nurses were expected to notify physician and resident's representative about changes |
| Director of Nursing | DON | Confirmed notification requirements and acknowledged concerns about notification and wound care delays |
| Administrator | Nursing Home Administrator | Interviewed multiple times regarding abuse allegations, reporting, and call system issues |
| Chief Nursing Officer | Interviewed regarding sexual abuse allegations | |
| Geriatric Nursing Assistant #2 | GNA | Signed statement indicating no knowledge of incident |
| Geriatric Nursing Assistant #28 | GNA | Signed statement indicating no knowledge of incident |
| Unit Manager #4 | Provided witness statement and was aware of resident conflicts | |
| Geriatric Nursing Assistant #5 | GNA | Reported awareness of conflicts involving Resident #107 |
| Registered Nurse #13 | RN | Confirmed Resident #116 did not have air mattress but should have one |
| Maintenance/EVS Director | Reported laundry equipment status and dryer lint cleaning issues | |
| Nursing Home Administrator | NHA | Interviewed about laundry equipment and phone system issues |
| LPN #31 | Licensed Practical Nurse | Confirmed broken call light for Resident #19 |
| Maintenance Director | Confirmed broken call light and service call details | |
| LPN #14 | Licensed Practical Nurse | Confirmed call bell placement expectations |
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 28
Date: Sep 4, 2025
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Pines Nursing and Rehab.
Findings
The facility was found to have multiple deficiencies including failure to ensure residents' dignity and privacy, delays in meal service, inadequate care planning and participation, failure to provide adequate wound care and pressure ulcer prevention, improper medication management, insufficient linen supply, broken call light systems, unsanitary food storage and preparation, and failure to maintain essential equipment.
Deficiencies (28)
Failure to honor residents' right to a dignified existence and privacy, including staff entering rooms without knocking and delays in assistance.
Failure to provide timely meal service and assistance with feeding, resulting in residents watching others eat while waiting.
Failure to invite resident to participate in care planning process.
Failure to promote and facilitate resident self-determination through support of resident choice, including inappropriate placement on a locked unit without documented justification.
Failure to ensure resident council meetings are private, grievances addressed timely, and grievance feedback provided.
Failure to ensure residents were notified of all Resident Rights.
Failure to offer residents and representatives opportunity to develop advanced directives.
Failure to maintain resident privacy during medication administration.
Failure to provide a clean, safe, and homelike environment, including stained floors, sticky substances, and strong urine odors.
Failure to address missing clothing grievances in a timely manner.
Failure to timely report suspected abuse and failure to investigate abuse allegations.
Failure to provide bed hold notice and notify Ombudsman of transfers and discharges timely.
Failure to complete admission Minimum Data Set (MDS) assessment within required timeframe.
Failure to transmit MDS assessment within 14 days of completion.
Failure to develop and implement complete care plans that meet residents' needs, including timely updates and wound care plans.
Failure to provide appropriate treatment and care according to orders, including turning and repositioning, hospice orders, and sufficient linens.
Failure to ensure feeding tubes are used appropriately and care is provided according to orders.
Failure to provide safe and appropriate respiratory care, including proper labeling and storage of oxygen equipment and nebulizers.
Failure to post updated nurse staffing information daily.
Failure to provide routine and 24-hour emergency dental care in a timely manner.
Failure to ensure medical records are accurate, complete, and readily accessible.
Failure to ensure accurate coding and assessment of Minimum Data Set (MDS) assessments.
Failure to ensure medical records are complete and organized.
Failure to implement infection prevention and control practices, including proper storage of linens, urine specimens, leftover food, and enhanced barrier precautions.
Failure to maintain essential equipment operational, including laundry machines and telephone system.
Failure to maintain nurse call system in working order and ensure residents have access to call bells.
Failure to maintain a safe, clean, and comfortable environment, including unsecured construction areas and unsanitary laundry conditions.
Failure to ensure food is stored and prepared in a sanitary manner, including undated/unlabeled food, improper protective gear, and improper sanitization.
