No sales calls · nothing personal collected unless you ask us to · no facility pays to be here
Text size
Contrast

Pines Nursing Home

301 NE 141 Street, Miami, FL 33161 · For profit - Limited Liability company · 46 certified beds · (305) 893-1102 Medicare & Medicaid certified

Call the home — (305) 893-1102 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0607, F0608) — most recent Oct 2022
Insights

On the public record, this home looks stronger than most — but visit before you decide.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (17% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0608) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Genorthix<0.1 mi
1001 NE 125th St · (305) 891-4686 · Call to confirm hours
Pharmacy
Grocery
893 NE 125th St · (786) 288-3222 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 2 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 improved from 1 to 3 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.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased5.9%8.7%15.4%better
Long-stay residents who lose too much weight6.8%5.5%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.3%0.9%better than state — see note marked double-dagger below the table
Long-stay residents with a urinary tract infection0.0%0.7%2.0%better than state — see note marked double-dagger below the table
Long-stay residents with depressive symptoms7.8%4.6%6.5%worse
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%2.5%3.3%check this — see note marked star below the table
Long-stay residents whose ability to walk worsened6.4%9.5%16.1%better
Long-stay residents on antianxiety or hypnotic medication10.9%14.4%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%99.2%95.3%typical
Long-stay residents with pressure ulcers10.6%4.5%4.7%worse
Long-stay residents with worsening bladder/bowel control1.6%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 table30.6%8.6%17.1%worse
Short-stay residents who newly got an antipsychotic medication7.7%1.5%1.4%worse
Short-stay residents given the seasonal flu vaccine89.2%94.7%79.4%better
Short-stay residents rehospitalized after admission42.9%26.1%22.6%worse
Short-stay residents with an outpatient ER visit10.3%9.1%12.0%better
Long-stay hospitalizations per 1,000 resident days2.182.131.67worse
Long-stay outpatient ER visits per 1,000 resident days0.641.151.80better

* 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.

31.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 91 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

31.6%U.S. median 51.5%
Got home and stayed home
11.5%U.S. median 10.7%
Went back to hospital
75.0%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.23hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.03hours / resident / day
Speech therapy

Met the expected recovery: 75.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 40 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF31.6%CMS range 24.1–42.151.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.5%CMS range 8.3–16.310.7%Oct 2022–Sep 2024no 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 discharge75.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge75.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge42.5%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting75.8%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge72.7%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.4%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.4%CMS range 4.7–12.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 2022–Sep 2024CMS 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

0.82
RN hours/ resident / day
0.75
LPN hours/ resident / day
2.51
Aide hours/ resident / day
4.08
Total nurse hours/ resident / day
0.70
RN hoursweekends
16.7%
Total nursing turnover
11.1%
RN turnover

How full it usually is: this home is certified for 46 beds and averages 44.2 residents a day — about 96% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

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 4.08 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.51 is at or above 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 3.42 hrs/resident/day on weekends vs 4.35 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 0.87 to 0.70 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 17% is below 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

4
deficiencies at the latest standard inspection (2025-04-30)
9
at the previous standard inspection (2023-12-07)

Deficiencies are fewer than at the previous inspection — improving. 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.

