Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Trail Nursing And Rehab Center during CMS and state inspections, most recent first.
The facility failed to refund the personal funds of three residents within the required 30-day period following their discharge or expiration. Despite the facility's policy to refund overpayments within 30 days, refunds for a resident who expired and two residents who were discharged were delayed by over three months. The Business Office Manager attributed the delays to the corporate office's processing and acknowledged a lack of access to timely reports on check issuance.
The facility failed to issue refunds to three residents or their representatives within the required 30-day period following discharge. Refunds were delayed by over three months due to a lack of timely processing by the corporate office. The Business Office Manager was unaware of the delays until the survey and did not have access to the necessary reports to track refund issuance.
A resident with severe cognitive impairment and a history of falls was found on the floor with a hip fracture, but the facility failed to update the care plan or conduct a thorough investigation. The fracture was deemed pathological without supporting documentation, and required safety measures like floor mats were absent. The event was not reported as a deficiency by the facility.
The facility failed to maintain adequate hot water temperatures, secure handrails, and accessible emergency call systems, impacting resident comfort and safety. Observations revealed cold water temperatures in several rooms, worn handrails, and short emergency cords. Additionally, fluorescent light fixtures lacked covers, and personal property and medical records were unsecured. Fire doors were also improperly propped open, indicating a lack of maintenance and oversight.
The facility failed to follow regular diet menus, affecting 53 residents. Due to a non-working oven, the facility used a 7 Day Hot Weather/Cold Food Menu but did not adhere to it consistently. Improvisations were made due to equipment failures, and the facility lacked a scale to measure food portions accurately, leading to estimations. The Certified Dietary Manager communicated the need for a scale to the owner, but no action was taken.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 53 of 55 residents. Observations revealed open and improperly stored food, unlabeled substances, rusty surfaces, and missing panels on the ice machine. The walk-in refrigerator and freezer contained open items without dates, and the dry goods pantry had numerous open items. A dietary aide was observed without a beard net, and the CDM admitted to inadequate sanitization practices.
The facility's administration failed to manage resources effectively, affecting all residents. Four LPNs administered IV medications without certification, and a resident's unwitnessed fall with a fracture was not properly reported or investigated. The Administrator was unaware of a pest control issue, and two broken ovens were observed in the kitchen.
The facility's QAPI/QAA failed to implement effective corrective actions for repeated deficiencies in food services and pest control, affecting all 55 residents. Deficiencies included issues with menus, kitchen sanitation, and pest control, previously cited during a survey. The Administrator acknowledged these ongoing issues during a recent interview.
The facility failed to maintain kitchen equipment, with two broken ovens and issues with the walk-in freezer and refrigerator not maintaining temperatures. The kitchen also lacked a scale for weighing food, an issue noted by the CDM since May 2024. The Administrator was unaware of these deficiencies until the survey.
The facility failed to maintain an effective pest control program, resulting in a roach infestation observed in resident rooms and common areas. Multiple residents reported seeing roaches, and the Nursing Home Administrator was unaware of the issue until informed by surveyors. The facility's pest control services were inconsistent, with a gap in service while searching for a cheaper provider, and the new service was ineffective, as residents continued to report sightings.
The facility failed to ensure dignity during dining for two residents. A CNA was observed standing while feeding a resident with severe cognitive impairment, contrary to usual practice. Another resident, with Alzheimer's and hand stiffness, experienced a delay in receiving feeding assistance, as trays for those needing help were delivered last. An LPN referred to this resident as a "feeder," contributing to the delay.
Two residents experienced inadequate care due to staffing shortages. One resident, with Major Depressive Disorder, was unable to walk outside independently due to lack of staff availability, while another resident requiring substantial assistance faced delays in transfers and meal assistance. Staff confirmed the facility's short-staffing, leading to rushed care and unmet resident needs.
A resident with severe cognitive impairment experienced a fall resulting in a confirmed acute left acetabular fracture. Despite this, the facility's IDT concluded the fracture was spontaneous and not due to the fall, based on undocumented hospital records. The facility did not report the incident, as the Administrator believed it was not reportable. Interviews revealed a lack of documentation and consultation with the physician regarding the decision.