Report Facts
Residents observed for dining: 38
Residents affected by dignity deficiency: 14
Residents affected by meal delay: 10
Residents reviewed for care planning: 5
Residents reviewed for care plans: 23
Residents reviewed for advanced directives: 7
Residents reviewed for respiratory care: 3
Residents reviewed for hydration: 7
Residents reviewed for dental care: 1
Residents reviewed for medical records: 3
Residents reviewed for infection control: 2
Residents reviewed for call systems: 6
Residents reviewed for call bell access: 4
Residents reviewed for hydration: 7
Residents reviewed for unnecessary medications: 5
Residents reviewed for pressure ulcer care: 2
Residents reviewed for accidents: 6
Residents reviewed for care plan meetings: 22
Residents reviewed for care plan timing and revision: 23
Residents reviewed for pressure injuries: 23
Residents reviewed for feeding tube care: 1
Residents reviewed for medication regimen review: 5
Residents reviewed for immunizations: 5
Residents reviewed for nurse aides education: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Geriatric Nursing Assistant #3 | Named in dignity and privacy deficiency for entering room without knocking | |
| Registered Nurse #13 | Named in dignity and privacy deficiency and feeding assistance observation | |
| Geriatric Nursing Assistant #45 | Named in dignity and privacy deficiency and feeding assistance observation | |
| Unit Manager #4 | Named in dignity and privacy deficiency and feeding assistance observation | |
| Licensed Practical Nurse #14 | Named in dignity and privacy deficiency and feeding assistance observation | |
| Registered Nurse #20 | Named in dignity and privacy deficiency and feeding assistance observation | |
| Geriatric Nursing Assistant #28 | Named in dignity and privacy deficiency and feeding assistance observation | |
| Geriatric Nursing Assistant #24 | Named in dignity and privacy deficiency for not wearing name badge | |
| Geriatric Nursing Assistant #12 | Named in dignity and privacy deficiency for not wearing name badge and using cell phone | |
| Licensed Practical Nurse #18 | Named in dignity and privacy deficiency for staff expectations on knocking | |
| Director of Nursing | Named in dignity and privacy deficiency and feeding assistance observation | |
| Nursing Home Administrator | Named in dignity and privacy deficiency and feeding assistance observation | |
| Regional Social Worker | Named in care planning and resident participation deficiency | |
| Social Worker Assistant | Named in care planning and resident participation deficiency | |
| Licensed Practical Nurse #1 | Named in infection control deficiency for urine specimen storage | |
| Licensed Practical Nurse #16 | Named in respiratory care deficiency for oxygen tubing labeling | |
| Certified Medication Aide #5 | Named in infection control deficiency for leftover pudding removal | |
| Certified Medication Aide #38 | Named in infection control deficiency for leftover pudding removal | |
| Maintenance/EVS Director | Named in laundry equipment and environment deficiencies | |
| Geriatric Nursing Assistant #17 | Named in nurse aide education deficiency | |
| Geriatric Nursing Assistant #35 | Named in nurse aide education deficiency | |
| Geriatric Nursing Assistant #39 | Named in nurse aide education deficiency | |
| Geriatric Nursing Assistant #40 | Named in nurse aide education deficiency | |
| Geriatric Nursing Assistant #41 | Named in nurse aide education deficiency |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 28
Date: Mar 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaints alleging deficiencies in care, medication management, staffing, and facility conditions.
Complaint Details
The complaint investigation was triggered by multiple complaints alleging issues with resident care, medication management, abuse, staffing shortages, food quality, and facility maintenance. The investigation reviewed 44 residents and multiple facility reported incidents.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity, failure to inform residents or representatives about medication changes, inadequate notification of physicians, insufficient linen and maintenance services, abuse and neglect incidents, incomplete assessments and care plans, medication errors, inadequate staffing, food quality issues, pest control problems, and failure to maintain working equipment and call systems.
Deficiencies (28)
Facility staff failed to treat a resident with dignity by leaving the resident uncovered and naked in the shower room.
Facility staff failed to inform residents or their representatives about changes in treatment plans related to medication and failed to obtain consent prior to initiating psychotropic medication.
Facility staff failed to notify a resident's physician of a change in status and failed to notify the physician when a medication was not available.
Facility staff failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and provide necessary linens for the residents.
Facility failed to keep vulnerable residents free from physical abuse, resulting in harm to residents.
Facility failed to keep residents' personal items safe, including loss of wallet and personal belongings.
Facility failed to timely report suspected abuse, neglect, or theft and failed to report the results of investigations to proper authorities.
Facility failed to provide documentation that allegations of abuse, injuries of unknown origin, and a gas leak were thoroughly investigated.
Facility failed to conduct a complete and accurate assessment by failing to assess a resident's cognition, mood, and behavior on a quarterly assessment.
Facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded.
Facility failed to have regular care plan meetings and failed to update interventions on the care plan.
Practitioner failed to follow professional standards by prescribing end-of-life medication to a full code resident without ensuring informed consent; nursing staff failed to document administration of psychotropic medication.
Facility nursing staff failed to follow professional standards of nursing practice when administering psychotropic medication by failing to document in the medication administration record when the medication was given.
Facility failed to provide timely medication to meet the needs of residents.
Facility failed to ensure prescribed medication was available to be administered, resulting in resident not receiving medication as prescribed.
Facility failed to ensure medication was available in a timely manner and failed to accurately document when medications were not given or not available.
Facility staff failed to keep medication carts locked when unattended.
Facility failed to store food and monitor temperatures in a manner that maintains professional standards of food service safety.
Facility failed to maintain the resident call bell system in working order.
Facility failed to have an effective pest control program as evidenced by numerous flies, gnats, and ants seen in the kitchen and parts of the facility.
Facility failed to provide ADL care for residents who were dependent for all ADL care.
Facility failed to provide supervision to a cognitively impaired resident with a history of a fall with fracture, resulting in Immediate Jeopardy.
Facility failed to maintain complete and accurate medical records in accordance with accepted professional standards.
Facility failed to employ a qualified social worker on a full-time basis.
Facility's registered dietician failed to document assessments and facility failed to have a registered dietician on site to assess residents' nutritional needs.
Facility failed to provide proper neuro checks and document change in condition following falls, failed to order oxygen for a resident, and failed to follow-up on medication for a specific medical condition.
Facility failed to ensure the kitchen's dishwasher, boiler, laundry washer and dryer were in working order.
Facility failed to ensure nurse aide competency training occurred no less than 12 hours per year.
Report Facts
Residents reviewed: 44
Residents affected by abuse: 3
Residents affected by medication errors: 3
Residents affected by staffing issues: 114
Residents with pressure ulcers: 20
Residents with incontinence: 61
Residents with behavioral healthcare needs: 19
Medication administration times missed: 19
Medication administration times inaccurately documented: 18
Medication administration times given outside parameters: 2
Medication administration times given without BP monitoring: 38
Medication administration times missed: 43
Medication doses dispensed: 22
Medication doses dispensed: 6
Medication doses dispensed: 6
Medication doses dispensed: 6
Medication doses dispensed: 8
Medication doses dispensed: 8
Medication doses dispensed: 28
Medication doses dispensed: 28
Residents needing assistance with toileting: 97
Residents needing assistance with bathing: 100
Residents needing assistance with dressing: 97
Residents needing assistance with transferring: 102
Residents needing assistance with eating: 72
Residents reviewed for staffing adequacy: 114
Days with insufficient staffing: 30
Residents with bed baths documented: 12
Residents with bed baths documented: 13
Residents with bed baths documented: 14
Residents with bed baths documented: 12
Residents with bed baths documented: 14
Residents with bed baths documented: 12
Residents with bed baths documented: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #22 | Nurse | Named in dignity deficiency for leaving resident uncovered in shower |
| GNA #71 | Geriatric Nursing Assistant | Discovered resident left uncovered in shower |
| Staff #64 | Nurse Practitioner | Prescribed end-of-life medications for Resident #12 |
| Staff #66 | Attending Physician | Discussed concerns about end-of-life medication use for Resident #12 |
| Staff #31 | Unit Manager | Reported verbal abuse incident involving LPN #23 |
| LPN #23 | Licensed Practical Nurse | Involved in verbal abuse incident with Resident #18 |
| Staff #28 | Unit Manager | Responsible for 2 units, left medication cart unlocked |
| Staff #67 | Staff Educator | Discussed lack of formal GNA yearly training documentation |
| Staff #69 | Previous Dietician | Discussed lack of nutritional assessments documentation |
| Staff #7 | Director of Maintenance | Discussed hot water and pest control issues |
| Staff #34 | Regional Director of Maintenance | Discussed hot water and pest control issues |
| Staff #30 | Dietary Director | Discussed food quality and snack issues |
| Staff #8 | MDS Coordinator | Discussed incomplete quarterly assessment for Resident #16 |
| Staff #24 | Nursing Scheduler | Discussed staffing scheduling and PPD |
| Staff #46 | Nurse | Discussed staffing shortages and impact on care |
| Staff #53 | Nurse | Discussed staffing shortages and impact on care |
| Staff #49 | Nurse | Discussed staffing shortages and impact on care |
| Staff #66 | Physician | Discussed end-of-life medication concerns for Resident #12 |
Inspection Report
Annual Inspection
Census: 88
Capacity: 170
Deficiencies: 23
Date: Sep 11, 2022
Visit Reason
Annual recertification survey and complaint investigations to assess compliance with state and federal regulations for nursing home care.
