Pine Trail Nursing And Rehab Center
4445 Pine Forest Dr, Lake Worth, FL 33463 · For profit - Limited Liability company · 52 certified beds · (561) 965-5954 Medicare & Medicaid certified
The public record raises real questions here. Weigh the concerns below carefully.
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (27) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $16,800 in federal fines (most recent 2024-12-20)
- its payroll- and facility-reported staffing and quality-measure scores sit well above its independent inspection score
- its independent health-inspection rating is low (1/5)
- nursing-staff turnover (56%) runs well above the national median (45%)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's staffing and quality-measure ratings run 4 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself, and staffing on its payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 9.8% | 8.7% | 15.4% | better |
| Long-stay residents who lose too much weight | 0.0% | 5.5% | 5.4% | check this* — see note marked star below the table |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.3% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 0.7% | 2.0% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with depressive symptoms | 1.0% | 4.6% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.9% | 2.5% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 9.3% | 9.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 19.9% | 14.4% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 99.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 9.9% | 4.5% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 9.4% | 10.5% | 21.2% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.7% | 8.6% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.7% | 1.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 90.9% | 94.7% | 79.4% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.00 | 2.13 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.16 | 1.15 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 37% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 9.8%CMS range 6.6–14.5 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.06 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.28 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.58 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.30 hrs/resident/day on weekends vs 3.28 on weekdays — about the same on weekends as weekdays. RN hours go from 0.63 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 56% is well above the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
27 citations, most serious first. The 11 most serious are shown; the remaining 16 are one tap away and print in full.
- Actual harm · Gcited before2024-12-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistive devices to prevent accidents and injuries, and ensure a safe environment, failed to ensure a complete investigation and follow up were completed for 1 of 2 sampled residents reviewed for falls, Resident #32. The findings included: Record review revealed Resident #32 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Unspecified Intracapsular Fracture of left femur, Hypertension, and Major Depression. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Review of a fall investigation and nursing progress note dated 09/23/24 at 6:00 AM revealed the resident was found on the floor next to his bed. The resident was observed laying on his left side. He was unable to give a description of what happened and was showing signs and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-20 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure adequate hot water temperatures for 3 of 31 residents' rooms (Rooms 4, 27 and 28) and 1 of 2 shower rooms reviewed for comfortable temperature levels; failed to ensure 4 of 4 hallways had firmly secured handrails to the walls; failed to ensure the emergency call system cord were long enough and accessible for 5 of 31 resident's bathrooms (Rooms 16, 20, 21, 24, and 27); failed to provide covers for florescent light fixtures located above residents' beds for 60 of 61 beds reviewed for safe, comfortable, homelike environment; and failed to secure residents' personal property and medical records. The findings included: 1. During tour of the facility conducted on 12/16/24 at 10:34 AM of room [ROOM NUMBER] and 28, it was observed that after running the hot water in the bathroom for 2 minutes, it was not hot to the touch. An interview was conducted on 12/16/24 at 10:38 AM with both residents residing in room [ROOM NUMBER] who stated the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-20 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interview, the facility failed to follow the regular diet menus, affecting 53 of 55 residents receiving a regular diet. The findings included: Review of the facility's menu, titled, Pine Trail Menu F/W 24/25 Week at a Glance for Regular/Regular Week 1, listed Monday (Day 2) lunch as open face hot turkey sandwich, poultry gravy, garlic mashed potatoes, California blend vegetables, pineapple tidbits, bread for open-face sandwich, coffee/tea, and condiments; and listed Wednesday (Day 3) lunch as beef cubed steak with onion gravy, scalloped potatoes, buttered carrots, chocolate chip cookie, dinner roll, margarine, coffee/tea and condiments. Review of the facility menu, titled, 7 Day Hot Weather/Cold Food Menu Week 1, listed