A facility failed to complete a Quarterly MDS assessment within the required time frame for a resident. The resident's assessment was due but not started or completed on time due to the MDS coordinator being overwhelmed and out sick, with no coverage available. The coordinator mistakenly believed she had more time to complete the assessment and could not provide documentation to support this claim.
A resident with a PICC line received IV Vancomycin from multiple LPNs who lacked the required IV certification. The facility failed to ensure that these LPNs met the necessary competency and knowledge requirements for administering IV therapy, as mandated by the Florida Board of Nursing. The Director of Nurses was unaware of the lack of certification among the LPNs involved.
A facility failed to maintain a sanitary PICC line dressing for a resident. The dressing was not changed since admission, despite a physician's order for weekly changes. An LPN inaccurately documented the dressing changes, and the DON confirmed the lack of a policy for PICC line dressing changes.
A resident with a primary diagnosis of an unspecified neck fracture and a BIMS score indicating cognitive intactness did not receive the required pre and post-respiratory assessments during nebulizer treatment. A registered nurse administered the treatment without evaluating the resident's baseline respiratory rate, pulse, oxygen saturation, and breath sounds, as required by the facility's nebulizer competencies. The Nursing Home Administrator acknowledged the absence of a specific policy for respiratory care, relying instead on nebulizer competencies.
The facility failed to adequately monitor side effects and behaviors for residents on psychotropic medications, as evidenced by incomplete and inaccurate documentation in MARs and TARs. Interviews with staff revealed inconsistencies in documentation practices, with several residents' records lacking required monitoring details. This deficiency affected residents with conditions such as depression, anxiety, and mood disorders, highlighting a systemic issue in medication management.
A resident with a history of cerebral infarction and hypertension was administered the incorrect dosage of Nifedipine due to a failure in updating medication orders and removing discontinued medications. The resident received a 60 mg dose instead of the prescribed 90 mg, despite having a systolic blood pressure below the safe administration threshold. The error was attributed to a pharmacy communication issue and oversight by nursing staff.
The facility failed to implement an effective infection control program, as evidenced by a resident with a PICC line not being placed on Enhanced Barrier Precautions (EBP), staff not donning PPE gowns during catheter care, and unsanitary meal tray transportation. These deficiencies highlight gaps in staff training and awareness, as well as a lack of action to address known issues.
Delayed Refunds of Resident Funds
Penalty
Summary
The facility failed to refund the personal funds of three residents within the required 30-day period following their discharge or expiration. The admission packet of the facility clearly stated that any overpayment would be refunded within 30 days. However, for Resident #1, who expired, a refund of over $1040 was delayed, with the family receiving the check approximately 3 months and 8 days after the resident's expiration. Similarly, Resident #2 was discharged, and a refund of $23,857.87 was processed approximately 3 months and 19 days later. Resident #3, who also expired, had a refund of $664.63 processed after the same delay of 3 months and 19 days. The Business Office Manager (BOM) explained that the facility's process involves sending a package for each resident to the corporate office, which then processes the refunds. The BOM believed that the packages were sent on time but acknowledged that the checks were delayed. She noted that she did not have access to the report showing the dates the checks were issued, which contributed to the delay. The BOM agreed with the findings of the surveyor, indicating a lapse in the facility's refund process management.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident # 1 refund issued Resident #2 refund issued Resident # 3 refund issued 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of discharged residents since to current to ensure refunds are issued within 30 days of discharge by the Business Office Manager/ designee to be completed by 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Business Office Manager re-educated by the Administrator on the components of this regulation and to ensure refunds are issued within 30 days of discharge completed 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Ongoing quality monitoring to be completed by the Business Officer Manager /designee to ensure refunds are issued within 30 days of discharge 2 x weekly x 4 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Delayed Refunds to Residents Post-Discharge
Penalty
Summary
The facility failed to refund the residents or their representatives all refunds due within 30 days from the residents' date of discharge, as required by regulations. This deficiency was identified for three residents. Resident #1 expired and had a refund amount of over $1040 owed, which was only received by the family approximately 3 months and 8 days after the resident's death. Similarly, Resident #2 was discharged and received a refund of $23,857.87 approximately 3 months and 19 days later. Resident #3 also expired, and a refund of $664.63 was processed approximately 3 months and 19 days after discharge. The Business Office Manager (BOM) explained that the facility's process involves sending a package for each resident to the corporate office, which then processes the refunds. However, the BOM believed she had sent the refund requests on time and was unaware of the delay until the survey. She did not have access to the report showing the dates the checks were issued, which contributed to the delay in processing the refunds. The BOM agreed with the findings after reviewing the refund dates with the surveyor.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 refund issued Resident #2 refund issued Resident #3 refund issued 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review of discharged residents since to current to ensure refunds are issued within 30 days of discharge by the Business Office Manager/designee to be completed by. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Business Office Manager re-educated by the Administrator on the components of this regulation and to ensure refunds are issued within 30 days of discharge completed. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Ongoing quality monitoring to be completed by the Business Office Manager/designee to ensure refunds are issued within 30 days of discharge 2 x weekly x 4 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.
