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 Tierra Pines Center during CMS and state inspections, most recent first.
The facility failed to maintain proper storage for medical gas cylinders, as observed during a tour. The 1st floor clean utility and soiled utility rooms had doors that could not close, latch, and lock, failing to prevent unauthorized entry. This deficiency was confirmed through an interview with the RMS.
The facility failed to complete and update PASARRs for residents with mental disorders and intellectual disabilities, affecting eight residents. PASARRs were incomplete or outdated, lacking current diagnoses such as dementia, anxiety disorder, and epilepsy. Interviews with the DON and SSA revealed oversight and delays in updating PASARRs, with no formal policy in place to manage them.
The facility failed to properly monitor the sanitation solution for the dish machine, as observed during a kitchen tour. A Dietary Aide was unaware of the required rinse cycle temperature and found no sanitation during testing. The sanitation bucket was empty, and the CDM admitted to not having a clear expectation for checking sanitation levels. The NHA confirmed the CDM's responsibility to ensure proper dish sanitation.
A facility failed to incorporate PASRR Level II recommendations into a resident's care plan. The resident, with multiple psychiatric diagnoses, had recommendations for psychiatric medication management and supportive counseling, along with close monitoring for mood and behavioral issues. However, these were not included in the care plan, and staff were unaware of the need to do so. The facility also lacked a PASRR policy.
Two residents with moderate cognitive impairment and mobility issues were not assisted with shaving their facial hair, despite expressing a desire for such care. The facility's staff failed to offer or document shaving assistance during scheduled shower days, as required by the residents' care plans.
The facility failed to provide adequate wound care for two residents, resulting in continuous bleeding and inadequate treatment. One resident had multiple areas of bruising and bleeding, with staff failing to follow care plans and physician orders. Another resident's wound care orders were not consistently completed, with missing documentation in the Treatment Administration Record. These deficiencies highlight the facility's failure to ensure proper wound care and monitoring.
The facility failed to maintain essential equipment, including laundry washers and dryers, a gas stove, and an exhaust hood, leading to significant operational issues. The maintenance requests were not properly logged, and the previous Maintenance Director had resigned.
Improper Storage of Medical Gas Cylinders
Penalty
Summary
The facility failed to maintain proper storage for medical gas cylinders, as observed during a tour conducted on March 3, 2025. The deficiency was identified in the 1st floor clean utility and soiled utility rooms, where medical gas is stored. The doors to these rooms, which open to the corridor, were found to be unable to close, latch, and lock, thereby failing to ensure unauthorized entry prevention. This issue was confirmed through an interview with the RMS conducted concurrently with the observations. The report highlights the importance of proper storage and handling of compressed gases for the safety of staff, patients, and visitors within the facility. The facility's failure to comply with NFPA 99 and NFPA 101 standards, specifically regarding the security and proper enclosure of medical gas storage areas, constitutes a significant safety concern. The deficiency was documented based on the observations and interviews conducted during the facility tour.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, 1st floor clean utility and soiled utility room doors were immediately assessed for parts to fix the unlatched doors. No negative outcome identified. On 3/3/25, 1st floor clean utility and soiled utility keypads were immediately ordered for doors. No negative outcome identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken? On 3/3/25, an assessment of all rooms where stored oxygen cylinders were inspected. No additional areas of concern were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 3/7/25, 1st floor clean utility and soiled utility room doors were corrected with new lock and latch to ensure proper closure. On 3/7/25, 1st floor clean utility and soiled utility room door keypads were added to ensure authorized entry. On 3/4/25, maintenance staff was educated on the components of K923 Gas Equipment, Cylinder and Container Storage with an emphasis to maintain proper storage for medical gas cylinders by the Administrator/Designee. Any newly hired Maintenance Director will be educated on maintaining proper storage for medical gas cylinders by the Administrator/Designee on the components of K923 Gas Equipment, Cylinder and Container Storage. (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: Administrator/designee to conduct door and storage audits 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure proper storage for medical gas cylinders. The findings of these quality monitoring audits to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met. 3/11/25 (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 3/3/25, 1st floor clean utility and soiled utility room doors were immediately assessed for parts to fix the unlatched doors. No negative outcome identified. On 3/3/25, 1st floor clean utility and soiled utility keypads were immediately ordered for doors. No negative outcome identified. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken? On 3/3/25, an assessment of all rooms where stored oxygen cylinders were inspected. No additional areas of concern were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur,
Incomplete and Outdated PASARRs for Residents with Mental Disorders
Penalty
Summary
The facility failed to complete and update the Pre-admission Screening and Resident Reviews (PASARRs) for residents with mental disorders and intellectual disabilities. This deficiency was identified for eight out of twelve residents reviewed. The PASARRs were either incomplete or not updated to reflect the residents' current diagnoses, which included conditions such as dementia, anxiety disorder, major depressive disorder, bipolar disorder, and epilepsy. In several cases, the Level I PASARRs were left blank or did not have the qualifying diagnoses checked, and Level II evaluations were not submitted for consideration following the acquisition of new qualifying diagnoses. Interviews with the Director of Nursing (DON), Social Services Director (SSD), and Social Services Assistant (SSA) revealed that the facility had identified the need to correct the PASARRs but had not yet completed the necessary updates. The DON acknowledged being behind in updating the PASARRs and confirmed that the facility did not have a policy in place for managing PASARRs. The SSA was responsible for checking the PASARRs against the residents' charts and discussing any discrepancies with the DON, but this process was not effectively ensuring that PASARRs were complete and up-to-date. Specific examples included residents with diagnoses such as major depressive disorder, bipolar disorder, and epilepsy, where the PASARRs did not reflect these conditions. The DON admitted to oversight and delays in updating the PASARRs, which were identified during audits. The lack of a formal policy and procedure for PASARR management contributed to the deficiency, as the facility did not have a structured approach to ensure compliance with PASARR requirements.