ABCDEFGHIJKL

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.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · D2025-04-30 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 safeguard and ensure privacy of residents' confidential Electronic Health Records (EHR); as evidenced by one out of two of the facility's medication carts' computer screen was left unlocked and unattended and a physical note posted on two of two medication carts revealing residents' information. There were 44 residents residing in the facility at the time of the survey. The findings include: On 04/27/25 at 08:51 AM during an observational of the facility, a note pertaining to Resident #23's allowed visitors and what steps to follow (Photo evidence) was observed posted on Medication Cart A and Medication Cart B computer screens. On 04/27/25 at 09:15 AM during medication administration observation the Electronic Medication Administration Records (EMAR) screen on the computer on Medication Cart A was left unlocked and unattended with a resident's EMAR information visible (Photo evidence). Interview on 04/27/25 at 09:45 AM Registered Nurse (Staff B) stated: Yes I forgot to lock the computer before going to…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 and interview, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR)for individuals with a serious mental illness (SMI), or intellectual disability or related conditions (ID)was completed accurately prior to admission and failed to revise the screenings following admission for three (Resident #13, Resident #8 and Resident#12) out of 20 sampled residents. There were 44 residents residing in the facility at the time of the survey. The findings Included: Resident #13 During observations on 04/27/25 at 08:36 AM, Resident #13 is awake in bed. On 04/28/25 at 07:39 AM Resident #13 was observed in room walking around and stated she is ok, just getting around for the day. Observation on 04/29/25 at 10:23 A; Resident #13 was her room sitting on the side of the bed, conversing with roommate and stated, today is a good day. Review of the medical records for Resident #13 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set 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 Assessment and Assurance (QAA)/QAPI) committee demonstrate effective plan of action were implemented to correct identified quality deficiency in problem areas related to repeated deficient practice for F880-Infection Prevention & Control. As evidenced by: F880 was cited during a Recertification survey ending 12/07/23 when the facility failed to implement infection control procedures. This repeated deficient practice has the potential to affect any of the 44 residents residing in the facility at the time of the survey. The findings included Record review of the facility's survey history revealed, during a recertification conducted on December 04, 2023, through December 07, 2023, F880- Infection Prevention & Control was cited due to the facility's failure to implement infection control procedures related to staff's not changing gloves during tracheostomy care and staff failure to adhere to proper sharps disposal related to used Blood Glucose Monitoring supplies. Review of the facility's policy and procedure…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 observation, record review and interview, the facility failed to implement infection control procedures for two Residents (Resident 23 and Resident #34), out of 20 sampled residents. As evidenced by staff failed to dispose used Blood Glucose Monitoring supplies in the sharps container, failed to clean the insulin vial before extracting medications via needle syringe and failed to wear Personal protective equipment (PPE) during catheter care for one ( Resident # 34)out of one resident reviewed indwelling urinary catheter. There were 44 residents residing in the facility at the time of the survey. The findings Included: During a Blood Glucose Monitoring observation on 04/27/25 at 11:08 AM for Resident #34 with Staff A, Licensed Practical Nurse. Staff A prepared the supplies, entered the resident's room, identified the resident, explained treatment, washed hands, donned gloves, cleaned the residents right index finger with an alcohol pad, checked the Blood Glucose (BG), the results was 326. Staff A,…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 accurately code the Minimum Data Set (MDS) for one resident (Resident # 47) out of 23 sampled residents. Resident # 47's MDS was coded wrong for a discharge to the hospital, but the resident was discharged home. This deficiency has the potential to affect 45 residents residing in the facility at the time of survey. The findings included: Record review of the clinical records for Resident # 47 revealed the resident was admitted on [DATE], and discharge on [DATE]. Clinical diagnoses include, but were not limited to, Bipolar Disorder, Psychotic disorder (other than schizophrenia), Schizophrenia, Rhabdomyolysis, Muscle Weakness (Generalized), Other Abnormalities of Gait and Mobility, Weakness, Drug induced Acute Dystonia, Gastro-Esophageal Reflux Disease without Esophagitis. Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section A, Discharge status - short term, - General Hospital, Section C, Cognitive Status revealed, 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-07 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    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 interview, the facility failed to ensure enteral feeding was administered as prescribed and enteral feeding equipment/supplies were dated, labeled and changed daily for one (Resident #12) out of 13 residents receiving enteral tube feeding. The findings included: During an observation on 12/04/23 at 09:43 AM, Resident #12 was observed in bed, the bed was in the lowest position, and the Enteral feeding (TF) was not infusing. The TF supplement in the residents room was Fiber Source and was dated 12/04/2023, the enteral feeding syringe was dated 11/29/23, and the water for tube feeding flush did not have a label and was not dated. (Photograph obtained). On 12/05/23 at 09:34 AM, the Resident was not in the facility, the residents bed was stripped of linen, and facility staff stated the resident went to the hospital. Review of the medical records for Resident #12 revealed, the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to:…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-07 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide 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, record review and interview, the facility failed to follow physician's order for oxygen therapy for one (Resident #36) out of 9 residents receiving respiratory services and to obtain a physician order for oxygen therapy for one (Resident #12) out of 9 residents receiving respiratory services. The findings included: 1. Observation on 12/04/23 at 09:56 AM, Resident #36 was in bed asleep, and the resident was receiving Oxygen (02) at 4 liters per minute (lpm) via trach collar. On 12/05/23 at 09:36 AM, Resident #36 was observed in bed asleep, and the resident was receiving 02 at 4lpm via trach collar. During a Tracheostomy care observation on 12/06/23 at 07:51 AM, Licensed Practical Nurse (Staff C) gathered tracheostomy care supplies, entered Resident #26's room. The resident was in bed asleep, the head of bed was elevated, Staff C checked the resident's oxygen (02). Staff C reported, the resident's 02 was infusing at 5 liters per minute (lpm). Review of the medical records for Resident #36…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-07 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure nine out of ten sampled nursing staff (Staff 1, 2, 3, 4, 5, 6, 8, 9, and 10) received the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility had no documentation that the staff received the orientation in-service training including Alzheimer's and Dementia, Abuse, Neglect, and Exploitation. The findings included: Review of the facility's staff records revealed, Staff 1 was hired on 08/14/2023; Staff 2 was hired on 10/02/2023; Staff 3 was hired on 10/23/2023; Staff 4 was hired on 08/15/2023; Staff 5 was hired on 05/14/2023; Staff 6 was hired on 05/23/2023; Staff 8 was hired on 07/14/2023; Staff was 9 hired on 06/26/2023; Staff 10 was hired on 08/15/2023. Further review of the facility's staffing records relating to new hire orientation revealed, Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, Staff 6, Staff 8, Staff 9, and Staff 10 did not…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, the facility failed to implement pharmacy procedures for recording daily refrigerator temperatures for the refrigerator in the Medication Storage room. There were 45 residents residing in the facility at the time of the survey. The findings included: During the Medication Storage Room observation on 12/07/23 at 7:40 AM with Licensed Practical Nurse (Staff A) the temperature log for the medication refrigerator in the medication storage room was observed to be last filled out on 12/5/23 with a recorded temperature of 37 degrees Fahrenheit (F). Interview on 12/07/23 at 07:53 AM with the Director of Nursing (DON) it was reported, the 11-7pm nurses are responsible for filling out the refrigerator temperature logs. The DON was shown the temperature log posted on the refrigerator in the medication room, the DON acknowledged the refrigerator Temperature log was not filled out since 12/5/23. The DON had Staff A to check the temperature of the refrigerator and update the log for today,12/7/23. The temperature was recorded as 38 F. Review of the undated…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-07 · tag F0814 — failed to dispose of garbage properly — isolated
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to ensure the garbage disposal was clean and discarded materials were properly disposed and contained on the facility grounds. The findings included: Observation on 12/04/23 at around 09:36 AM showed the outside dumpster area was noted with a large dumpster for trash and a medium dumpster for card board. The dumpster for the cardboard was observed to be overflowing, and the lid was unable to closed. On 12/07/23 at 01:46 PM, during an interview with the Administrator, he stated that he did not see or notice the dumpster on Monday. He stated, he looked at the dumpster earlier today and saw it was not full at all. He then stated that he thinks they picked up the trash this morning. On 12/07/23 at 02:35 PM, the Administrator brought the policy and procedure document and stated, You remember I told you about the dumpster. it's pretty much empty now. You can go and verify. Review of the facility's undated policy and procedures relating to Recycling/waste disposal revealed: Intent: It is the policy of the facility to…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · D2023-12-07 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    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 interview, the facility failed to maintain