Day 2 lunch as egg salad sandwich, marinated beet and onion salad, fruit mix, sandwich bread, coffee/tea, and condiments; and listed Day 4 lunch as tuna salad sandwich, three bean salad, chilled pears, sandwich bread, coffee/tea and condiments. On 12/16/24 (Monday) at 11:20 AM, the facility served sliced turkey on bread with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-20 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to ensure food was stored and served in sanitary manner with potential to affect 53 of 55 residents. The findings included: During the initial kitchen tour conducted on 12/16/24 at 9:10 AM with the Certified Dietary Manager (CDM), the following was observed: a. Small refrigerator with open cheese in zip lock type plastic bag was not closed. b. Baking potatoes in a cardboard box under prep counter across from 2 compartment sink was wet and upon closer observation the potatoes in the bottom of the box were wet. c. Divided plates were stored right side up on shelf under prep table. Photographic Evidence Obtained. d. Two (2) red buckets with water and rag in each bucket. e. Unlabeled white granular substance in clear container with lid in beverage serving area. Photographic Evidence Obtained. f. Bottom shelf of beverage serving area covered with tin foil, pulled back to reveal rusty surface. g. Ice machine with missing panels on both sides, exposing corroded material and rust. h. Ice scoop in blue plastic holder on wall with large…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-20 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interviews and record review, the Administrator failed to ensure the facility was administered in a manner that enabled use of its resources effectively and efficiently which affected all 55 residents in the facility at the time of the survey. The findings included: 1. An interview was conducted with the Administrator / Risk Manager on 12/20/24 at 12:30 PM. The Administrator was apprised of the concerns of the survey team relating to Administration, as follows: a) Four Licensed Practical Nurses administering (IV) intravenous medications without IV certification. Refer to F694 for details. b) Discussed the resident who had an unwitnessed fall with fracture and who was not able to verbalize how it happened. There was no immediate or 5 day report done and the fall investigation did not determine how the fall occurred or what interventions were in/or not in place at the time of the fall. Refer to F689 for details. c) The Administrator was not aware the facility had a pest control issue and had not had a pest technician visit since 12/02/24 when the facility's…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-20 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interview and record review, the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F803, Menus Meet Resident Nds/Prep in Adv/Followed; F812, Food Procurement, Store/Prepare/Serve Sanitary; and F925, Maintains Effective Pest Control Program. These repeated deficient practices have the potential to affect all 55 residents residing in the facility at the time of this survey. The findings included: Review of the facility's survey history revealed the facility was cited F803 - Food and Nutrition Services related to menus, F812 - Food and Nutrition Services related to kitchen sanitation issues, and F925 - Physical Environment related pest control, during the Recertification and Relicensure survey with an exit date of 09/28/23. Review of the QAPI program with the Administraor revealed the lack of an effective corrective action plan for the above defeciencies.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-12-20 · tag F0908 — failed to keep essential equipment working — patternKeep all essential equipment working safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interview, the facility failed to ensure kitchen equipment was maintained in safe operating conditions for 2 of 2 ovens, 1 of 1 freezer and 1 of 1 walk-in refrigerator. The findings included: During the kitchen tour conducted on 12/16/24 at 9:10 AM, an observation was made of 2 broken ovens, labeled with signs saying 'broken'. An interview was conducted on 12/17/24 at 1:20 PM with the Administrator and the Certified Dietary Manager (CDM) who stated there are 2 ovens in the kitchen and both are broken. When the CDM was asked if there is any equipment in the kitchen including the refrigerator and freezer, that has issues, the CDM stated that she felt there might be some issues with the walk-in freezer and the walk-in refrigerator since the initial tour of the kitchen with surveyor on 12/16/24. The administrator stated she had only discovered today that the walk-in freezer and walk-in refrigerator was not keeping food at appropriate temperatures and had contacted a vendor to come on 12/17/24 to repair the freezer, but they were unable to repair walk-in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-12-20 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of exterminator service inspection reports, the facility failed to maintain an effective pest control program, as evidenced by observed insects in all stages of life in 1 of 4 hallways ([NAME]), documentation of inconsistent extermination during the past five months, and voiced resident confirmation during interviews. The findings included: During a resident observation on 12/16/24 at 10:36 AM, roach activity