Improper Monitoring of Dish Machine Sanitation
Penalty
Summary
The facility failed to ensure proper monitoring of the sanitation solution for the dish machine in the kitchen. During a kitchen tour, a Dietary Aide, Staff F, revealed that he did not usually record the temperatures or sanitizing parameters for the dish machine, which is a low-temperature machine. He was unsure of the required rinse cycle water temperature and, upon testing, found that the sanitation level was inadequate as the test strip remained white, indicating no sanitation. Additionally, the sanitation bucket below the dish machine was empty. The Certified Dietary Manager (CDM) stated that staff should check and record sanitation levels daily, but there was no clear expectation for when the sanitation should be checked. The CDM was uncertain who filled out the log for a specific breakfast service and admitted to not noticing the empty sanitation bucket. The Nursing Home Administrator (NHA) confirmed that the CDM should ensure the dish machine is in good repair and that dishes are properly cleaned and sanitized. Photographic evidence was obtained to support these findings.
Failure to Incorporate PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II into the care plan for a resident. The resident, who was admitted and readmitted with diagnoses including major depressive disorder, bipolar disorder, schizophrenia, and generalized anxiety disorder, had a PASRR Level II determination that recommended psychiatric medication management and supportive counseling. Additionally, it was advised that staff closely monitor the resident for mood and behavioral issues and inform a licensed mental health professional of any changes. However, a review of the resident's Electronic Health Record (EHR) showed no evidence of these recommendations being included in the care plan. During an interview, the Director of Nursing, Social Service Director, and Social Service Assistant stated they were unaware that the PASRR Level II recommendations needed to be added to the care plan. The facility also lacked a PASRR policy.
Failure to Assist Residents with Shaving
Penalty
Summary
The facility failed to provide or assist with shaving facial hair for two residents, both of whom expressed a desire to have their facial hair shaved. Resident #72, who has a primary diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was observed with unkempt facial hair and stated that staff had not offered assistance with shaving. Despite being scheduled for showers twice a week, there was no documented evidence that Resident #72 received facial hair care. The resident's care plan indicated a need for assistance with ADLs due to limited mobility and cognitive impairment. Similarly, Resident #78, diagnosed with Parkinson's disease, was observed with unkempt facial hair and expressed a desire to be shaved. The resident's care plan also indicated a need for assistance with ADLs, and the documentation showed no evidence of facial hair care being provided. Interviews with staff revealed that shaving was supposed to be offered during shower days, but it was not consistently provided. Both residents had moderate cognitive impairment, which may have contributed to their inability to independently manage their grooming needs.
Inadequate Wound Care and Documentation for Residents
Penalty
Summary
The facility failed to provide appropriate wound care for Resident #73, who was observed with multiple areas of bruising and bleeding on his arms, hands, and cheek. Despite having orders to apply specific treatments and monitor for excessive bleeding, the resident's wounds were not properly managed, leading to continuous bleeding and crusted blood on his skin and linens. Interviews with staff and family members revealed that the resident's condition was known, yet appropriate measures were not taken to address the bleeding and protect the wounds from infection. Resident #73 had a history of skin picking, which contributed to his skin impairments. His care plan included interventions such as applying lotion, monitoring skin changes, and reporting any signs of breakdown to the physician. However, these interventions were not effectively implemented, as evidenced by the resident's ongoing bleeding and lack of wound coverage. The facility's failure to adhere to the care plan and physician orders resulted in inadequate wound care and potential risk of infection. Similarly, the facility failed to follow physician orders for wound care for Resident #4, who had a history of pressure ulcers and other skin conditions. The Treatment Administration Record (TAR) showed multiple instances where wound care orders were not completed, and documentation was missing. Interviews with staff indicated a lack of adherence to the facility's policy on wound care documentation, leading to gaps in treatment and monitoring. This deficiency highlights the facility's failure to ensure consistent and effective wound care for its residents.
Facility Fails to Maintain Essential Equipment
Penalty
Summary
The facility failed to maintain essential equipment, resulting in one of two laundry washers and two of three laundry dryers being non-functional for almost two weeks. Staff interviews revealed that the laundry equipment had been experiencing intermittent issues for the past year, causing significant delays in laundry processing. Additionally, the facility had no hot water for over a week, and repair services were not being rendered due to unpaid previous repair jobs. Observations confirmed the presence of out-of-order signs on the equipment and a backlog of laundry in the laundry room. Further deficiencies were noted in the kitchen, where a six-burner gas stove was found to be unclean with heavy debris and drippings, and the exhaust hood above it had peeling paint. The garbage disposal was leaking, with a pan placed underneath to catch the water. The Interim Maintenance Director confirmed that these issues were not logged into the electronic maintenance request system, and the previous Maintenance Director had resigned the previous week. The Interim Maintenance Director was unaware of the hot water issue and stated that maintenance requests were not being properly communicated to the maintenance department.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sabal Palms Health & Rehabilitation | 1.1 mi | ★★★★★ | 2 | 0 |
| East Bay Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Aviata At Bryan Dairy | 2.1 mi | ★★★★★ | 4 | 4 |
| Palm Garden Of Largo | 2.3 mi | ★★★★★ | 2 | 0 |
| Palm Garden Of Pinellas | 2.9 mi | ★★★★★ | 2 | 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.