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 Pines Nursing Home during CMS and state inspections, most recent first.
Surveyors found that staff failed to protect resident privacy by leaving a note with confidential visitor information visible on both medication carts and by leaving an EMAR screen unlocked and unattended, exposing a resident's medical information. The DON confirmed the notes were meant for staff awareness but should not have been displayed, and a nurse admitted to not securing the computer as required.
The facility did not ensure accurate completion and revision of Level I PASRR screenings for three residents with serious mental illness or intellectual disability, despite documented diagnoses and use of psychotropic medications. PASRR screenings failed to reflect residents' conditions, and staff responsible for assessments lacked the required qualifications.
Surveyors identified that the facility failed to implement and sustain effective infection control procedures, including proper glove use and sharps disposal, despite ongoing QAPI committee meetings and written policies. This repeated deficiency under F880 had the potential to impact all residents in the facility.
Surveyors found that staff failed to follow infection control protocols for two residents, including improper disposal of blood glucose monitoring supplies, not cleaning an insulin vial before medication extraction, and not wearing required PPE during care for a resident on Enhanced Barrier Precautions. These actions did not align with the facility's infection prevention policies.
Surveyors found that staff failed to protect resident privacy by leaving confidential notes about a resident's authorized visitors visible on medication cart computer screens and by leaving an EMAR screen unlocked and unattended, exposing resident health information. A nurse acknowledged forgetting to lock the computer, and the DON stated that notes were meant to be flipped to hide information but were not. These actions did not comply with the facility's policy on resident privacy and confidentiality.
Surveyors found that two exit doors with magnetic locks did not release within the required 15 seconds during a facility inspection, and this deficiency was acknowledged by both the Maintenance Director and Administrator.
Failure to Safeguard Resident Privacy and Confidentiality of Records
Penalty
Summary
Surveyors identified a deficiency in the facility's protection of resident privacy and confidentiality of medical records. During observations, a note containing information about a resident's allowed visitors and specific steps to follow was found posted on the computer screens of both medication carts. This note was visible to anyone in the area, thereby exposing confidential resident information. The Director of Nursing (DON) confirmed that the signs were intended to inform all staff, including PRN nursing staff, about visitor restrictions for the resident, but acknowledged that the signs should have been flipped to the blank side when not in use to prevent displaying resident information. Additionally, during a medication administration observation, the Electronic Medication Administration Records (EMAR) screen on one of the medication carts was left unlocked and unattended, with a resident's EMAR information visible. A registered nurse admitted to forgetting to lock the computer before leaving to administer medications, acknowledging awareness of the requirement to secure the computer screen when not present with the medication cart. The facility's policy on resident rights and confidentiality was reviewed and indicated a commitment to providing personal privacy and confidentiality of records. However, the observed actions of leaving confidential information visible on both physical notes and electronic screens demonstrated a failure to adhere to these policies and federal regulations regarding the safeguarding of residents' personal and medical information.
Plan Of Correction
1. Resident #23 posted information was immediately removed on and a search of the common facility areas was conducted to ensure that no other resident information was visible to outside sources, no other issues were found. 2. Medication carts and computer were checked for identifiable resident information and no other issues were found. 3. The DON or designee will educate current staff to ensure that personal and/or confidential information is safeguarded. 4. HR will be responsible for training new hires on measures to safeguard information and HIPAA compliance. 5. On all departments were re-educated by the DON on the importance of residents' rights to privacy to ensure that residents' names are kept confidential and not posted. 6. The nurse on cart B who left the computer screen open, unattended was re-educated by DON on the importance of locking his screen when moving away from the cart. 7. On an in-service was held by the DON with all the nurses on confidentiality and privacy of residents' information related to safeguarding personal and confidential information. 8. Nursing supervisor will monitor for compliance daily and Director of Nursing or designee will make random checks weekly to ensure that residents' rights to confidentiality and privacy are not being violated for the next 3 months. 9. Findings will be reported monthly in the QA meeting until substantial compliance has been determined, to ensure compliance has been achieved.