Failure to Ensure Adequate Supervision and Safety Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents and injuries for a resident with severe cognitive impairment. The resident, who had a history of falls and was at risk for injury, was found on the floor next to his bed with signs of pain in the left hip. An x-ray revealed an acute left acetabular fracture, and the resident was sent to the emergency room for evaluation. However, the facility's fall investigation did not include the fracture or any follow-up actions, and there were no updates to the care plan post-fall. Interviews with the Director of Nurses (DON) and the Rehab Director revealed that the facility concluded the fracture was a spontaneous pathological event based on hospital records, although no documentation was provided to support this claim. The DON admitted that no in-services were conducted with the staff, and there was no documentation of the interdisciplinary team meeting where this conclusion was reached. The care plan for the resident included various interventions, but there were no new interventions added after the fall with the fracture. Observations of the resident's room showed that floor mats, which were part of the care plan, were not present. A Certified Nursing Assistant (CNA) confirmed that she had never seen floor mats by the resident's bed. The Administrator stated that the event would not be reported as it was determined to be a pathological fracture, and no immediate or 5-day report was made. This lack of documentation and follow-up indicates a deficiency in ensuring a safe environment and adequate supervision for the resident.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to ensure adequate hot water temperatures in several residents' rooms and a shower room, impacting the comfort and hygiene of the residents. Observations revealed that the hot water temperatures in rooms 4, 27, and 28, as well as a shower room, were significantly below the required levels, with temperatures ranging from 84°F to 95°F. Residents reported that the water was often too cold for showers, and staff interviews confirmed that the issue had persisted for weeks. Despite maintenance logs indicating awareness of the problem, the issue remained unresolved, with the Maintenance Supervisor initially unaware of the extent of the problem. Additionally, the facility failed to maintain a safe and homelike environment in other areas. Handrails in four hallways were found to be worn and loosely affixed to the walls, posing a potential safety hazard. Emergency call system cords in five resident bathrooms were too short and inaccessible, and fluorescent light fixtures above 60 of 61 beds lacked proper covers. Furthermore, the facility did not secure residents' personal property and medical records, with boxes of medical records and personal items stored haphazardly in a conference room and the Central Supply Room. The facility also had issues with fire safety, as observed with fire doors being propped open in two hallways. The Regional Director of Maintenance acknowledged that this was against protocol. The combination of these deficiencies indicates a lack of adequate maintenance and oversight, affecting the safety and comfort of the residents. Interviews with staff revealed a lack of awareness and urgency in addressing these issues, contributing to the ongoing deficiencies.