communication with the hospice provider to ensure continuation of care for 1 (Resident #36) out of 5 residents receiving Hosice services, as evidenced by no updated hospice communication were notes available in Resident #36's medical records, and services provided by Hospice were not coordinated and communicated in the written documentation. The findings included: Observation on 12/04/23 at 09:56 AM revealed, Resident #36 in bed asleep, Tube Feeding (TF) was infusing with - Fiber Source at 70ml/hr(milliliters/hour)., Water flush at 30ml/hr., the supplies and equipment was dated 12/04/23, and the resident was receiving Oxygen (02) at 4 liters per minute (lpm) via trach collar. On 12/05/23 at 09:36 AM Resident #36 was observed in bed asleep, the TF infusing at 70ml/hr, the supplies and equipment was dated 12/5/23,. The 02 was on at 4lpm via trach collar. During Tracheostomy care observation on 12/06/23 at 07:51 AM, Licensed…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interview and record review, the facility failed to demonstrate effective plans of action were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F641 Accuracy of Assessment. The facility failed to accurately code Minimum Data Set (MDS) Section A for one (Resident # 47) out of 23 sampled residents. This deficiency has the potential to affect 45 residents residing in the facility at the time of survey. The findings included: Record review of the facility's survey history revealed, during a recertification survey with exit date of 10/06/2022, F641 Accuracy of Assessment was cited related to the accurate coding for MDS Section A for a Resident. Interview with Administrator and the Director of Nursing on 12/07/2023 at 1:40 PM, the Administrator stated that the QAPI (Quality Assurance and Performance Improvement) meetings are held on the last Thursday of each month. Record review of the policy and procedure revealed: Our…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-12-07 · tag F0880 — failed to prevent and control infections — isolated
    Provide 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 observation, record review and interview, the facility failed to implement infection control procedures for two (Residents #36, and #198) out of 23 sampled residents. As evidenced by a Licensed Practical nurse (Staff C) not changing gloves during the entire tracheostomy care observation for Resident #36 and not disposing the used Blood Glucose Monitoring supplies in the sharps container. There were 45 residents residing in the facility at the time of the survey. The findings included: 1. During a Tracheostomy care observation on 12/06/23 at 07:51 AM, Licensed Practical Nurse (Staff C) gathered tracheostomy care supplies, entered Resident #26's room, the resident was in bed asleep, the head of the bed was elevated, the resident's oxygen (02) was checked, Staff C stated resident #36 was receiving 02 at 5 liters per minute (lpm), the resident did not require suctioning. Staff C donned gloves, Staff C removed the trach gauze, cleaned the trach area with normal saline solution (NSS) with gauze and trach…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-10-06 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    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 and interview, the facility failed to develop a discharge care plan for one (Resident # 46 ) out of three resident reviewed for discharge care plan at the time of the survey. This deficient practice has the potential to affect 44 residents residing in the facility at the time of survey. The findings included: Review of Resident # 46's admission records revealed the resident was admitted to the facility on [DATE] and discharged to an Assisted Living Facility on 08/08/2022. Record review of Resident # 46's medical records revealed the resident's diagnoses included, but not limited to, Type 2 Diabetes Mellitus without Complications; Venous Insufficiency (Chronic) (Peripheral); Other abnormalities of Gait and Mobility. Review of the Social Services Notes dated 07/08/2022 revealed Resident #46 was admitted to the facility on [DATE] via ambulance stretcher accompanied by attendants, with Diagnosis of Type 2 Diabetes Mellitus without Complications. Resident was a Full Code. Resident was verbal…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-10-06 · tag F0755 — failed to provide safe pharmacy services — pattern
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    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, it was determined the facility failed to provide pharmacy services according to the requirements and according to the facility's policy and procedure. This failure had the potential to affect all 44 residents admitted to the facility. The findings included: 1. On [DATE] at 8:40 AM, during observation of the medication administration on Cart B with Staff E, a Registered Nurse (RN). Staff E took a Retacrit 10,000IU/ml (International unit/Milliliter) vial to Resident #27's bedside to administer 10,000 units subcutaneously. Staff E was observed to draw the Retacrit into a syringe with a 1½ inch, 22 gauge needle. Prior to giving the injection, Staff E was asked whether this was the correct needle size to use for a subcutaneous injection and she reported, yes and gave Resident #27 the Retacrit in his left abdomen. The needle size was observed to be the size used for an intramuscular injection. 