Above 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 Pinecrest Center For Rehabilitation And Healing during CMS and state inspections, most recent first.
The facility failed to ensure proper storage of medications and biologicals for several residents, leading to deficiencies in medication management. Observations revealed medications and ointments at residents' bedsides and discontinued medication in the cart. Staff interviews indicated lapses in protocol adherence, with medications not being stored according to the facility's policy, which requires storage in the pharmacy or medication rooms.
A facility failed to timely reorder and receive a routine breathing medication for a resident, resulting in the medication being unavailable at the prescribed time. An LPN confirmed the inhaler was not in stock, and records showed discrepancies in reorder and delivery dates. The resident expressed that the medication occasionally ran out, and the facility's policy on timely medication receipt was not followed.
A facility failed to reorder and receive a routine asthma inhaler in a timely manner for a resident with Seizure and Asthma. An LPN confirmed the inhaler was unavailable at the prescribed time, and documentation showed a delay in reordering. The resident expressed that medication shortages occur occasionally. The DON acknowledged the issue, referencing a policy on timely medication receipt.
The facility failed to protect residents' personal and medical information, as evidenced by unattended paperwork with residents' details left visible in public areas. An LPN and the ADON acknowledged the breaches, confirming that such information should not be left unattended. The DON stated that measures are in place to safeguard information, but these were not effectively implemented.
The facility failed to maintain a medication error rate below 5%, with an observed rate of 13.89%. An LPN administered medications to a resident outside the prescribed time frame due to being busy with other duties, and Vancomycin was unavailable as it was ordered at midnight. The Director of Nursing confirmed the policy allows for a one-hour window for medication administration, but this was not adhered to, contributing to the high error rate.
A facility failed to maintain a medication error rate of 5% or lower, with an observed rate of 13.89%. An LPN administered medications to a resident outside the prescribed time frame due to being busy with other duties, and one medication was unavailable as it was ordered late. The facility's policy requires medications to be administered within 60 minutes of the scheduled time, but this was not adhered to, contributing to the high error rate.
The facility failed to properly store medications for several residents, with medications found at the bedside instead of in a locked medication room or cart. Observations included bottled pills, a bottle of medication, and a bingo card with discontinued medication improperly stored. Staff interviews revealed that rounds were conducted, but they were ineffective in identifying these storage issues.
The facility failed to maintain a safe environment by leaving a shaving razor protruding from a container in a resident's room and lancets unattended on a medication cart. Staff acknowledged the oversight, and the DON confirmed the facility's policy requires proper storage of sharp objects.
The facility failed to protect residents' privacy, with observations of unattended paperwork containing resident information left visible in public areas. An LPN and the ADON acknowledged the breaches, confirming that such information should not be visible or unattended. The DON stated that measures are in place to safeguard residents' information.
The facility failed to maintain its essential electric system generator as per NFPA 101 standards due to the absence of high mortality spare parts in the generator room. This deficiency was identified during a Life Safety Survey tour, with the Maintenance Director acknowledging the issue. The lack of spare parts suggests a potential risk in meeting emergency power requirements.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals for five residents, leading to deficiencies in medication management. Observations revealed that a resident had bottled pills inside a plastic bag at their bedside, while another resident had a bottle labeled Zicam on their side table. Additionally, a tube labeled Zinc Oxide Ointment was found at another resident's bedside, and two bottles labeled Acetic Acid Irrigation Solution were observed on a nightstand. Furthermore, a bingo card with discontinued medication was found in the medication cart for another resident. These findings indicate a lack of adherence to the facility's policy on medication storage, which requires medications to be stored in the pharmacy or medication rooms according to specific guidelines. Interviews with staff members revealed lapses in the protocol for medication storage. One LPN admitted to conducting rounds but failed to notice medications at a resident's bedside, while another LPN stated that medications should not be at the bedside. An RN acknowledged the presence of discontinued medication in the cart, which should have been removed and returned to the pharmacy or destroyed. The facility's policy, revised in January 2018, mandates that all medications be stored according to the manufacturer's recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The failure to adhere to these protocols resulted in the observed deficiencies.
