Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Healthcare Center during CMS and state inspections, most recent first.
Incomplete Assessment of Non-Pressure Skin Impairment: A resident with stroke-related weakness, DM2, CKD, COPD, anemia, and hidradenitis suppurativa had purple buttock areas and an open axillary area documented after returning from the hospital, but staff did not complete a comprehensive assessment of the skin impairment. A DON and LPN later reported no impairment or no awareness of the documented areas, while observation found buttock discoloration, a scabbed area, and pain with pressure; a wound NP later identified bilateral buttock abscesses related to hidradenitis suppurativa.
Failure to provide timely incontinence care for a resident with chronic respiratory failure, DM2, depression, morbid obesity, and dependence for toileting and hygiene. The resident’s care plan called for regular checks and perineal care, but during observation the room had a strong urine odor and the bed linens and under pad were saturated with urine; the resident was wet from the middle of her back to mid-thigh. The resident said she had last been placed on the bedpan the prior morning, and the CNA, DON, and ADON verified the findings.
Accurate medical records were not maintained for two residents. One resident’s weekly skin checks noted skin areas, but no corresponding assessments were found, despite documentation suggesting the entries related to treatment of abdominal/breast folds and bilateral buttocks. Another resident with dementia and hearing impairment had inconsistent documentation of family notification for changes in condition and orders, including a STAT KUB for GI symptoms and a telehealth visit for increased confusion with new orders; the DON confirmed the missing documentation.
An LPN failed to use a gown during wound care for a resident who was on EBP for wounds. The resident had diabetes mellitus type II, a coccyx wound, and orders for wound treatments, while the facility policy required targeted gown and glove use during wound care for residents with wounds.
A resident with a history of malignant melanoma of the nose did not receive daily wound cleansing with normal saline as ordered by the wound NP. Review of treatment records and staff interview confirmed the absence of documentation that the prescribed wound care was performed, despite facility policy emphasizing skin and wound management.
A resident with diabetes and severe cognitive impairment received incorrect medication administration when an RN failed to prime an insulin pen and gave only half the prescribed dose of fish oil, resulting in a medication error rate above 5%.
The facility failed to report an allegation of sexual abuse involving three residents to the State Agency within the required two-hour timeframe. The incident, reported by an LPN, involved alleged fornication on the smokers' patio. Despite initiating an investigation and supervising the area, the facility did not adhere to its policy of immediate reporting, resulting in non-compliance.
The facility failed to accurately assess smoking risks for two residents, leading to inadequate supervision. A resident with severe cognitive impairment was incorrectly assessed as an independent smoker, resulting in unsupervised smoking breaks and an incident of potential abuse. Another resident's assessment failed to acknowledge their dementia diagnosis. The facility's policy on smoking assessments was not properly followed.
The facility failed to document an alleged incident of sexual abuse involving three residents in their medical records. An LPN reported the incident, which was based on hearsay, to the DON, and an investigation was initiated. Despite interviews and supervision of the smoking patio, no documentation was made in the residents' records, violating the facility's policy.
Incomplete Assessment of Non-Pressure Skin Impairment
Penalty
Summary
The facility failed to ensure a non-pressure related skin impairment was comprehensively assessed for one resident with diagnoses including left-sided weakness and paralysis following a stroke, hypertensive heart and chronic kidney disease, COPD, anemia, hidradenitis suppurativa, type 2 diabetes mellitus, and generalized muscle weakness. After the resident returned from the hospital, a nursing note documented a purple area to bilateral buttocks and an open area to the left armpit, but there was no evidence staff assessed the etiology of the purple areas at that time. A weekly skin check later noted skin areas that were not new, but the record did not identify what those areas were. The DON was informed that no comprehensive assessments of the skin impairment noted in the nursing note were located. The DON stated the resident was assessed weekly and had no skin impairment. An LPN later stated she assessed the resident’s skin and found no impairment, then clarified that chronic areas on the buttocks and arms were related to hidradenitis suppurativa and that a more comprehensive assessment had not been completed because she was not informed of the impaired skin documented on the weekly skin check. Observation with the LPN identified a dime-sized purple area to the right buttock, a scabbed area to the inferior left buttock, and a pink/purple area to the left buttock where the buttocks touch, with pain reported when pressure was applied. A wound NP note later identified abscesses to bilateral buttocks with hidradenitis suppurativa as the primary etiology.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Timely incontinence care was not provided for a resident who was admitted with chronic respiratory failure with hypoxia, type II diabetes mellitus, depression, morbid obesity, and a need for assistance with personal care. The resident’s care plan identified her as occasionally incontinent of bowel and bladder related to limited mobility, weakness, and obesity, with interventions to check for incontinence, wash, rinse, and dry the perineum, and change clothing as needed after episodes. A quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact, and also documented that she was dependent on staff for toileting and hygiene. During observation, the resident’s room had a strong smell of urine, and the top sheet and bath blanket used as a draw sheet were visibly soiled with a light brown liquid. The resident was saturated from the middle of her back to the middle of her thigh, and the under pad and bed sheet were wet with urine and had a foul odor. The resident stated the last time she was placed on the bedpan was the previous morning. A CNA, along with the DON and ADON, verified the strong urine odor and the observed findings indicating a lack of incontinence care at the time of the observation.