was seen in Resident #7's room. Multiple dead roaches and a roach egg were noted behind the resident's bed. Upon further observation, 2 live roaches were seen crawling underneath the resident's bed and wheelchair. Photographic Evidence Obtained. During an interview on 12/16/24 at 11:07 AM, when asked if she had seen any insects in her room, Resident #22 voiced she had seen roaches in her room. She stated, I don't like them. During an interview on 12/16/24 at 11:14 AM, when asked if they had ever seen any bugs in their room, Resident #49 stated he had seen roaches…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview, and record review, the facility failed to ensure dignity with dining for 2 of 55 sampled residents reviewed for dining, Residents #1 and #14, as eced by standing to feed the resident, assisting one resident later than the roommate and calling the reisdent a feeder. The findings included: 1. Record review for Resident #1 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Alzheimer's Disease, Dementia, Chronic Obstructive Pulmonary Disease, and Major Depressive Disorder, and Nonexudative Age-Related Macular Degeneration Bilateral Early Dry Stage. Review of the Minimum Data Set (MDS) assessment for Resident #1 dated 11/29/24 documented in Section C, a Brief Interview of Mental Status (BIMS) score of 3 indicating severe cognitive impairment. On 12/17/24 at 8:40 AM, an observation was made of Staff L, Certified Nursing Assistant (CNA), who was standing over Resident #1 feeding the resident oatmeal. An interview was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents' accommodation of needs with sufficient staffing to ensure care and services were provided that assured residents maintain the highest practicable physical, mental, and psychosocial well-being as required by the residents' diagnoses or medical condition for 2 of 25 sampled residents, Residents #48 and #52. The findings included: 1. Review of the facility's, Leave of Absence Sign-Out/Sign-In Release of Responsibility, sheet revealed the following: The undersigned, resident or responsible party on behalf of the named Resident, desires to temporarily leave Pine Trail. By signing below, I understand and agree that Pine Trail shall not be liable for any injuries that occur or be subjected to any demand or any claim for injuries or damages, whatsoever that result from any event occurring outside or off of the premises of Pine Trail. Record review for Resident #48 revealed the resident was admitted to the facility on [DATE]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to report an adverse event for 1 of 1 sampled resident reviewed for a fall with fracture, Resident #32. The findings included: Record review revealed Resident #32 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Unspecified Intracapsular Fracture of left femur, Hypertension, and Major Depression. The documented Brief Interview for Mental Status (BIMS) score, on the significant change Minimum Data Set (MDS) assessment dated [DATE], was 3 indicating severe cognitive impairment. Review of a fall investigation and nursing progress note for 09/23/24 at 6:00 AM documented the resident was found on the floor next to his bed. He was observed laying on his left side. He was unable to give a description of what happened and was showing signs and symptoms of pain to the left hip. He was transferred into bed. The Physician and family were notified and the Physician ordered an x-ray to the left hip.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · D2024-12-20 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment within the regulated time frame for 1 of 2 sampled residents reviewed for resident assessments, Resident #46. The findings included: Record review revealed Resident #46 was admitted to the facility on [DATE]. An admission assessment was done with an assessment reference date (ARD) of 05/05/24. This was followed by a quarterly assessment with an ARD of 08/05/24. The next quarterly assessment was scheduled to be completed for 11/30/24. This assessment was not started on 11/05/24 and not completed as of the time of the interview on 12/17/24. On 12/17/24 at 2:18 PM, an interview was conducted with the Minimum Data Set (MDS) coordinator. She stated she was the only MDS coordinator for the facility but sometimes the regional MDS coordinator will assist her. She was asked about Resident #46's quarterly MDS assessment as it was marked late under the resident assessment facility task. A quarterly assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services provided, that included Administration of Intravenous [IV] medication, met professional standard of quality for 4 Licensed Practical Nurses (LPNs) employed by the facility for 1 of 1 sampled resident with a Peripherally Inserted Central Catheter (PICC), Resident #365. The findings included: Review of the Florida Board of Nursing located at the web address: https://floridasnursing.gov/administration-of-intravenous-therapy-by-licensed-practical-nurses/ Included in part the following: CHAPTER 64B9-12 ADMINISTRATION OF INTRAVENOUS THERAPY BY LICENSED PRACTICAL NURSES 64B9-12.005 Competency and Knowledge Requirements Necessary to Qualify the LPN to Administer IV Therapy. (1) The course necessary to qualify a licensed practical nurse or graduate practical nurse to administer IV therapy shall be not less than a thirty (30) hour post-graduation