Plan Of Correction
1. What corrective action will be accomplished? The bottled pills inside a plastic bag were removed from Resident #381's bedside and secured. The was removed from Resident #47's bedside and secured. The from Resident #12's bedside was removed and secured. The 2 bottles labeled Acetic Irrigation Solution were removed from Resident #47's bedside. The bingo card labeled tablet of discontinued medication for Resident #65 was returned to the pharmacy. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: The DON/Designee conducted an audit of occupied resident rooms and medication carts to ensure no medications or biologicals were at bedside and no discontinued medications were in the med carts. 3. Measures/systematic changes put into place: The DON/Designee re-educated the nursing staff on the facility policy for storage of medications and biologicals. Education for storage of biologicals was added to the new hire orientation and annual nursing education. The pharmacy nurse consultant will audit medication carts monthly to ensure no discontinued medications are stored in cart. The Nursing supervisor will conduct a daily audit (5 days per week) of medication carts to ensure no expired medications are in cart. 4. How corrective action will be monitored: The DON/Designee will conduct daily observation room rounds audit (times 5 weeks) to ensure no medications or biologicals are at bedside. Med cart audit for discontinued medications weekly (times 5 weeks). The results of these audits will be reviewed at the monthly QA meeting until compliance has been determined.
Failure to Timely Reorder and Receive Breathing Medication
Penalty
Summary
The facility failed to ensure the timely reordering and receipt of a routine breathing medication for a resident, leading to the medication being unavailable at the prescribed time. During an observation, a Licensed Practical Nurse (LPN) confirmed that the inhaler for the resident was not in stock. The LPN stated that the inhaler had been reordered, but records showed discrepancies in the reorder and delivery dates. The Medication Administration Record (MAR) confirmed the inhaler had not been administered, and a progress note indicated that the physician was contacted to order the medication once it was received. The resident, who had been admitted and re-admitted with certain diagnoses, expressed that the medication occasionally ran out. The Care Plan for the resident included giving medications as ordered and monitoring side effects and effectiveness. During an interview, the Director of Nursing (DON) explained that inhalers should be reordered before they run out, depending on the type of inhaler. The facility's policy on medication ordering and receiving from the pharmacy emphasized timely receipt and accurate record-keeping, which was not adhered to in this instance.
Plan Of Correction
1. What corrective action will be accomplished? Resident #48 received ordered inhaler @ 5:59pm on. Resident #48 was assessed by ARNP and found to have no adverse effect related to delayed administration of inhaler. The licensed nurses caring for resident #48 were re-educated on the facility policy for re-ordering medication. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: An audit was conducted of current residents who have physicians order/receives inhalers to ensure all are stocked and re-ordered timely. 3. Measures/systematic changes put into place: The licensed nurses were re-educated by the DON/Designee on the facility policy for re-ordering medications (including inhalers). Re-ordering medication (including inhalers) was added to new nurse hire orientation and annual education. 4. How Corrective action will be monitored: The DON/Designee will conduct a daily audit (for 5 weeks) of residents with a physician order for inhalers to ensure the inhaler is available and re-ordered timely. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.
Failure to Timely Reorder and Administer Asthma Medication
Penalty
Summary
The facility failed to ensure that a routine breathing medication was reordered and received in a timely manner for a resident with a diagnosis of Seizure and Asthma. On March 12, a Licensed Practical Nurse (LPN) confirmed that the inhaler for asthma was not available for Resident #48 at the prescribed time. The LPN initially stated that the inhaler was reordered on March 10, but documentation revealed that the reorder actually occurred on March 12, with delivery on March 13. The March Medication Administration Record confirmed the inhaler had not been administered, and a progress note indicated that the physician was contacted and ordered the medication to be administered once received. Resident #48, who was admitted with diagnoses including Seizure and Asthma, expressed that the facility occasionally runs out of medication. The resident's Care Plan included interventions to give medications as ordered and monitor for side effects and effectiveness. During an interview, the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged the concern, with the ADON presenting the inhaler to the surveyor. The DON explained that inhalers should be reordered before they run out, depending on the type of inhaler, and referenced a policy on medication ordering and receiving that emphasized timely receipt from the pharmacy.
Plan Of Correction
1. What corrective action will be accomplished? Resident #48 received ordered inhaler @ 5:59pm on Resident #48 was assessed by ARNP and found to have no adverse effect related to delayed administration of inhaler. The licensed nurses caring for resident #48 were re-educated on the facility policy for re-ordering medication. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: An audit was conducted of current residents who have physicians order/receives inhalers to ensure all are stocked and re-ordered timely. 3. Measures/systematic changes put into place: The licensed nurses were re-educated by the DON/Designee on the facility policy for re-ordering medications (including inhalers). Re-ordering medication (including inhalers) was added to new nurse hire orientation and annual education. 4. How Corrective action will be monitored: The DON/Designee will conduct a daily audit (for 5 weeks) of residents with a physician order for inhalers to ensure the inhaler is available and re-ordered timely. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.