Incomplete Medical Record Documentation and Notification Gaps
Penalty
Summary
The facility failed to maintain accurate and comprehensive medical records for two residents. For one resident with diagnoses including left-sided weakness and paralysis following a stroke, hypertensive heart and chronic kidney disease, COPD, anemia, hidradenitis suppurativa, type 2 diabetes mellitus, and generalized muscle weakness, weekly skin checks documented that skin areas were noted on 03/27/26 and 05/08/26, but no corresponding assessments of those skin areas could be located in the medical record. The resident also had a skin assessment indicating a history of hidradenitis suppurativa with no open areas at the time, and an order for miconazole nitrate powder to abdominal and breast folds for fungal areas. The DON, an LPN, and written statements from the same LPN indicated the skin-area documentation was entered because of treatment to the abdominal and breast folds and bilateral buttocks, but no new or impaired areas were observed and no further assessments were documented. For another resident with diagnoses including dementia, angina pectoris, COPD, constipation, major depressive disorder, and cognitive communication deficit, the record showed hearing problems, severe cognitive impairment, and a BIMS score of 7. The resident’s listed representative information identified the resident as her own representative, with a son listed as an emergency contact and a niece listed as POA/alternate contact, without specifying whether the POA was financial or medical. During interview, the POA stated she did not feel she was consistently notified of changes in orders or treatment plans. Review of progress notes showed some notifications to the son, but two events lacked documentation of family notification or involvement: a STAT KUB ordered for diarrhea with nausea and vomiting, and a telehealth encounter for increased confusion with orders for urinalysis/urine culture and hydroxyzine. The DON confirmed the lack of documentation and later entered notes indicating the son or POA had been updated.
EBP Not Used During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was not followed when enhanced barrier precautions (EBP) were not used during wound care for Resident #11. Resident #11 was admitted on 04/03/19 and had significant diagnoses including diabetes mellitus type II. The resident’s orders included cleansing the right heel and coccyx wounds, applying prescribed wound treatments, and using EBP related to wounds. The quarterly MDS showed a BIMS score of 14, indicating the resident was cognitively intact, and also documented non-surgical dressings, ointments, and dressings to the feet. During observation of wound care on 05/13/26 at 10:05 A.M., the facility wound care nurse, an LPN, provided care to Resident #11’s coccyx wound without wearing a gown. The LPN verified that the gown was not used and stated she forgot. The resident’s care plan required EBP, including appropriate PPE during high-contact activities, and the facility policy stated that EBP includes targeted gown and glove use during wound care for residents with wounds.
