Inspection visit
Inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) for one
resident (Resident # 47) out of 23 sampled residents. Resident # 47's MDS was coded wrong for a
discharge to the hospital, but the resident was discharged home. This deficiency has the potential to affect
45 residents residing in the facility at the time of survey.
Residents Affected - Few
The findings included:
Record review of the clinical records for Resident # 47 revealed the resident was admitted on [DATE], and
discharge on [DATE]. Clinical diagnoses include, but were not limited to, Bipolar Disorder, Psychotic
disorder (other than schizophrenia), Schizophrenia, Rhabdomyolysis, Muscle Weakness (Generalized),
Other Abnormalities of Gait and Mobility, Weakness, Drug induced Acute Dystonia, Gastro-Esophageal
Reflux Disease without Esophagitis.
Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed, Section A, Discharge
status - short term, - General Hospital, Section C, Cognitive Status revealed, the resident's Brief Interview
for Mental Status (BIMS) summary score was 15 out of 15 indicating the resident did not have cognitive
impairment.
Record review of the progress note dated 10/26/2023 revealed, the resident will be discharged home,
tomorrow as per Medical Physician orders and resident's request. He has good family support. Resident
appears alert and oriented to place, person and time currently. He is able to communicate coherently
verbally at this time. Resident has a BIMS score of 15 at this time. Resident receives prescriptions for
medications. Resident is able to walk without any assistive device at this time. Facility will provide
transportation for the discharge date . Family will provide food, shelter and clothing for discharge. Social
Worker called resident's wife to inform regarding the discharge.
Record review of the discharge Care Plan initiated on 10/31/2023 revealed, Focus: Resident is a new admit
to facility. Resident is here for short-term Rehab Therapy. Resident plans to discharge home when able with
Home Health services. Goal: Resident will attend Therapy as scheduled and participate in treatment
program to enable discharge home through Next Review Date (NRD). Approach: Coordinate transportation
home. Encourage resident to attend therapy to regain strength. Meet with resident and family at an
appropriate time to discuss discharge plans and possible need for home Health agency services. Meet with
resident and family at an appropriate time to discuss discharge plans and possible need for home Health
agency services. Speak to the family about equipment that may be needed in order for resident to return
home safely.
Interview over the phone with MDS coordinator on 12/07/23 at 01:44 PM revealed, that she has been
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 16
Event ID:
105057
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
working in the facility for a few months only. When asked what happened with the coding on Section A of
the MDS she stated, I have to make a correction, I cannot explain.
Review of undated Policies and Procedures for Comprehensive Assessments revealed, The Resident
Assessment Instrument (RAI) consists of three basic components: The Minimum Date Set (MDS) Version
3.0, the Care area assessment (CAA) process and the resident care plan. The Utilization of the three
components of the RAI yield information about a resident's functional status, strength, weakness, and
preferences, offers guidance on further assessment once problems have been identified, as well as guides
resident care.
I. The RAI manual will be the source for instructions on how to complete each section on the MDS, CAA,
and resident Care plan.
II. The MDS coordinator will check the CMS web site periodically for any changes to the RAI manual.
III. Social Services will complete section A, D, and Q. Section Q will only be completed by the social
services department when discharge planning is involved. In all other cases, section Q will be completed by
the MDS Coordinator.
Submission of the MDS is the responsibility of the MDS coordinator.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 2 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and
provide appropriate care for a resident with a feeding tube.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to ensure enteral feeding was administered as
prescribed and enteral feeding equipment/supplies were dated, labeled and changed daily for one
(Resident #12) out of 13 residents receiving enteral tube feeding.
The findings included:
During an observation on 12/04/23 at 09:43 AM, Resident #12 was observed in bed, the bed was in the
lowest position, and the Enteral feeding (TF) was not infusing. The TF supplement in the residents room
was Fiber Source and was dated 12/04/2023, the enteral feeding syringe was dated 11/29/23, and the
water for tube feeding flush did not have a label and was not dated. (Photograph obtained).
On 12/05/23 at 09:34 AM, the Resident was not in the facility, the residents bed was stripped of linen, and
facility staff stated the resident went to the hospital.
Review of the medical records for Resident #12 revealed, the resident was admitted to the facility on
[DATE]. Clinical diagnoses included but were not limited to: Dysphagia, Oropharyngeal and Gastrostomy
Status. Resident #12 was discharged on 12/05/2023.
Review of the Physician's Orders Sheet for December 2023 revealed, Resident #12 had orders that
included but were not limited to: Enteral Feed-every shift related to dysphagia, oropharyngeal phase Fiber
Source @ 55ml/hr. x 22 hrs. - total volume infused in 24 hrs. is 1210ml-(off 11am/ on 1pm). Autoflush @
25ml/hr. x 22 hrs. (off 11am/ on 1pm).
Record review of Resident #12 's admission Minimum Data Set (MDS) dated [DATE] revealed, Section C
for Cognitive patterns documented Brief Interview for Mental Status Score was unable to be determined.