Failure to Complete Accurate PASRR Screenings Prior to Admission
Penalty
Summary
The facility failed to ensure that Level I Preadmission Screening and Resident Review (PASRR) assessments were accurately completed prior to admission and appropriately revised following admission for three residents with serious mental illness (SMI) or intellectual disability (ID) or related conditions. For these residents, medical records indicated diagnoses such as unspecified depressive disorder, major depressive disorder, and generalized anxiety disorder, as well as the use of psychotropic medications. However, the PASRR Level I screenings did not reflect these diagnoses, and in some cases, no diagnoses were checked or identified, despite clear documentation in the medical records and care plans. For one resident, the PASRR Level I completed by a hospital social worker did not indicate any mental illness or ID, even though the resident's medical record and care plan documented diagnoses and ongoing use of psychotropic medications. Another resident's PASRR Level I similarly failed to identify SMI, despite the presence of relevant diagnoses and medication orders. In the third case, the PASRR Level I did not check for SMI, and the screening was not updated to reflect the resident's current condition, even though the care plan and psychiatric consultation documented a history of major depressive disorder and generalized anxiety disorder. Interviews with facility staff revealed that the Social Services Director (SSD) was responsible for completing the Level I PASRR assessments, but the SSD stated she did not have the required license to complete these assessments. The Director of Nursing (DON) indicated that she would complete the assessments if the SSD did not. The facility's policy required that all residents have a PASRR Level I completed prior to admission and that the screening reflect the resident's current condition and diagnosis, but this was not followed for the residents in question.
Plan Of Correction
F 645 1. Residents #8, 12, 13 PASRR were immediately updated on after finding out that there was some missing information on them. 2. An audit on all current residents to ensure that their PASRR were completed accurately was conducted. 3. Regulations and criteria for completing PASRR were reviewed. 4. Admission personnel was instructed to ensure that PASRR comes in completed with every new admission. 5. Social Service with MDS Coordination will review all PASRR within 72 hours of admission for accuracy to alert D.O.N if there is any discrepancy. 6. If found incorrectly completed, the D.O.N will do the PASRR over and social worker will upload updated PASRR into the resident's record. 7. D.O.N or designee will do random checks monthly on all new admission PASRR to ensure compliance for the next 3 months. Good day. Review of the medical records for Resident #13 revealed the resident was admitted to the facility on. Clinical diagnoses included but were not limited to: Unspecified unspecified severity, without behavioral disturbance, disturbance, disturbance, Major recurrent unspecified. Unspecified is not due to a substance or known physiological condition. Review of the Physician's Orders Sheet for Resident #13 revealed, Resident #13 had orders that included but not limited to: Oral Tablet 25 Milligram (MG) - Give one (1) tablet by one time a day for Unspecified; Oral Tablet 5 MG - Give 1 tablet by one time a day for; oral tablet 50 MG - give 1 tablet by at bedtime for; unspecified; Oral Tablet 7.5 MG - Give 1 tablet by at bedtime for. Record Review of Resident #13's Level | PASRR (Preadmission Screening and Resident Review) documented Section 1: PASARR Screen Decision Making: A: Mental Illness( ) or suspected (check all that apply) - No diagnoses checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked-no. Does individuals have validating documentation to support or related - no. Section III Not a provisional admission. Section No diagnosis or suspicion of Serious Mental Illness (SMI) or intellectual. Findings will be brought to the monthly QA meetings until such time as substantial compliance has been determined, to ensure compliance has been achieved.
Repeated Deficiency in Infection Control and QAPI Implementation
Penalty
Summary
The facility was cited for failing to implement effective Quality Assurance and Performance Improvement (QAPI) activities, specifically in relation to repeated deficiencies under F880, which pertains to infection prevention and control. Surveyors found that the facility did not maintain effective systems to ensure staff adhered to proper infection control procedures, such as changing gloves during care and correctly disposing of sharps and used monitoring supplies. These lapses were identified through observations, interviews, and record reviews during the recertification survey. The report details that the facility's QAPI/QAA committee met monthly and included members such as the Medical Director, Administrator, DON, Preventionist, and other interdisciplinary team members. Despite these meetings and the existence of written policies and procedures intended to guide QAPI activities, the facility failed to correct previously identified quality deficiencies. The repeated citation of F880 indicates that the facility did not successfully implement or sustain corrective actions to address infection control issues. The deficiency was not limited to a single event but reflected a pattern of non-compliance with infection control protocols, as evidenced by staff not changing gloves between resident care tasks and improper disposal of sharps. These failures had the potential to affect all 44 residents residing in the facility at the time of the survey. The report does not provide specific details about individual residents' medical histories or conditions at the time of the deficiency.