2. During the observation of the facility's one Medication Storage storage…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor 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 observation, interview, and record review the facility failed to provide a safe and comfortable environment for one (Resident #9) out of twenty sampled residents, as evidenced by a broken and detached bed rail observed at Resident #9's bedside. There were 44 residents residing in the facility at the time of the survey. The Findings Included: On 10/03/22 at 08:54 AM, Resident #9 was observed in bed awake. Resident #1 stated that the bedrail was broken. The resident reported, it's not fixed, its broken, I need it for my safety. Observation revealed the right-side bed rail leaning on the wall beside Resident #9's bed. On 10/04/22 at 10: 00 AM Resident #9 was observed in bed awake. Resident #1 stated, the staff is aware that the bed rail is broken. Resident #9 could not recall how long her bed rail has been broken and reported it has been a while. On 10/05/22 at 08:43 AM, Resident #9 was observed in bed eating breakfast. Resident #9 reported that she was told that her bed rail will be fixed today by…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    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 and interviews, the facility failed to respond to a grievance for one (Resident #5) out of one resident reviewed for grievances. The facility failed to address a concern after Resident #5's wife established communication with the facility's administrator concerning speaking with the doctor about his care. There were 44 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, Grievance Program (dated August 2019) documented the following: Policy: It is the policy of the facility to ensure that individuals are encouraged to discuss comments and concerns which may be positive or negative and when indicated to bring such to a formal grievance status. Right to File Grievances: Residents and visitors have the right to present grievances on behalf of himself or herself or others to the staff or administrator of the facility either verbally or in writing; to receive a written decision related to the grievance filed.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 observation, the facility failed to develop written Abuse, Neglect and Exploitation policies and procedures. The facility's Abuse, Neglect and Exploitation policy and procedure didn't include components for the investigation, protection and reporting/response. This affected 1 (Resident #15) out of 20 sampled residents. This had the potential to affect all 44 residents admitted to the facility. The findings included: Observation of Resident #15 on 10/3/2022 at 8:58AM revealed, the resident sitting up at her bedside, the resident had a bruised bump on her head, another wound on her forehead and a small wound to her nose. The resident reported, she was walking into her room, and a former resident (Resident #10) pushed her, she fell and hit her head on the bottom of her bed. Resident #15 reports, she went to hospital and she feels awful since the fall. The resident reported, Resident #10 no longer resided at the facility. On 10/03/2022 at 9:30AM, Resident #15 was observed in 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · tag F0608 — failed to report suspected crimes — isolated
    Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
    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 interview, the facility failed to 1. Include in their written Abuse, Neglect and Exploitation policies and procedures the requirement to report crimes occurring in long term care facility, reporting suspicion of crimes to law enforcement immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. 2. The facility failed to report a suspicion of a crime that resulted in serious bodily harm to 1 (Resident #15) out of 20 sampled residents. This had the potential to affect all 44 residents admitted to the facility. The findings included: Observation of Resident #15 on 10/3/2022 at 8:58 AM revealed, the resident sitting up at her bedside, the resident had a bruised bump on her head, another wound on her forehead and a small wound to her nose. The resident reported, she was walking into her room,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 and interview, the facility failed to accurately code the Minimum Data Set (MDS) for three residents (Residents # 2, Resident # 45 and Resident # 46) out of three resident's MDS assessments reviewed at the time of survey. This deficient practice has the potential to affect 44 residents residing in the facility at the time of survey. The findings included: Record Review of Resident # 2 's admission record revealed Resident # 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Medical diagnoses included but were not limited to, encounter for other orthopedic aftercare; fracture of Unspecified part of neck . and unspecified sequelae of cerebral infarction. Review of the Transfer and Discharge records revealed Resident # 2 was discharged from the facility on 05/04/2022 and 05/13/2022. Review of Resident # 2' Minimum Data Set (MDS) dated [DATE] documented : Return not Anticipated and revealed the resident was discharged . The MDS documentation indicated : Discharge Return not…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-10-06 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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 interview the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for one( Resident #35) out of one resident PASRR reviewed. This had the potential to affect the 44 