Complaint Details
Multiple complaints were investigated related to staffing shortages, medication errors, resident neglect, abuse, and inadequate care. Several complaints involved failure to provide timely medications, lack of assistance with activities of daily living, poor food quality, and inadequate infection control. Some complaints involved missing resident property and failure to notify responsible parties of significant changes.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, care planning, medication management, staffing, infection control, environment, activities, and quality assurance. Significant issues included failure to provide timely and appropriate care, inadequate staffing, poor infection control practices, incomplete and inaccurate documentation, and failure to maintain a safe and clean environment.
Deficiencies (23)
Facility staff failed to treat residents with dignity, including failure to knock before entering rooms, improper feeding posture, and use of disposable plates when glassware was available.
Failure to ensure resident council concerns were addressed and communicated in writing.
Failure to post complete survey results accessible to residents and families.
Failure to offer and document advance directive discussions and opportunities for residents.
Failure to notify residents, responsible parties, and physicians timely of significant changes including weight loss, pressure ulcers, lab results, choking episodes, medication changes, and hospitalizations.
Failure to maintain a clean, safe, and homelike environment including broken equipment, mold, rust, poor water temperature, and pest issues.
Resident property misappropriation with missing cash, credit cards, and gift cards.
Failure to document resident discharge details including status, instructions, and notification to receiving facilities and responsible parties.
Failure to prepare residents for hospital transfer and document preparation and notification.
Failure to notify residents and responsible parties in writing of bed hold policies upon hospital transfer.
Failure to complete timely and accurate comprehensive assessments including Minimum Data Set (MDS) assessments.
Failure to develop and provide baseline care plans and care plan summaries to residents and responsible parties.
Failure to develop comprehensive, individualized care plans addressing all resident needs including behaviors, nutrition, wounds, and medical conditions.
Failure to provide restorative nursing and therapy services as ordered and to document care provided.
Failure to provide timely and appropriate medication administration including pain management and adherence to physician orders.
Failure to maintain complete and accurate medication records including reconciliation and avoiding duplicate or inaccurate medication orders.
Failure to maintain medication storage safety including locked medication carts, discarding expired medications, and maintaining refrigerator temperatures.
Failure to maintain accurate and complete medical records including timely physician notes and documentation of care.
Failure to provide sufficient nursing staff to meet resident needs and failure to provide adequate staff training and competency evaluations.
Failure to maintain a safe, clean, and comfortable environment including broken call bells, unsafe bed rails, and environmental hazards.
Failure to provide adequate infection prevention and control including COVID-19 testing, vaccination education, PPE use, and outbreak reporting.
Failure to provide adequate nutrition including palatable food served at proper temperatures, appropriate diabetic beverages, and timely snacks.
Failure to provide timely and appropriate rehabilitation services as ordered.
Report Facts
Deficiencies cited: 77
Resident census: 88
Total licensed capacity: 170
Weight loss percentage: 19.6
Weight loss percentage: 7.4
Weight loss percentage: 12.15
Medication administration errors: 2
Expired medications: 30
Staff COVID-19 testing compliance: 34
Staff COVID-19 testing compliance: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #20 | Director of Human Resources and Business Office Manager | Interviewed about lack of yearly evaluations, training, and staff competencies. |
| Staff #7 | Interim Director of Nursing | Interviewed about multiple deficiencies including staffing, documentation, and infection control. |
| Staff #61 | Certified Dietary Manager | Interviewed about food temperature issues and kitchen observations. |
| Staff #62 | Nurse Practitioner Wound Consultant | Interviewed about wound care and documentation deficiencies. |
| Staff #25 | Facility Dietician | Interviewed about nutritional assessments and weight loss concerns. |
| Staff #3 | Social Worker | Interviewed about limited availability and lack of involvement in resident care. |
| Staff #11 | Assistant Maintenance Director | Interviewed about environmental issues including call bell repairs and kitchen plumbing. |
| Staff #14 | Registered Nurse | Interviewed about staffing and care on COVID unit. |
| Staff #27 | Activities Assistant | Interviewed about lack of activities and no activity director. |
| Staff #85 | Facility Staff | Religious exemption for COVID-19 vaccine and inconsistent testing. |
| Staff #92 | Director of Nursing at another Peak facility | Interviewed about Healthcare Virtual Assistant assessments signed without performing them. |
| Staff #30 | Charge Nurse | Interviewed about medication administration and narcotic counts. |
| Staff #86 | Laboratory Administrator | Interviewed about lab result notifications and critical lab value reporting. |
| Staff #16 | Registered Nurse | Interviewed about medication delays and pain management. |
| Staff #4 | Registered Nurse | Interviewed about medication cart security and medication administration. |
Inspection Report
Annual Inspection
Deficiencies: 25
Date: Oct 25, 2018
Visit Reason
Annual recertification survey of Pines Nursing and Rehab to assess compliance with regulatory requirements.