Failure to Protect Residents' Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information. During an observation at the Northside Nursing station, a demographic sheet containing a resident's information was found visible and unattended on the counter. Staff I, an LPN, acknowledged the breach, explaining that the paperwork was left by a person who came to pick up a deceased resident. The LPN confirmed that no resident information should be visible or left unattended, indicating a lapse in following the facility's protocol for safeguarding residents' information. Additionally, during a dining observation, paperwork containing residents' information was found unattended on a chair in the dining room. The Assistant Director of Nursing (ADON) was informed and confirmed that the paperwork should not have been left unattended. The Director of Nursing (DON) stated that the facility has measures in place to protect residents' information, but the observations indicate these measures were not effectively implemented. The facility's policy on HIPAA security measures emphasizes the importance of maintaining the confidentiality and integrity of residents' information, which was not adhered to in these instances.
Plan Of Correction
1. The resident demographic sheet was removed from the counter and secured in the resident's chart. The unattended paperwork ("activities haircut list") was removed from the dining room chair and secured. 2. A facility-wide audit was conducted to ensure no other resident's information was inappropriately placed and visible. No other information was found visible. 3. All staff training/education was provided by the DON/Designee on ensuring resident privacy and confidentiality. *Resident privacy and confidentiality training will be included in new hire and annual education. 4. The DON/Designee will conduct daily (for 5 weeks) facility observation rounds audit to ensure that no resident information is visible. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or lower, as evidenced by an error rate of 13.89% out of 36 opportunities. During a medication observation, an LPN was found administering medications to a resident outside the prescribed time frame. The medications, which included Bumetanide, Calcium Acetate, Carvedilol, and Ferrous Sulfate, were scheduled to be given at 9:00 AM, but were not administered until after 11:07 AM. The LPN admitted to being busy with other duties, which delayed the administration of the medications. Additionally, Vancomycin, which was ordered at midnight, was not in stock, and the LPN had to contact the physician and pharmacy to follow up on its availability. The Director of Nursing confirmed that the facility's policy allows for medications to be administered within an hour before or after the scheduled time. However, the delay in administering the medications and the unavailability of Vancomycin contributed to the high medication error rate. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and within the designated time frame, but this was not adhered to in this instance, leading to the deficiency.
Plan Of Correction
1. What corrective action will be accomplished? Resident #379 showed no adverse effect from late medication administration (46 minutes). The physician for Resident #379 was notified of the late medication administration. No new orders were received. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: The DON/Designee conducted an audit of the AM (9:00AM) medication pass to ensure medications are administered timely. 3. Measures/systematic changes put into place: The pharmacy nurse consultant provided "med-pass" education/competency to licensed nurses. Med-pass education/competency will be added to licensed nurse new hire and annual education. Medication administration times will be reviewed by the DON and pharmacy consultant to ensure there is enough time to administer medications within the required time frame and adjust times as indicated. 4. How corrective action will be monitored: The DON/Designee will conduct daily (times 5 weeks) random audit observation of nurses AM (9:00AM) med-pass, to ensure that medications are administered timely. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or lower, resulting in an observed error rate of 13.89% out of 36 opportunities. During a medication observation, an LPN on the Northside medication cart was found administering medications to a resident outside the prescribed time frame. The medications were scheduled to be given at 9:00 AM, with an acceptable administration window from 8:00 AM to 10:00 AM. However, the LPN had not administered the medications by 11:07 AM, citing being busy with other duties as the reason for the delay. Additionally, one of the medications was not in stock because it was ordered by the physician at midnight the previous night, and the LPN had to contact the physician and pharmacy to follow up on its availability. The facility's policy on medication administration states that medications should be administered within 60 minutes of the scheduled time unless specified otherwise by the prescriber. The Director of Nursing confirmed this policy during the survey. Despite this policy, the facility's medication distribution system failed to ensure timely administration, contributing to the high error rate. The surveyor's findings highlighted a lack of adherence to the established medication administration schedule and insufficient staffing or system processes to prevent unnecessary interruptions in medication administration.