Failure to Follow Regular Diet Menus and Portion Control
Penalty
Summary
The facility failed to adhere to the regular diet menus, impacting 53 out of 55 residents on a regular diet. The Pine Trail Menu for the week listed specific meals for each day, but the facility did not follow these menus. On Monday, the facility served sliced turkey on bread with cooked carrots and pineapple tidbits instead of the scheduled open-face hot turkey sandwich with garlic mashed potatoes and California blend vegetables. On Wednesday, the facility served pasta with meat and tomato sauce containing sausage, along with cooked sliced carrots and peas with sliced peaches, instead of the scheduled beef cubed steak with onion gravy and scalloped potatoes. The Certified Dietary Manager explained that the facility had been using a 7 Day Hot Weather/Cold Food Menu due to a non-working oven and had been substituting items to provide at least one hot component per meal. Further issues were identified when the facility did not follow the 7 Day Hot Weather/Cold Food Menu on Wednesday, as they had to discard refrigerated and frozen food due to malfunctioning equipment. The Certified Dietary Manager improvised with a pasta dish, using sausage that was also served for breakfast to prevent spoilage. Additionally, the facility lacked a scale to measure food portions accurately, leading to estimations of serving sizes. The Certified Dietary Manager acknowledged the absence of a scale since her arrival in May 2024 and had communicated this need to the owner, but no action had been taken to address the issue.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure food was stored and served in a sanitary manner, potentially affecting 53 of 55 residents. During an initial kitchen tour, several deficiencies were observed, including open cheese in a refrigerator, wet baking potatoes in a cardboard box, and divided plates stored improperly. Additionally, there were unlabeled substances, rusty surfaces, and missing panels on the ice machine, which exposed corroded material. The walk-in refrigerator contained several open items with no dates, and the walk-in freezer had items exposed to air with no dates, some of which were partially defrosted or had freezer burn. The dry goods pantry also had numerous open items without dates, and the kitchen had cracked and missing plastic covers on light fixtures, stained cutting boards, and dirty baking sheets and pots. During an observation, a dietary aide was seen working without a beard net, and the Certified Dietary Manager (CDM) admitted to several issues, including the lack of sanitization chemicals in red buckets and the absence of proper sanitization of food prep surfaces. The CDM also mentioned that the administration was aware of broken ovens and the ice machine's condition. These observations and interviews highlight significant lapses in maintaining sanitary conditions in the facility's food storage and preparation areas.
Deficiencies in Administration and Resource Management
Penalty
Summary
The Administrator failed to ensure the facility was administered effectively and efficiently, impacting all 55 residents. Four LPNs were found administering IV medications without proper IV certification, which is a violation of standard care protocols. Additionally, a resident experienced an unwitnessed fall resulting in a fracture, and there was no immediate or 5-day report completed. The fall investigation did not determine the cause or assess the interventions in place at the time. Furthermore, the Administrator was unaware of a pest control issue, with no interior pest treatment conducted since the last exterior treatment. During a kitchen tour, two ovens were found broken, indicating a lack of maintenance and resource management.
Repeated Deficiencies in Food Services and Pest Control
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to implement effective corrective actions for identified quality deficiencies, as evidenced by repeated deficient practices. These deficiencies were related to F803, concerning menus meeting resident needs and being prepared in advance and followed; F812, regarding food procurement, storage, preparation, and serving in a sanitary manner; and F925, involving the maintenance of an effective pest control program. These issues were identified during the Recertification and Relicensure survey, with an exit date of 09/28/23, and have the potential to affect all 55 residents residing in the facility at the time of the survey. The facility's survey history review revealed that these deficiencies were previously cited, indicating a lack of effective corrective action plans. During an interview with the facility's Administrator, it was acknowledged that these deficiencies would be cited again in the current survey, highlighting the ongoing nature of the issues.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating conditions, as observed during a kitchen tour. Two ovens were found broken and labeled as such. Additionally, the Certified Dietary Manager (CDM) indicated potential issues with the walk-in freezer and refrigerator, which were later confirmed by the Administrator. The Administrator discovered that the freezer and refrigerator were not maintaining appropriate temperatures and had contacted a vendor for repairs, but only the freezer was addressed. Further interviews revealed that the kitchen lacked a scale for weighing food, a deficiency noted by the CDM since May 2024. The CDM communicated this issue to her superior, but no action was taken. The Administrator was unaware of the scale's absence and the refrigerator and freezer issues until the survey. Although she received emails about the broken ovens, there was no documentation or invoices regarding their repair or replacement.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches in various stages of life in one of the hallways and multiple resident rooms. Observations on different dates revealed live and dead roaches, as well as roach eggs, in Resident #7's room and other areas. Residents, including Resident #22, Resident #49, and Resident #44, confirmed seeing roaches in their rooms, with Resident #44 expressing concern that his family was reluctant to visit due to the infestation. The Nursing Home Administrator (NHA) was unaware of the issue until informed by surveyors and was unable to provide evidence of consistent pest control services. The facility's pest control services were inconsistent, with a gap in service during October 2024 while searching for a more affordable provider. The previous exterminator targeted rodents, flies, and fire ants, but the new company, [Company Name] Solutions, documented no obvious signs of insect activity during their initial inspection. However, residents continued to report roach sightings, indicating the new service was ineffective. The NHA acknowledged the ineffectiveness of the cheaper pest control company and noted that the scheduled service for the week of 12/16/24 was missed due to an emergency, further contributing to the ongoing pest issue.