Plan Of Correction
F 867 1. On , the QAPI committee met to discuss and re-invent the facility's current QAPI plan that failed to prevent repeated deficiencies related to control practices as staff failed to adhere to proper sharps disposal of used monitoring supplies. Upon discussion, it was determined that failure in the system occurred and intervention to address it would be implemented. During monthly meetings, control and personal privacy audits will be collected for tracking and monitoring. Any adverse findings discovered through monitoring will be addressed among the interdisciplinary team during QAPI gatherings. Department heads will ensure all new processes are implemented in applicable locations. 2. New hire files will be reviewed during the QAPI meeting to ensure educational training on control and residents' rights to privacy/confidentiality is received. 3. The facility QAPI process and current performance improvement plans were reviewed, and revisions needed were made by the Administrator to ensure that no other areas were affected. DON implemented training, education, and a plan of correction expressed in other areas to address failures in the system discussed during the meeting on 4. 4. A performance improvement project was implemented on control practices to include previous survey citations related to control (e.g., monitoring supplies disposal, cleaning vial, PPE usage when performing care). 5. The preventionist and the Director of Nursing were in-serviced by the administrator on the revised QAPI/QA&A policy and procedures. After conducting training, the Administrator observed compliance by each staff member. 6. The administrator re-educated and reminded all department heads of the importance of following the QAPI Policy & Procedures. After conducting training, the Administrator observed compliance by each staff member. 7. The administrator will conduct QAPI audits once a month for the next 3 months. The administrator will track and monitor audits performed to verify systems are working. 8. These audits will be presented to the QA&A committee monthly for recommendations. 9. The committee will determine the need for further auditing beyond the three months if any.
Infection Control Deficiencies in Monitoring, Medication Administration, and PPE Use
Penalty
Summary
Surveyors identified deficiencies in the facility's infection prevention and control practices involving two residents. In one instance, a Licensed Practical Nurse (LPN) failed to properly dispose of used blood glucose monitoring supplies, including a lancet, test strips, and used pads, by placing them in the regular garbage can in the resident's room instead of a sharps container. Additionally, the LPN did not clean the top of the insulin vial with an alcohol wipe before extracting medication with a needle syringe. The LPN later admitted to forgetting to clean the vial and was unsure about the correct disposal of unused supplies taken into a resident's room. Another deficiency was observed during care for a resident who required Enhanced Barrier Precautions (EBP) due to the presence of a medical device. The LPN providing care did not don a gown as required by EBP protocols, although gloves were used. The used care supplies were discarded in a biohazard bag and placed in the appropriate bin outside the room, but the omission of the gown was inconsistent with the facility's policy and the resident's care plan, which specified the use of PPE including gloves and gown for residents on EBP. Both residents involved had significant medical needs. One resident required regular blood glucose monitoring and insulin administration, while the other had a medical device and was at risk for infection, necessitating EBP. The facility's own policies and staff interviews confirmed that the observed practices did not align with established infection control standards, including the use of PPE and proper disposal of potentially infectious materials.
Plan Of Correction
F 880 F 880 F 880 1. The involved nurses were in-serviced by the Director of Nursing on the importance of preventing the spread of via instruction of proper place to dispose of used Accu-Chek supplies, wiping vial before drawing the desired units, and wearing PPE while providing care. 2. The DON implemented a performance improvement project with the nurse causing repeat citation for one month on control. 3. On 9 2025, an in-service was done by the DON with all nurses to ensure that everyone is reminded of the proper disposal of used Accu-Chek supplies as well as their role in preventing and controlling in the building. The DON demonstrated techniques through exercises of the proper way to prevent the spread of. One on one return demonstration was conducted. DON and nursing supervisor observed compliance by each nurse. 4. D.O.N or designee will do some extra shadowing of the nurses involved to monitor the quality of their control practices. 5. Nursing supervisor will do random checks weekly to monitor for compliance for the next 3 months. 6. Findings will be discussed monthly in QA meetings until substantial compliance has been achieved. F 880 F 880 F 880
Failure to Safeguard Resident Privacy and Confidential Health Records
Penalty
Summary
The facility failed to protect the privacy and confidentiality of residents' electronic health records (EHR) and personal information. During a survey, it was observed that a note containing information about a resident's authorized visitors and instructions for staff was posted on the computer screens of two medication carts. This note was visible to anyone passing by, thereby exposing confidential resident information. Additionally, during medication administration, the electronic medication administration record (EMAR) for a resident was left open and unattended on a computer screen, making the resident's medical information accessible to unauthorized individuals. Staff interviews confirmed these lapses in privacy. A registered nurse admitted to forgetting to lock the computer screen before leaving the medication cart to administer medications, acknowledging awareness of the requirement to secure the screen when not present. The Director of Nursing (DON) explained that the notes regarding visitor restrictions were intended to inform all staff, including PRN nursing staff, about specific instructions for a resident with challenging family dynamics. However, the notes were supposed to be flipped to the blank side when not in use, but this protocol was not followed, resulting in the exposure of resident information. The facility's own policy on resident rights and confidentiality was reviewed and found to require the protection of personal privacy and confidentiality of records. Despite this policy, the observed actions and inactions by staff led to a failure to safeguard residents' confidential information, as evidenced by the visible notes and unlocked EMAR screens on medication carts. At the time of the survey, there were 44 residents in the facility.