residents residing in the facility at the time of the survey. The Findings Included: On 10/03/22 at 08:58 AM, Resident # 35 was observed in room in chair by bed. On 10/04/22 at 10:14 AM Resident #35 was observed in activities during bingo. On 10/05/22 at 02:45 PM Resident #35 was observed standing at the nurse's station conversing with staff, wander alert device noted on left forearm. Review of Resident # 35's Level I PASRR (Preadmission Screening and Resident Review) dated 9/01/22 under Section I: Section I: PASRR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) - no diagnosis checked (Anxiety Disorder, Depressive Disorder, and Psychotic…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    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, observation and interview, the facility failed to provide care and services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being, related to dialysis services for one (Resident #32) out of one resident reviewed and two residents receiving in-house dialysis services. Written documentation was not available in the medical records. Services provided by the Dialysis nurse were not coordinated and communicated in written documentation. This practice has the potential to increase the risk of negative resident outcomes and to affect all two in-house dialysis residents residing in the facility at the time of this survey. The findings included: Record review of the Dialysis Contract revealed a local Dialysis Company entered into a written agreement with this facility effective on May 23, 2022. The Provider will perform dialysis treatments for residents upon the request and written orders. All requested treatments will be delivered by trained 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    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 and interview, the facility failed to have the pharmacy consultant conduct medication regimen review at least monthly. This practice has the potential to increase the risk of negative resident outcomes and to affect all twenty-four residents receiving psychoactive medications residing in the facility at the time of this survey. The findings included: Record review of the Demographic Face Sheet for Resident #32 documented the resident was admitted on [DATE] with diagnoses to include muscle wasting, end stage renal disease, anemia, schizophrenia and hypertensive heart disease. Review of the Minimum Data Set (MDS) Quarterly Assessment for Resident #32 dated 8/25/22 documented the resident's Mental Status (BIMS) Summary Score had a BIMS Summary Score of 06 out of 15 indicating cognitive impairment and the resident was not able to make his needs known. The resident required extensive assistance with one person physical assist for ADLs (Activities of Daily Living). The resident received 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-10-06 · tag F0881 — failed to use antibiotics responsibly — isolated
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review the facility failed to establish a complete infection control program, as evidenced by no monthly infection surveillance and antibiotic stewardship documentation being available to review electronically or in print. This had the potential to affect the 44 residents residing in the facility at the time of the survey. The Findings Included: Review on 10/4/22 at approximately 4:00 PM with the Director of Nursing (DON) who is also the Infection Control Preventionist (ICP) of a list of Infection Control documentation that would be needed for the infection control interview on the last day of survey. On 10/5/22 infection control documents were requested twice during the time surveyor was at the facility, some documents received. On 10/6/22 the DON wrote down the list of documents needed. The DON was informed to provide the surveyor with the infection control documents as they became available. On 10/6/22 several times during the survey at the facility with the last request at 6:30 PM, the infection control documentation was requested from…

    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.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“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.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • 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.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
PINE HOLDINGS 2015, LLCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/23/2025
COSIOL, MEIRIndividualINDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/18/2015

CMS files one row per role, so the 6 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner 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.

$7.3M
Net patient revenuemost recent cost report
+12.5%
Operating marginrevenue minus expenses
$567K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 35%Medicare 41%Other / private 24%

This home reported $567K 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

$402per resident / day
operating cost
$12,224per month
≈ monthly operating cost
$459per day
avg. revenue, all payers

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

Paying with Medicaid

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.

Typical monthly cost in Florida
$10,342/mo
Nursing home (semi-private)
$12,167/mo
Nursing home (private)
$5,610/mo
Assisted living

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 105057. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-30, 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.

What to do next