Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pines At Medford during CMS and state inspections, most recent first.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
A resident with hemiplegia, hemiparesis, and an overactive bladder did not receive prescribed doses of nystatin powder as ordered, with missed administrations documented in the MAR. Interviews with nursing staff, including an LPN, RN/Unit Manager, and DON, confirmed that medications must be given and documented per physician orders, and that lack of documentation indicated the medication was not administered. This failure was found to be inconsistent with facility policy and state regulations.
The facility experienced significant staffing shortages due to unpaid wages, with eight staff call-outs reported. The DON had resigned, and the Assistant DON, who had not officially taken the title, managed duties. Residents were affected, with one unable to get out of bed and another experiencing delayed call bell responses. Despite efforts to mitigate the issue, including offering incentives, the facility struggled to maintain adequate staffing levels.
The facility failed to appoint a full-time DON after the previous DON resigned, affecting all 82 residents. The resignation was reported to the Department of Health, and upon the surveyor's visit, it was found that the facility was experiencing staffing issues due to unpaid employees. The MOD/IP attempted to manage the situation, but the identified ADON clarified she had not officially taken the title and was only assisting due to the staffing shortage.
The facility failed to maintain consistent hot water temperatures, with the Dogwood and Birch Units experiencing significant fluctuations. The maintenance staff indicated that a small, used boiler was unable to meet demand, affecting all 82 residents.
A resident was unable to participate in morning activities due to a staffing shortage at the facility, which resulted in a delay in being assisted out of bed. The resident, who requires a hoyer lift and two staff members for transfers, was not helped out of bed until 2 PM, missing morning activities and coffee. The facility experienced eight staff call-outs, leaving only three nurses and four CNAs for 82 residents, impacting the resident's right to self-determination.
The facility failed to maintain a safe and operable kitchen stove, which caught fire in May 2024 and was deemed unsafe by the fire department. The stove remained out of service, affecting meal preparation, with staff using electric burners instead. The FSD and DON were aware of the issue, but the LNHA, responsible for equipment replacement, was not interviewed.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
A deficiency was identified when a resident with diagnoses including hemiplegia, hemiparesis, and an overactive bladder did not receive medications as prescribed by the physician. The resident's care plan included the administration of nystatin powder to specific areas of the body at designated times. Review of the Medication Administration Record (MAR) revealed that nystatin powder was not signed out as administered on several occasions, including missed doses for the abdominal fold and scrotum on specific dates. Interviews with nursing staff, including an LPN, RN/Unit Manager, and the Director of Nursing, confirmed that medications should be administered according to physician orders and documented on the MAR. All staff interviewed stated that if a medication was not signed out on the MAR, it indicated the medication was not given. The facility's policy on administering medications, revised in March 2019, requires that medications be administered in a safe and timely manner as prescribed. The failure to administer and document the administration of nystatin powder as ordered for the resident constituted a violation of both facility policy and state regulations. The deficiency was substantiated through record review, staff interviews, and review of facility policies.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its 82 residents, as evidenced by multiple staff call-outs due to unpaid wages. On the morning of the survey, the Manager on Duty/Infection Preventionist (MOD/IP) reported eight staff call-outs, leaving only three nurses and four CNAs for the 7 AM - 3 PM shift. The Director of Nursing (DON) had resigned the previous night, and attempts to contact the facility's Consultant Administrator, Administrator, and Executive Director were unsuccessful. The Assistant DON, who had not officially taken the title, stepped in to manage duties due to the staffing shortage. Residents were directly affected by the staffing issues. One resident, who required a hoyer lift for transfers, was unable to get out of bed and missed morning activities and coffee due to the lack of available staff. Another resident noted that call bell response times were significantly delayed, taking about 30 minutes instead of the usual 5 minutes. Despite efforts by department heads to assist with non-nursing tasks and a consultant offering incentives for staff to pick up extra shifts, the facility continued to struggle with staffing shortages throughout the day.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DON) on a full-time basis after the DON resigned on 12/6/24. This deficiency affected all 82 residents. The resignation was reported to the Department of Health Complaints' Hotline by the DON herself. Upon the surveyor's arrival at the facility on 12/7/24, it was observed that the front entrance was locked, and a sign directed visitors to use the back entrance. The Manager on Duty/Infection Preventionist (MOD/IP) reported that eight employees had called out due to not being paid, and when she attempted to contact the DON, she was informed of the resignation. The MOD/IP mentioned that an Assistant Director of Nursing (ADON) was on the way, but upon arrival, the nurse identified as the ADON stated she never officially took the title and was only present to assist with the staffing shortage.
Inconsistent Hot Water Temperatures Due to Boiler Issues
Penalty
Summary
The facility failed to maintain consistent hot water temperatures within the required range of 95 to 120 degrees Fahrenheit, as observed during a survey. On the Dogwood Unit, initial hot water temperatures were recorded at 122 degrees in the pantry and shower, and 123 degrees in one room, but later dropped to as low as 86 degrees in some rooms. The Birch Unit showed even more significant inconsistencies, with temperatures ranging from 60 to 90 degrees, while the Cedar Unit maintained temperatures within the acceptable range. The maintenance staff attributed the inconsistent water temperatures to a small boiler that could not meet the demand, especially since the kitchen dish machine and laundry also used the same boiler. The boiler and holding tank were noted to be used units, which may have contributed to the issue. These deficiencies had the potential to affect all 82 residents in the facility, as consistent hot water is essential for maintaining hygiene and safety standards.
Resident Misses Morning Activities Due to Staffing Shortage
Penalty
Summary
The facility failed to ensure that a resident was assisted out of bed in a timely manner to participate in morning activities, which compromised the resident's right to self-determination. On the morning of December 7, 2024, the facility experienced staffing shortages due to eight staff call-outs, reportedly because they were not paid. The staffing assignment for the 7 AM to 3 PM shift included only three nurses and four CNAs for a census of 82 residents. Resident #1, who requires a hoyer lift and two staff members for transfers, was unable to get out of bed in time for morning activities and coffee due to the shortage. The resident expressed frustration and disappointment to the surveyor, stating that he was not assisted out of bed until 2 PM, missing the morning activities entirely. The unit nurse was observed distributing medications, and the CNA was unavailable for interview during the surveyor's observations.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe and operable condition, specifically the stove, which was not functioning. The Food Service Director (FSD) reported that the stove caught fire in May 2024, leading to the fire department's intervention, which deemed the stove unsafe and in need of repair or replacement. Despite this, the stove remained out of service, covered with metal sheet pans, and the staff resorted to using electric burners to prepare meals. The FSD acknowledged that the lack of a working stove affected the types of food prepared for residents, although nutritional meals were still being provided. The Acting Director of Nursing (DON) confirmed awareness of the stove's condition since May 2024 and expressed that broken equipment should be replaced promptly. The DON stated that the Licensed Nursing Home Administrator (LNHA) was responsible for addressing broken kitchen equipment but noted the absence of a policy regarding such issues. The surveyor was unable to interview the LNHA to gather further information on the matter.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Medford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medford Leas | 0.9 mi | ★★★★★ | 0 | 0 |
| Wiley Mission | 5.9 mi | ★★★★★ | 0 | 0 |
| Complete Care At Voorhees, Llc | 6.5 mi | ★★★★★ | 2 | 0 |
| Complete Care At Kresson View, Llc | 7.1 mi | ★★★★★ | 0 | 0 |
| Careone At Evesham | 7.6 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.