Failure to Complete Ordered Wound Care for Skin Cancer
Penalty
Summary
The facility failed to ensure that wound care treatment was completed as ordered for a resident with a right lateral nose skin cancer. The resident, who had a diagnosis of malignant melanoma of the nose along with cognitive communication deficit and weakness, was assessed to have intact cognition. Wound assessments conducted by a nurse practitioner on multiple dates documented a melanoma wound on the right nostril, with specific orders to cleanse the wound daily with normal saline and leave it open to air. A review of the resident's medication and treatment administration records over a period of nearly one month did not show evidence that the prescribed daily wound cleansing was performed. This was confirmed during an interview with the wound nurse, who acknowledged the absence of documentation indicating the treatment was completed as ordered. The facility's policy emphasized the importance of preventing skin impairment and promoting wound healing, but the required wound care was not documented as provided.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 6.67% error rate during observed medication administration. During a medication pass, a registered nurse administered four medications to a resident and made two errors: the nurse did not prime the resident's Humalog KwikPen before administering insulin, and administered only 500 mg of Omega-3 fish oil instead of the ordered 1000 mg. These errors were confirmed by both observation and subsequent interview with the nurse involved. The resident affected had diagnoses including type two diabetes, weakness, and anemia, and was noted to have severe cognitive impairment. Physician orders specified the correct dosages and administration techniques for both the insulin and fish oil. Facility policy required medications to be administered safely and in accordance with residents' needs, but these protocols were not followed during the observed medication pass.
Failure to Timely Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving three residents to the State Agency within the required two-hour timeframe. The incident was initially reported by an LPN to the Director of Nursing, who then informed the Administrator. The allegation involved reports of fornication on the smokers' patio, allegedly involving three residents. Despite the immediate initiation of an investigation and supervision of the smoking patio, the facility did not report the incident to the State Agency as required by their policy. The residents involved had varying degrees of cognitive impairment and medical conditions. One resident was severely cognitively impaired with a history of hemiparesis and schizophrenia, another was moderately cognitively impaired with chronic kidney disease and bipolar disorder, and the third resident was cognitively intact with a history of chronic heart failure and depression. The facility's policy mandates that all alleged violations involving abuse must be reported immediately, but this protocol was not followed, resulting in non-compliance.
Inaccurate Smoking Assessments and Supervision Failures
Penalty
Summary
The facility failed to complete accurate smoking risk assessments for two residents, leading to inadequate supervision and potential safety hazards. Resident #7, who was severely cognitively impaired and had multiple diagnoses including hemiparesis, hemiplegia, and schizophrenia, was incorrectly assessed as an independent smoker. The assessment failed to note the resident's dexterity problems and swallowing difficulties. As a result, Resident #7 was left unsupervised during a smoke break, during which an allegation of potential sexual abuse occurred. The Director of Nursing confirmed the inaccuracies in the smoking assessment and acknowledged that the resident's care plan did not reflect the use of nicotine. Similarly, Resident #12, who was moderately cognitively impaired with a diagnosis of dementia, was also incorrectly assessed. The smoking assessment failed to acknowledge the resident's dementia diagnosis. The facility's policy requires that the interdisciplinary team assess residents' ability to smoke safely, either independently or with supervision, but this was not properly executed for these residents. The Administrator confirmed the inaccuracies in Resident #12's smoking assessment.
Failure to Document Alleged Incident in Resident Records
Penalty
Summary
The facility failed to maintain complete medical records for three residents involved in an alleged incident of sexual abuse. The incident was reported by an LPN to the Director of Nursing, who was informed by a resident that another resident had heard about fornication occurring on the smoker's patio involving the three residents. An investigation was initiated immediately, and the smoking patio was subsequently supervised during smoking breaks. However, interviews with the involved residents revealed no concerns, and there were no witnesses to confirm the alleged incident. Despite the investigation, the medical records of the three residents did not contain documentation of the alleged incident, as confirmed by the Administrator. This lack of documentation was in violation of the facility's policy, which requires that facts and findings of incidents be documented in each resident's medical record and that the physician of each resident be notified. The deficiency was identified during a complaint investigation, affecting three of the four residents reviewed for abuse, with the facility census being 77.
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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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hall Of Fame Rehabilitation And Nursing Center | 0.5 mi | ★★★★★ | 26 | 0 |
| Astoria Skilled Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 2 | 1 |
| Canton Christian Home | 1.3 mi | ★★★★★ | 14 | 0 |
| The Pavilion At Edgefield For Nursing And Rehabili | 1.9 mi | ★★★★★ | 38 | 0 |
| Bethany Nursing Home, Inc | 2 mi | ★★★★★ | 52 | 0 |
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