Failure to Ensure Dignity During Dining
Penalty
Summary
The facility failed to ensure dignity during dining for two residents. For the first resident, who was admitted with Alzheimer's Disease, Dementia, Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, and Nonexudative Age-Related Macular Degeneration, a Certified Nursing Assistant (CNA) was observed standing over the resident while feeding her oatmeal. The resident, who had a severe cognitive impairment as indicated by a Brief Interview of Mental Status (BIMS) score of 3, usually fed herself. However, on this occasion, the CNA noticed the resident had not eaten and decided to feed her while standing, which is not the usual practice. For the second resident, who was admitted with Alzheimer's Disease and stiffness in both hands, the facility failed to provide timely assistance with feeding. The resident's lunch tray was delivered 19 minutes after her roommate received theirs, and she was assisted with feeding 14 minutes after her tray was delivered. The resident's BIMS score could not be completed due to communication difficulties, and she was on a regular diet with pureed texture fortified foods. A Licensed Practical Nurse (LPN) referred to the resident as a "feeder" and explained that trays for residents who need assistance are passed last, which resulted in the delay.
Staffing Shortages Impact Resident Care and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of its residents due to insufficient staffing, impacting the well-being of two residents. Resident #48, diagnosed with Major Depressive Disorder, expressed a desire to walk outside the facility independently, as he used to do. However, he was informed that he could only do so if accompanied by staff, which was rarely possible due to staffing shortages. The Director of Nursing confirmed that residents could not leave the facility without staff accompaniment, even if they had an intact cognitive response, citing safety concerns. This restriction led Resident #48 to feel confined and unable to enjoy outdoor activities as he preferred. Resident #52, who requires substantial assistance for activities of daily living due to conditions such as muscle weakness and abnormal posture, experienced delays in receiving necessary assistance. Observations revealed that a CNA struggled to find another staff member to help with a Hoyer lift transfer, eventually receiving assistance from the Director of Admissions, who lacked proper training. Additionally, Resident #52 reported difficulties in receiving help with meals, often having to eat in his room due to delays in being transferred to the dining area. Staff interviews confirmed that the facility was short-staffed, leading to rushed care and inadequate support for residents' needs. The facility's staffing issues resulted in residents not receiving the care and services required to maintain their highest practicable well-being. The lack of available staff to assist with outdoor activities and necessary transfers, as well as the improper use of untrained personnel for resident care, highlighted the facility's failure to meet regulatory requirements for accommodating residents' needs and preferences.