level course teaching aspects of IV therapy. The didactic intravenous therapy education must contain…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0694 — isolatedProvide for the safe, appropriate administration of IV fluids for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to maintain a Peripherally Inserted Central Catheter (PICC) line in a sanitary manner for 1 of 1 sampled resident reviewed for PICC lines, Resident #365. The findings included: Record review revealed Resident #365 was admitted to the facility on [DATE] with diagnoses that included Fracture of Neck, Pneumonitis and Dysphagia. He was admitted to the facility with a PICC line. On 12/18/24 at 8:19 AM, Resident #365 was observed in bed eating breakfast. The surveyor observed the PICC line dressing exposed on his right arm. The dressing was dated 11/27/24. The resident was admitted to the facility on [DATE] revealing the dressing change was not changed since the resident has been admitted to the facility. Photographic Evidence Obtained. Review of the Physician order for the PICC line dressing change was ordered on 11/29/24, Change IV (intravenous)PICC line dressing to right arm every night shift every Tuesday. Review of the December 2024…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide an assessment before and after respiratory care for 1 of 7 sampled residents observed during medication administration, Resident #365. The findings included: Record review revealed Resident #365 was admitted [DATE] with the primary diagnosis of unspecified Fracture of the Neck. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #365 had a Brief Interview for Mental Status (BIMS) score of 15, on a 0 to 15 scale, indicating the resident was cognitively intact. Review of the active orders documented: Ipratropium-Albuterol inhalation solution every 6 hours as needed for shortness of breath and/or wheezing. Nebulizer: Assess prior to administering Nebulizer Treatment Document Lung Sounds as 1=Clear 2=Rales 3=Congested 4=Crackles 5=Rhonci 6=Rubs 7=Wheezing 8=Diminished every 6 hours for monitoring. Nebulizer: Assess after administering Nebulizer Treatment Document Lung Sounds as 1=Clear 2=Rales…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Record review revealed Resident #32 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Depression, and Hypothyroidism. The resident was prescribed Sertraline HCl Tablet 50 MG (milligrams) Give 0.5 tablet by mouth one time a day for Depression Give 25 mg; 0.5 tablet equals 25 mg. Review of the current Medication Administration Record (MAR) for December 2024 revealed there were no behavior monitoring documentations as specified in the order which documents, Monitor for the following behaviors (specify): itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift for monitoring. Observe closely for significant side effects of Anti-Depressant medication including drowsiness, blurred vision, dizziness, nausea, fatigue, trouble sleeping, dry mouth, hallucinations, other changes in mood or behavior every shift. Document:…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure residents are free of significant medication errors for 1 of 7 sampled residents reviewed during medication administration, Resident #42. The findings included: Review of the facility's policy, titled, Medication Administration Policy - General, dated 08/07/23, included the following: Procedure: 3. Dose Preparation: take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 3.7 Verify that the medication name and dose are correct when compared to the medication order on the medication administration record. 4. Verify each time a medication is administered that it is the correct medication, at the current dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as ser forth in facility's medication administration schedule. 4.1 Confirm that the MAR reflects the most recent medication order. Record review for Resident #42 revealed the resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-20 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews, the facility failed to ensure they had implemented an infection control program that ensured a resident with a Peripherally Inserted Central Catheter (PICC) line was placed on Enhanced Barrier Precautions (EBP) for 1 of 8 sampled residents reviewed for EBP, Resident #365; failed to don proper Personal Protective Equipment (PPE) during perineal care observation for 1 of 1 sampled resident reviewed for indwelling catheter, Resident #19; and failed to ensure meal trays were transported in a sanitary manner for 1 of 3 meal tray carts reviewed during dining observations. The findings included: Review of the Centers for Disease Control and Prevention (CDC) guidelines, titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 07/12/22, documented, in part, at https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, the following: Key Points: 2. Enhanced Barrier Precautions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0803 — failed to meet residents' dietary needs — widespreadEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and menu review, the facility failed to follow approved menus for 39 of 40 residents who consume foods orally, and failed to follow the fortified food menu for 5 of 5 sampled residents who had orders for fortified foods (Residents #13, #14, #35, #10, and #4). The findings included: 1) Review of the approved menu