Pines Nursing and Rehab: Wound Care Order Failures - MD
The problem came to light when a staff member returned to the facility and recognized on her own that the orders were not being placed into the system in a timely manner. She offered to step in and help correct it.
That a staff member had to volunteer to fix a documentation gap, rather than the gap being caught through any routine oversight process, is the detail the inspection report leaves hanging.
Federal inspectors cited the facility under tag F0686, which covers the provision of care and services for pressure injuries and wounds. The deficiency was rated at the lowest level of harm, meaning inspectors found minimal harm or potential for actual harm, and noted that only a few residents were affected.
The inspection was a complaint survey, meaning someone, a resident, a family member, or a staff member, had contacted regulators before inspectors arrived. The report does not identify who filed the complaint or what specifically prompted it.
What the record does show is a straightforward failure: orders existed, but they were not making it into the system where nurses and aides would see them and act on them. A wound care order that lives outside the electronic medical record is, in practical terms, invisible to the staff responsible for carrying it out.
Pines Nursing and Rehab is located at 610 Dutchman's Lane in Easton, a small city on Maryland's Eastern Shore. The facility carries the CMS provider identification number 215010.
The inspection report does not describe what types of wounds the affected residents had, how long the orders went unrecorded, or whether any resident's condition changed during the period the orders were missing from the system. It does not name the staff member who identified the problem or describe her role at the facility.
What it does not say is as notable as what it does. There is no indication that the facility had identified the documentation gap before the staff member flagged it. There is no description of a quality assurance process that caught the problem. The correction, by the account in the report, came from one person noticing something was wrong and offering to fix it.
For residents with wounds, the margin for error is narrow. Pressure injuries can worsen within hours if not properly treated. A wound care regimen that depends on orders being visible in the medical record, and those orders are not there, means the care may not happen, or may happen inconsistently, or may happen differently than the treating clinician intended.
The inspection report rates the harm as minimal. That rating reflects what inspectors were able to document at the time of the survey. It does not describe what the weeks before the survey looked like for the residents whose orders were missing.
For information on the facility's plan to correct the deficiency, CMS directs the public to contact Pines Nursing and Rehab directly or reach the Maryland state survey agency.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pines Nursing and Rehab from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 26, 2026 · Our methodology
PINES NURSING AND REHAB in EASTON, MD was cited for violations during a health inspection on September 4, 2025.
She offered to step in and help correct it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.