Failure to Report Fall with Fracture
Penalty
Summary
The facility failed to report an adverse event involving a resident who experienced a fall resulting in a fracture. The resident, who had severe cognitive impairment and a history of an unspecified intracapsular fracture of the left femur, was found on the floor next to his bed, showing signs of pain in the left hip. An x-ray confirmed an acute left acetabular fracture, and the resident was sent to the emergency room for evaluation. Despite these findings, the facility's Interdisciplinary Team (IDT) concluded that the fracture was spontaneous and not a result of the fall, based on hospital records, although no documentation or consultation with the physician supported this conclusion. Interviews with the Director of Nurses (DON), Rehab Director, and Administrator revealed that the facility did not report the incident as they believed it was a pathological fracture. The DON admitted there was no documentation of the IDT meeting where this decision was made, and the Rehab Director could not find any hospital notes confirming a pathological fracture. The Administrator stated that she reviewed the regulations and determined the event was not reportable, thus no immediate or day-5 report was submitted. There was no documented evidence to support the facility's conclusion that the fracture was pathological.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a Quarterly Minimum Data Set (MDS) assessment within the regulated time frame for one resident. Resident #46 was admitted to the facility, and an admission assessment was conducted with an assessment reference date (ARD) of May 5, 2024. A subsequent quarterly assessment was completed with an ARD of August 5, 2024. The next quarterly assessment was due on November 5, 2024, but was not started by that date and remained incomplete as of December 17, 2024. During an interview, the MDS coordinator, who is the sole coordinator for the facility, stated she was overwhelmed with work and had been out sick, with no one available to cover her duties. She mistakenly believed she had an additional 30 days to complete the assessment, but could not provide documentation to support this claim. The coordinator has been working in the facility since mid-2024 and has been performing MDS assessments since 2013.
LPNs Administer IV Medication Without Certification
Penalty
Summary
The facility failed to ensure that the administration of intravenous (IV) medication met professional standards of quality for four Licensed Practical Nurses (LPNs) employed by the facility. This deficiency was identified in the case of a resident with a Peripherally Inserted Central Catheter (PICC) line, who was receiving Vancomycin intravenously for aspiration pneumonia. The Florida Board of Nursing requires LPNs to complete a minimum of a 30-hour post-graduation course in IV therapy, including specific training for central and PICC lines, to be certified to administer IV therapy. However, the personnel files for the LPNs involved did not contain the necessary IV certification. The resident in question was admitted to the facility with a PICC line in place and had a medical history that included a fracture of the neck, pneumonitis, and dysphagia. The Medication Administration Record (MAR) for the resident showed that Vancomycin was administered intravenously by different LPNs over several days. Despite the administration of IV medication, there was no documentation of IV certification for the LPNs involved, which is a requirement for administering such therapy. The Director of Nurses (DON) was interviewed and stated that she was unaware that the LPNs administering IV medications to the resident were not IV certified. This lack of awareness and oversight contributed to the deficiency, as the facility did not ensure that the LPNs met the competency and knowledge requirements necessary to administer IV therapy safely and in compliance with professional standards.
Failure to Maintain Sanitary PICC Line Dressing
Penalty
Summary
The facility failed to maintain a Peripherally Inserted Central Catheter (PICC) line in a sanitary manner for a resident. The resident was admitted with a PICC line and had a physician's order for the dressing to be changed every Tuesday night shift. However, the dressing was observed to be dated 11/27/24, indicating it had not been changed since the resident's admission. Despite this, the Treatment Administration Record (TAR) was initialed by an LPN as if the dressing had been changed on three separate occasions. The Director of Nurses acknowledged the discrepancy and confirmed there was no policy for PICC line dressing changes, stating they follow doctor's orders.