Plan Of Correction
1. Resident #23 posted information was immediately removed on , and a search of the common facility areas was conducted to ensure that no other resident information was visible to outside sources, no other issues were found. 2. Medication carts and computer were checked for identifiable resident information and no other issues were found. 3. The DON or designee will educate current staff to ensure that personal and/or confidential information is safeguarded. 4. HR will be responsible for training new hires on measures to safeguard information and HIPAA compliance. 5. On all departments were re-educated by the DON on the importance of residents' rights to privacy to ensure that residents' names are kept confidential and not posted. 6. The nurse on cart B who left the computer screen open unattended was re-educated by DON on the importance of locking his screen when moving away from the cart. 7. On an in-service was held by the DON with all the nurses on confidentiality and privacy of residents' information related to safeguarding personal and confidential information. 8. Nursing supervisor will monitor for compliance daily and Director of Nursing or designee will make random checks weekly to ensure that residents' rights to confidentiality and privacy are not being violated for the next 3 months. 9. Findings will be reported monthly in the QA meeting until substantial compliance has been determined, to ensure compliance has been achieved.
Egress Door Magnetic Locks Failed to Release Within Required Timeframe
Penalty
Summary
During a Life Safety Survey at Pines Nursing Home, surveyors observed that the facility failed to maintain egress doors in accordance with NFPA 101 requirements. Specifically, two exit doors—one located by the Dialysis Room and another by Resident Room 20—were found to have magnetic locking mechanisms that did not release within the required 15 seconds. These observations were made during a walkthrough of the facility with the Maintenance Director present. The deficiency was confirmed through direct observation and was acknowledged by both the Maintenance Director and the Administrator during the exit conference. The report details that the doors in question are part of the required means of egress and are subject to strict standards regarding locking mechanisms, especially those that may delay or prevent rapid exit in an emergency. The delayed release of the magnetic locks did not comply with the standards set forth in NFPA 101, which stipulate that delayed-egress locking systems must release within 15 seconds to ensure safe evacuation. No specific residents or patients were directly involved or affected at the time of the survey, and there is no mention of any medical history or condition related to the deficiency. The findings are based solely on the physical inspection of the egress doors and staff interviews, with no additional incidents or adverse outcomes reported in connection with the deficiency.
Plan Of Correction
1. All occupants had the potential of risk but no one was harmed. Corrective action taken was designee from Maintenance or Housekeeping checked door for proper functioning upon daily exit until repair completed. 2. Upon discussion failure in the system was identified and intervention to address the deficit was implemented. During monthly QAPI meeting door check audit meant to track and monitor will be collected by Administrator for three months. Any adverse finding discovered through monitoring will be analyzed amongst the interdisciplinary team during QAPI gatherings. Audit presented to the committee is for recommendations purposes and to ensure department heads practice processes in applicable locations. 3. Facility obtained company on May 6, 2025 to inspect and service the door. 4. Magnet on each deficient door was replaced on May 20, 2025. 5. Maintenance Director or designee will review to assess if any additional task is needed to ensure compliance according to state and federal guidelines. 6. Maintenance team will perform daily scheduled door check. 7. Any identified deficiency will be reported to Administrator. Maintenance Director or Administrator will ensure proper party is secured to perform repair. 8. Maintenance team will perform preventive maintenance monthly. 9. On May 15 the Maintenance team was re-educated by the administrator on the proper procedure to check the door equipment.
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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.
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Nursing homes near Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Maria Nursing Center | 0.1 mi | ★★★★★ | 4 | 2 |
| North Dade Nursing And Rehabilitation Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Biscayne Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Fountain Manor Health & Rehabilitation Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Pinecrest Center For Rehabilitation And Healing | 1.1 mi | ★★★★★ | 0 | 0 |
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