for Week 4 documented the Monday lunch menu included Turkey Tortilla Bake, Roasted Corn, and Fruited Gelatin. Review of the approved recipe for the Turkey Tortilla Bake included the use of cooked seasoned turkey thigh meat, cottage cheese, shredded mozzarella cheese, and frozen chopped spinach. Review of the Roasted Corn recipe included the use of whole kernel corn. Review of the Fruited Gelatin recipe included the use of canned fruit mix. Observation of the lunch meal served on Monday 09/25/23 revealed a tortilla folded in half with thin sliced up deli meat, a red sauce, and yellow cheese, a soup-like corn item, a chopped salad mix, and a gelatin dessert without any…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to store, prepare, and serve food in a sanitary manner, as evidenced by open and expired food, ceiling and walls in disrepair, rust-laden surfaces, not holding cold foods at required minimum temperature of 41 degrees Fahrenheit, lack of hand hygiene, and observation of pests, potentially affecting 39 of 40 residents who consume food orally. The findings included: 1) During the initial kitchen tour on 09/25/23 at 9:25 AM, the following was observed (Photographic Evidence Obtained): a) Dented cans of creamed corn in the dry storage area, with no designated area identified for the storage of dented cans to be returned. b) Two bags of au gratin potatoes being stored in open zip lock bags, and expired as of 08/22/23. c) A 5 pound bag of blueberry muffin mix opened with no cover or seal. d) The lower shelf of a food preparation table covered with old food debris, used to store three large 25 pound containers of soup base. e) Live crawling insects noted throughout the kitchen, to include on the floors, walls, shelving, food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-28 · tag F0925 — failed to control pests — widespreadMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of exterminator service inspection reports, the facility failed to maintain an effective pest control program, as evidenced by observed crawling insects in the kitchen and guest bathroom, documented roach activity by the exterminator during the past six months, and voiced resident confirmation during the resident council meeting. The findings included: During the initial kitchen tour on 09/25/23 beginning at 9:25 AM, live crawling insects were noted throughout the kitchen, to include on the floors, walls, shelving, food preparation and serving surfaces, and inside of old ovens that were out of service. Decorative tiles used as the base border were missing, exposing gaps in the base of the wall with insects crawling nearby (Photographic Evidence Obtained). Upon conclusion of the initial tour, the pests were pointed out to Staff A, day cook, who agreed with the issue. After the initial tour on 09/25/23 at 10:17 AM, the Administrator (NHA) was informed of the live…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2023-09-28 · tag F0805 — failed to prepare food in a form residents can eat — patternEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, the facility failed to provide food in proper form for 12 of 40 residents who consume mechanical soft diets, including sampled residents #4 and #13, and for 5 of 40 residents who consume pureed diets. The findings included: During the lunch observation on 09/25/23 in the dining area adjacent to the nurse's station, seven residents were observed, three of whom had menu tickets that documented a mechanical soft diet. Residents on a mechanical soft diet were served the same lunch as residents on a regular textured diet. The lunch served was a tortilla with meat, sauce, and cheese, soupy looking creamed corn, and a side chopped salad. Staff were having difficulty cutting up the tortilla and the lettuce in the salad was cut into large chunks (Photographic Evidence Obtained). Sampled residents #4 and #13 had orders for mechanical soft diets. During an interview on 09/25/23 at 2:40 PM, when asked the difference between the regular texture lunch diet and the mechanical soft diet, Staff B, night cook who was assisting with the lunch meal stated they were…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-09-28 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide dietary options per resident preferences for Residents #24 and #13, which had the potential to affect 39 of 40 residents who consume food orally. The findings included: 1) Resident #24 was admitted to the facility on [DATE] with diagnoses that included Cerebral Palsy, Asthma, and Morbid Obesity. The quarterly minimum data set with an assessment reference date of 08/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Resident #24's diet order dated 08/15/23 was a regular diet, double portion for lunch only. Resident #24 does not ambulate and stated on 09/25/23 at 10:42 AM that he has reservations about being in his wheelchair and does not get out of bed most of the time. Resident #24 further stated that he does not like gravy and received gravy on his food for lunch and dinner and at times he cannot discern what the food is. He stated if he does not know what the food…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-05-26 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy, observation, record review and interview, the facility failed to ensure a safe environment for a resident diagnosed with Dementia (Resident #6). This failure affected 1 of 