Failure to Conduct Pre and Post-Respiratory Assessments
Penalty
Summary
The facility failed to provide a proper assessment before and after administering respiratory care to a resident. Resident #365, who was cognitively intact with a BIMS score of 15, was admitted with a primary diagnosis of an unspecified fracture of the neck. The resident had an active order for Ipratropium-Albuterol inhalation solution to be administered every six hours as needed for shortness of breath and/or wheezing. The order required a pre and post-administration assessment of lung sounds, including documentation of specific lung sound characteristics. During a medication administration observation, a registered nurse, Staff Q, administered the nebulizer treatment to the resident without conducting the required pre or post-respiratory assessment. Staff Q admitted to forgetting to perform the assessments, which he normally does. The Nursing Home Administrator confirmed that there was no specific policy for respiratory care and nebulizer administration, and the facility relied on nebulizer competencies for guidance. A review of Staff Q's competency assessment indicated that he was expected to evaluate the resident's baseline respiratory rate, pulse, oxygen saturation, and breath sounds before and after treatment, which was not done in this instance.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving psychotropic medications. This deficiency was identified for five residents, each of whom was prescribed various psychotropic medications for conditions such as depression, anxiety, and mood disorders. The facility's records, including Medication Administration Records (MAR) and Treatment Administration Records (TAR), showed inconsistencies and inaccuracies in documenting the monitoring of side effects and behaviors as required by physician orders. For instance, Resident #6's MAR from December 9 to December 16 documented monitoring with check marks instead of the required 'Y' or 'N', and there was no documentation of behaviors or side effects in the progress notes. Interviews with facility staff, including registered nurses and the Director of Nursing (DON), revealed a lack of proper documentation practices. Staff members acknowledged that monitoring for side effects and behaviors should be documented on the MAR and in progress notes, but admitted that this was not consistently done. For example, Staff K and Staff O confirmed that interventions and side effects should be documented, yet the records for Resident #6 and others did not reflect this practice. The DON also acknowledged the documentation deficiencies, noting that not all nurses documented side effects or behaviors in the progress notes as required. The deficiency was further highlighted by the absence of behavior monitoring documentation for other residents, such as Resident #32, Resident #11, Resident #48, and Resident #5. These residents were prescribed medications for various psychiatric conditions, and their records similarly lacked the required documentation of monitoring for side effects and behaviors. The facility's failure to adhere to physician orders and document monitoring accurately indicates a systemic issue in ensuring the safety and well-being of residents receiving psychotropic medications.
Medication Administration Error Due to Incorrect Dosage
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a medication administration for a resident with a history of cerebral infarction, diabetes mellitus, hypertension, and cardiomegaly. The resident was administered Nifedipine ER 24-hour 60 mg instead of the prescribed 90 mg, despite having an order to hold the medication if the systolic blood pressure (SBP) was less than 110. At the time of administration, the resident's SBP was 101, which was outside the parameters for safe administration. The error was identified during a medication pass observation, where it was noted that the medication punch card still contained the discontinued 60 mg dose, and the new 90 mg dose had not been received due to a pharmacy error. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the oversight, noting that the discontinued medication was not removed from the medication cart, and the new order was not properly received or documented. The Consultant Pharmacist confirmed that the order for the 90 mg dose was sent to the wrong pharmacy, resulting in the facility not receiving the correct medication. The resident was monitored for side effects, and the physician was contacted to revert the order back to 60 mg due to the resident's current blood pressure. The incident highlighted a breakdown in communication and medication management processes within the facility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection control program, as evidenced by several deficiencies observed during the survey. One resident, who was admitted with a Peripherally Inserted Central Catheter (PICC) line, was not placed on Enhanced Barrier Precautions (EBP) as required. There was no physician's order for EBP, no signage indicating EBP, and no personal protective equipment (PPE) available near the resident's room. This oversight was acknowledged by the Director of Nursing, who realized the necessity of these precautions for the resident. Another deficiency was observed during the provision of perineal and catheter care for a resident with an indwelling catheter. The staff involved in the care did not don PPE gowns, which are required under EBP guidelines. Despite following hand hygiene protocols and using clean gloves, the absence of gowns indicated a lack of understanding and training regarding EBP among the staff. Interviews with the Certified Nursing Assistants involved revealed confusion about EBP, highlighting a gap in staff education and awareness. Additionally, the facility failed to ensure meal trays were transported in a sanitary manner. Observations revealed that meal carts used to transport trays were missing doors, compromising their cleanliness. Interviews with dietary staff and the Certified Dietary Manager confirmed that the carts had been in this condition for an extended period, with the administration being aware of the issue. This lack of action to address the unsanitary condition of the meal carts further demonstrated deficiencies in the facility's infection control practices.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 193 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palm Beach Nursing Center | 0.7 mi | ★★★★★ | 13 | 0 |
| Aviata At Coral Bay | 1.6 mi | ★★★★★ | 0 | 0 |
| Vi At Lakeside Village | 2.7 mi | ★★★★★ | 5 | 0 |
| Medicana Nursing And Rehab Center | 3 mi | ★★★★★ | 1 | 0 |
| Beach Breeze Rehab And Care Center | 3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.