Findings
The survey identified multiple deficiencies including failure to notify residents of room changes, failure to honor resident rights, inadequate care planning and documentation, medication administration errors, insufficient staffing, poor food service conditions, infection control lapses, and failure to maintain equipment and call systems.
Deficiencies (25)
Failed to notify a resident and their family in writing of a room change.
Failed to ensure a resident's right to move about the facility and exit was honored; resident was not informed about the WanderGuard bracelet or right to refuse.
Facility staff did not address resident council concerns about food quality, staffing, and meal service.
Failed to properly initiate and void MOLST forms for residents, and failed to include residents in MOLST completion.
Failed to notify resident's family of psychiatric medication reduction recommendation and failed to adjust medication accordingly.
Failed to maintain a safe and clean environment including broken glass, dirty feeding equipment, and odors in resident rooms.
Failed to protect a resident from verbal abuse by a staff member; staff was terminated and referred to the Board of Nursing.
Failed to notify resident, responsible party, and ombudsman in writing of hospital transfers and failed to provide bed-hold policy.
Failed to document accurate assessments on the MDS, including dental status.
Failed to provide resident and representative with a summary of baseline care plan within 48 hours of admission.
Failed to follow established care plan for nutrition; resident found lying flat in bed with cold food.
Failed to review and revise care plans to reflect current interventions and failed to ensure full interdisciplinary team participation in care plan meetings.
Failed to administer medications as ordered including Exemestane, NPH insulin, and Potassium; failed to clarify medication order irregularities.
Failed to provide appropriate pressure ulcer care including elevating heels as ordered.
Failed to obtain resident weights as ordered.
Failed to intervene and offer alternative pain management when resident verbalized medication was ineffective.
Failed to ensure sufficient nursing staff to meet resident needs; residents reported late food delivery, unanswered call lights, and lack of assistance during meals.
Consultant pharmacist failed to identify and notify facility staff of irregular medication order for Potassium.
Failed to offer and obtain dental services for a resident despite physician order.
Failed to serve meals and snacks in accordance with resident preferences; resident did not receive requested bedtime snack.
Failed to store and prepare food under sanitary conditions including dirty storage rooms, wet and slippery floors, leaking sinks, and unclean refrigerators.
Failed to maintain essential equipment in safe operating condition including improper use of power strips, leaking sinks, and failure to replace nebulizer filters.
Failed to maintain accurate and complete medical records including timely filing of physician orders and documentation of informed consent for MOLST.
Failed to post isolation signage on resident room door to alert visitors and staff.
Failed to maintain resident call bell within reach in bathroom and bathing areas.
Report Facts
Residents reviewed: 47
Residents reviewed for unnecessary medications: 6
Residents affected by failure to notify transfer: 3
Residents affected by failure to notify bed hold policy: 2
Residents affected by failure to maintain accurate medical records: 6
Residents affected by failure to maintain call bell within reach: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GNA #1 | Geriatric Nursing Assistant | Named in verbal abuse finding and terminated |
| Director of Nursing | Interviewed multiple times confirming findings and deficiencies | |
| Social Worker | Interviewed regarding psychiatric medication and care plan deficiencies | |
| Certified Medication Aide #1 | Failed to administer medication as ordered | |
| MDS Coordinator | Confirmed failure to document broken teeth | |
| Food Service Director | Acknowledged kitchen sanitation deficiencies | |
| Maintenance Director | Interviewed regarding equipment maintenance and safety |
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