4 residents sampled for falls. The findings included: Facility Policy titled Falls and Fall Risk, Managing, revised 9/24/2021 reads: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Facility Policy titled Housekeeping and Environmental Services Policy and Procedure, revised June 2009, states: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Documentation of a process to provide safety during mopping the floor in a resident's room was not noted in the housekeeping policy and procedures provided by the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-05-26 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to maintain accurate and complete resident records for 8 of 18 sampled residents whose records were reviewed regarding: 1) Advance Directives (Residents #4, #11, and #42); 2) Accuracy of MDS records (Resident #7 and #11); 3) Physician consults (Resident #5); 4) Immunization Information; 5) Neuro-checks (Resident #6), and 6) Wound Care (Resident #53). The findings included: The facility's Advanced Directives Policy (revised [DATE]) states: 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his family members, about the existence of any written advance directives. 4. Information about whether the resident has executed an advance directive shall be displayed prominently in the medical record. 1a) Resident #4 was admitted to the facility on [DATE] with diagnoses documented on Face Sheet which included Atrial Fibrillation, Diabetes, Malnutrition, Pressure-induced deep tissue damage of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2025-04-22 · tag F0582 — patternGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a review of the admission packet, record reviews, and interviews, the facility failed to refund to the resident or resident representative all refunds due to the resident within 30 days from the resident's date of death / discharge from the facility, for 3 of 3 sampled residents, Resident #1, Resident #2, and Resident #3. The findings included: The facility's admission packet stated that the facility will refund any overpayment within 30 days. 1. Record review revealed Resident #1 expired on [DATE] and had a refund amount of greater than $1040.00 owed to the resident. During an interview with Resident #1's daughter on [DATE], at 12:00 PM, the daughter said that the family received the check last Thursday ([DATE]) for the amount of money owed to her. That was approximately 3 months and 8 days after the resident's expired from the facility. Review of documents provided by the Business Office Manager (BOM), showed a refund to the Resident / Payer, Resident #1, which was processed on [DATE], in the amount…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2022-05-26 · tag F0657 — failed to keep the care plan current — patternDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and policy review, the facility failed to ensure documented Interdisciplinary Team (IDT) participation in the care planning process, in conjunction with the comprehensive and quarterly assessments, for 9 of 18 sampled residents whose care plan meetings were reviewed (Residents #5, #35, #42, #52, #7, #49, #27, #30, and #32). The findings included: Review of the policy Care Planning - Interdisciplinary Team revised 06/24/21 documented, Policy Interpretation and Implementation: . 2. The care plan is based on the resident's comprehensive assessment and is developed by a Care Planning Interdisciplinary Team which includes, but is not necessarily limited to the following personnel: a. The Social Services/Activities Director; b. The Food Services Director; c. Rehab Director (as applicable); d. Nursing; e. Nursing Assistants responsible for the residents' care if available; and f. Others as appropriate or necessary to meet the needs of the resident. Note this policy lacked the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$16,800 in federal fines across 2 penalties.
- $5,346 — penalty dated 2024-12-20
- $11,454 — penalty dated 2024-12-20
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to ELIYAHU MIRLIS — 13 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.1 | -0.1 vs chain |
| Health inspection | 1 of 5 | 2.0 | -1.0 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 5 of 5 | 3.2 | +1.8 vs chain |
The other 12 homes this chain runs (chain average 2.1★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| 4445 PINE FOREST DR LAKE HOLDCO LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 09/01/2023 |
| MIRLIS, ELIYAHU | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER | 99% | since 08/01/2023 |
| VRD 10 HLDCO LLC | Organization | INDIRECT OWNERSHIP INTEREST | — | since 09/01/2023 |
| BECHER, SARAH | Individual | INDIRECT OWNERSHIP INTEREST | — | since 09/01/2023 |
| COLMAN, RUBEN | Individual | MANAGING CONTROL - GOVERNING BODY; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/09/2025 |
| OLAZABAL, JUSTINA | Individual | MANAGING CONTROL - GOVERNING BODY; W-2 MANAGING EMPLOYEE; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/09/2025 |
CMS files one row per role, so the 12 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $87K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in FL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Florida Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 105835. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2024-12-20, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.