Plan Of Correction
1. What corrective action will be accomplished? Resident #379 showed no adverse effect from late medication administration (46 minutes). The physician for Resident #379 was notified of the late medication administration. No new orders were received. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: The DON/Designee conducted an audit of the AM (9:00AM) medication pass to ensure medications are administered timely. 3. Measures/systematic changes put into place: The pharmacy nurse consultant provided
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals for five residents, leading to a deficiency in compliance with the 59A-4.112(6), FAC Drug Storage regulation. Observations revealed that prescription and non-prescription medications were improperly stored at the bedside of several residents. For instance, a plastic bag of bottled pills was found on the nightstand of one resident, and a bottle of medication was observed on the side table of another resident. These medications were not secured in a locked refrigerator or medication room, as required by the regulation. Additionally, during a medication observation, two bottles labeled Acetic Irrigation Solution were found on the nightstand of a resident, which should have been stored in the medication cart. Another resident had a bingo card with discontinued medication in the medication cart, which should have been removed and either sent back to the pharmacy or destroyed. These findings indicate a lack of adherence to the facility's policy on medication storage, which mandates that all medications be stored according to the manufacturer's recommendations to ensure proper sanitation, temperature, light, moisture control, segregation, and security. Interviews with staff members, including LPNs and an RN, revealed that rounds were conducted to check the condition of residents and the environment for safety. However, the presence of medications at the bedside suggests that these rounds were not effective in identifying and addressing the improper storage of medications. The facility's failure to comply with the drug storage regulation was further confirmed by a review of the facility's policy and a statement from the Pharmacist Consultant, who emphasized the importance of removing discontinued medications from the cart.
Plan Of Correction
1. What corrective action will be accomplished? The bottled pills inside a plastic bag were removed from Resident #381's bedside and secured. The was removed from Resident #47's bedside and secured. The from Resident #12's bedside was removed and secured. The 2 bottles labeled Acetic Irrigation Solution were removed from Resident #47's bedside. The bingo card labeled tablet of discontinued medication for Resident #65 was returned to the pharmacy. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: The DON/Designee conducted an audit of occupied resident rooms and medication carts to ensure no medications or biologicals were at bedside and no discontinued medications were in the med carts. 3. Measures/systematic changes put into place: The DON/Designee re-educated the nursing staff on the facility policy for storage of medications and biologicals. Education for storage of biologicals was added to the new hire orientation and annual nursing education. The pharmacy nurse consultant will audit medication carts monthly to ensure no discontinued medications are stored in cart. 4. How corrective action will be monitored: The DON/Designee will conduct daily observation room rounds audit (times 5 weeks) to ensure no medications or biologicals are at bedside. Med cart audit for discontinued medications weekly (times 5 weeks). The results of these audits will be reviewed at the monthly QA meeting until compliance has been determined.
Failure to Secure Sharp Objects
Penalty
Summary
The facility failed to maintain a safe and sanitary environment as required by regulations. During the survey, a shaving razor was observed protruding from a resistant container in a resident's room. This posed a potential hazard to residents, as the razor was not fully secured within the container. Staff B, an LPN, was notified of the issue and acknowledged that the razor should have been completely inside the sharps container to ensure resident safety. Additionally, lancets were found unattended on top of medication cart #1 at the South nursing station. Staff A, an LPN, admitted to leaving the lancets on top of the cart because they forgot. Later, Staff H, an RN, was observed leaving lancets unattended on the same cart, stating it was acceptable while in use, but then placed them inside the cart when questioned. These actions indicate a lack of adherence to safety protocols regarding the storage of sharp objects. The Director of Nursing confirmed that the facility's policy requires staff to ensure that shaving razors are fully inside containers and that lancets should not be left unattended on medication carts. The facility's policy on accidents and supervision emphasizes maintaining an environment free of accident hazards and providing adequate supervision to prevent accidents. However, the observations during the survey revealed lapses in following these protocols, leading to the identified deficiencies.
Plan Of Correction
1. What corrective action will be accomplished? The lancets were removed and secured from the top of the medication cart #1. The shaving razor was disposed of and secured in the resistant sharps container. 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: A facility observation audit of medication carts and sharps containers was conducted by the DON/Designee to ensure no lancets were accessible on the medication carts and no objects were protruding from the sharps containers. 3. Measures/systematic changes put into place: The DON/Designee re-educated the nursing staff on the facility policy for "homelike environment" including no lancets accessible, no objects protruding from the sharps containers, and facility policy for accidents and supervision. These educations will be added to new hire and annual education. The DON/designee will conduct daily facility rounds to ensure no lancets are accessible on medication carts and no objects are protruding from sharps containers. 4. How corrective action will be monitored: The DON/Designee will conduct daily (times 5 weeks) observation audit of medication carts and sharps containers to ensure resident safety and homelike environment is maintained. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.
