Pines Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Pines Nursing and Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF678Sep 28, 2022

  Based on observation, medical record review, review of facility ' s policy and procedures, and interview with staff, it was determined the facility failed to ensure that they were able to provide Cardio-Pulmonary Resuscitation (CPR) in accordance with physician ' s orders and the residents ' wishes. This was evident for 5 of 84 residents (#50, #48, #52, 54 and #51) reviewed for code status accuracy during a follow-up survey. An immediate jeopardy regarding residents #50, #48, #52, #51, was identified on [DATE] at 3:00 PM and the facility was informed on [DATE] at 3:18 PM. The Findings Include: Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. […]

• Immediate jeopardy, patternF678Sep 28, 2022

  Based on observation, medical record review, review of facility ' s policy and procedures, and interview with staff, it was determined the facility failed to ensure that they were able to provide Cardio-Pulmonary Resuscitation (CPR) in accordance with physician ' s orders and the residents ' wishes. This was evident for 5 of 84 residents (#50, #48, #52, 54 and #51) reviewed for code status accuracy during a follow-up survey. An immediate jeopardy regarding residents #50, #48, #52, #51, was identified on [DATE] at 3:00 PM and the facility was informed on [DATE] at 3:18 PM. The Findings Include: Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. […]

• Immediate jeopardy, isolatedF689Mar 19, 2025

  Based on observation, interview, and record review it was determined the facility failed to provide supervision to a cognitively impaired resident with a history of a fall with fracture. This was evident for 1 (#16) of 35 residents in the [NAME] Unit during a complaint survey. As result of these findings an Immediate Jeopardy was called at 4:45 PM on 3/11/25. The facility submitted a plan to remove the Immediacy on 3/11/25 at 8:30PM. The survey team verified completion of the plan on 3/14/25 at 11:08 AM with a compliance date of 3/13/25. […]

• Actual harm, isolatedF684Aug 19, 2026

  Based on record review and interview, it was determined that the facility failed to ensure that Resident #1 received care in accordance with professional standards regarding utilizing 2 persons to transfer with a mechanical lift. This deficient practice resulted in a Harm. This was evident for 1 (#1) out of 3 residents reviewed for hoyer transfers.The findings include:The Facility's policy as it relates to the use of a Hoyer Lift reviewed/revised 10/3/25, 7/15/26 by CNO #9, reads in part: Safe Resident Handling/Transfer Policy- to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and… […]

• Actual harm, isolatedF689Jul 2, 2026

  Based on record review, staff and resident interviews, and facility documentation, the facility failed to ensure staff provided incontinent care using safe techniques for 1 (#22) of 1 residents reviewed for incontinent care. Specifically, staff failed to discontinue brief removal after the resident complained of pain and failed to remove the plastic fastening tabs before pulling the incontinent brief from beneath the resident. This deficient practice resulted in a deep laceration to the resident's left posterior thigh, uncontrolled hemorrhage requiring emergency medical services, hospitalization for approximately three weeks, and treatment including transfusion of four units of packed red blood cells and three units of platelets.Findings include:Intake # 3008785 was reviewed on 6/28/26 for… […]