Privacy Breach of Resident Information
Penalty
Summary
The facility failed to uphold residents' right to privacy of personal information, as evidenced by multiple observations of unattended paperwork containing residents' information left visible in public areas. During a morning observation at the North Nursing station, a demographic sheet with a resident's information was found unattended on the counter. Staff I, an LPN, acknowledged the breach, explaining that the paperwork was left by someone who came to pick up a deceased resident. The LPN confirmed that no resident information should be visible and stated that they usually keep all residents' information with them. Later, during a dining observation, paperwork with visible resident information was found unattended on a chair in the dining room. The ADON, who was present in the room, was informed and retrieved the paperwork, confirming it contained residents' information and should not have been left unattended. The DON was interviewed and reiterated that the facility has measures in place to safeguard residents' information, emphasizing that no resident information should be visible or left unattended. A review of the facility's HIPAA Security Measure policy indicated that reasonable and appropriate measures should be implemented to protect residents' identifiable information.
Plan Of Correction
1. The resident demographic sheet was removed from the counter and secured in the resident's chart. The unattended paperwork ("activities haircut list") was removed from the dining room chair and secured. 2. A facility-wide audit was conducted to ensure no other resident's information was inappropriately placed and visible. No other information was found visible. 3. All staff training/education was provided by the DON/Designee on ensuring resident privacy and confidentiality. *Resident privacy and confidentiality training will be included in new hire and annual education. 4. The DON/Designee will conduct daily (for 5 weeks) facility observation rounds audit to ensure that no resident information is visible. The results of this audit will be reviewed at the monthly QA meeting until compliance has been determined.
Deficiency in Generator Maintenance
Penalty
Summary
The facility failed to maintain its essential electric system generator in accordance with NFPA 101 standards. During a Life Safety Survey tour, it was observed that the generator room lacked high mortality spare parts, which are crucial for the maintenance and quick repair of the generator. This deficiency was identified during an inspection conducted at 2:00 pm on March 11, 2025, with the Maintenance Director present. The absence of these critical spare parts indicates a lapse in the facility's preparedness to ensure the generator's functionality in emergencies. The generator is required to supply power within 10 seconds, and regular maintenance and testing are mandated by NFPA 110. However, the lack of spare parts suggests that the facility may not be able to meet these requirements consistently, potentially compromising the safety and well-being of the residents. During a staff interview, the Maintenance Director acknowledged the deficiency, and this finding was also discussed with the Administrator during the exit conference. The report highlights the importance of having necessary spare parts readily available to maintain compliance with safety standards and ensure the reliability of the emergency power system.
Plan Of Correction
1. What corrective action will be accomplished? The following spare parts were ordered for our two on-site generators: 200 KW Generac Generator and 50KW Kato light Generator: * All engine filters: oil & air * All cooling system hoses & block heater hoses * All engine belts * Engine oil * Engine coolant 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: This deficiency could affect the occupants of the facility in the case of a loss of power. However, no residents have been affected by this practice. 3. Measures/systematic changes put into place: Once the supplies have been delivered, the Maintenance Director will establish a monthly inspection log to monitor all high mortality spare parts in the Generator Room. 4. How corrective action will be monitored: The Maintenance Director will ensure that all high mortality spare parts stored in the Generator Room are maintained in good working order and are available for use as needed. The inspection log will be reviewed at the monthly QA meeting until compliance has been determined. 1. What corrective action will be accomplished? The following spare parts were ordered for our two on-site generators: 200 KW Generac Generator and 50KW Kato light Generator: * All engine filters: oil & air * All cooling system hoses & block heater hoses * All engine belts * Engine oil * Engine coolant 2. How we identified other residents having the potential to be affected by the deficient practice & corrective action taken: This deficiency could affect the occupants of the facility in the case of a loss of power. However, no residents have been affected by this practice. 3. Measures/systematic changes put into place: Once the supplies have been delivered, the Maintenance Director will establish a monthly inspection log to monitor all high mortality spare parts in the Generator Room. 4. How corrective action will be monitored: The Maintenance Director will ensure that all high mortality spare parts stored in the Generator Room are maintained in good working order and are available for use as needed. The inspection log will be reviewed at the monthly QA meeting until compliance has been determined.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 323 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near North Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fountain Manor Health & Rehabilitation Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Claridge House Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 6 | 0 |
| Pines Nursing Home | 1.1 mi | ★★★★★ | 0 | 0 |
| Villa Maria Nursing Center | 1.2 mi | ★★★★★ | 4 | 2 |
| North Dade Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 9 | 0 |
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