Section GG for Functional Status documented resident is Dependent for care has impairment on both sides
of upper and lower extremities. Section K for Nutritional status documented no unknown weight loss/gain.
Section O for Special Procedures documented no special treatments received while a resident in the last
14 days.
Review of Resident #12's weight logs revealed on 10/30/2023, the resident weighed 86 pounds; last weight
recorded on 12/01/2023 the resident weighed 88 pounds.
Record review of resident #12 's care plans with a reference date of 10/30/23 revealed: Feeding tube
present. resident is at risk for nutrition/ hydration deficit related to medical diagnosis of: pneumonia;
dehydration; Parkinson's; dementia; failure to thrive; malnutrition; underweight; dysphagia, weight: 86# Body
mass index: 16.2, planned weight gain initiated. Interventions Include but not limited to: Assess my needs at
least quarterly and adjust TF as needed. Assess my weight per facility policy. Check patency of my tube
daily. Elevate the head of my bed as per facility policy. Flush my tube with water as ordered. Notify my MD
of any significant weight changes. Provide me with nutritional supplements via Tube as ordered.
Review of the discharge summary progress note for Resident # 12 dated 12/05/2023 time stamped 08:29
documented: Resident was found lying on bed this morning with respiratory distress evidenced by
Respirations-28, Oxygen saturation-88%. Doctor was called and order given to send resident to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 3 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
hospital by 911. Safety and comfort provided to resident. Head of bed elevated, oxygen in place. Continued
monitoring maintained until 911 arrived.
08:35 Resident was transferrd to the hospital by 911 as ordered by the Doctor. Family called and notified.
Interview on 12/07/23 at 08:56 AM with the Director of Nursing (DON) revealed, when asked about the tube
feeding protocols at the facility she reported, the night shift nurses on the 11-7PM shift are responsible for
changing the tube feeding supplies and equipment daily, they are supposed to change and date all
supplies, any assigned nurse can change and date supplies if they notice something is incorrect during
their rounds. The nurses have to make sure that the resident's tube feeding orders for administration are
being followed as prescribed, the tube feeing can be temporarily turned off when the Certified Nursing
Assistants are providing care. The DON was shown pictures of the water for tube feeding flush for the
resident hanging in a clear bag on the tube feeding pole with no identifying label, date or pertinent
information, an enteral syringe hanging from the tube feeding pole dated 11/29/23. The DON was informed
about the date and time of the observation.
Review of the undated facility's policy titled: Enteral Nutrition Care states: Enteral Nutrition will be available
for residents who are unable to meet their metabolic needs via oral administration.
Procedure: The nurse will review daily how the formula is being administered, monitor weight, skin
condition, labs, physical symptoms, and tolerance to feeding. The nurse will visit the residents to check the
pump for flow rate, assess down times, and medicine administration records for amount of feeding
administered and refer any problems to the nutrition care professional.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 4 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to follow physician's order for oxygen therapy for
one (Resident #36) out of 9 residents receiving respiratory services and to obtain a physician order for
oxygen therapy for one (Resident #12) out of 9 residents receiving respiratory services.
Residents Affected - Few
The findings included:
1. Observation on 12/04/23 at 09:56 AM, Resident #36 was in bed asleep, and the resident was receiving
Oxygen (02) at 4 liters per minute (lpm) via trach collar.
On 12/05/23 at 09:36 AM, Resident #36 was observed in bed asleep, and the resident was receiving 02 at
4lpm via trach collar.
During a Tracheostomy care observation on 12/06/23 at 07:51 AM, Licensed Practical Nurse (Staff C)
gathered tracheostomy care supplies, entered Resident #26's room. The resident was in bed asleep, the
head of bed was elevated, Staff C checked the resident's oxygen (02). Staff C reported, the resident's 02
was infusing at 5 liters per minute (lpm).
Review of the medical records for Resident #36 revealed, the resident was admitted to the facility on
[DATE]. Clinical diagnoses included but were not limited to: Acute Respiratory Failure and Anoxic Brain
Damage.
Review of the Physician's Orders Sheet for December 2023 revealed, Resident #36 had orders that
included but not limited to: Oxygen at 5 Liters per minute every shift.
Record review of Resident #36 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed,
Section C for Cognitive Patterns documented, Brief Interview for Mental Status score was unable to be
determined. Section GG for Functional Status documented, the resident is dependent for care. Section J for
Health Conditions documented, shortness of breath when lying flat and sitting at rest. Section O for special
procedures documented, resident received oxygen therapy, suctioning, and trach care while a resident.
Record review of Resident #36 's Care Plans Reference Date 10/26/2023 revealed, Resident has a
potential for alteration in respiratory function related to Tracheostomy. Interventions included but were not
limited to: Oxygen as ordered, Head of bed elevated as tolerated, and monitor vital signs as needed and
notify physician.
2. During observation on 12/04/23 at 09:43 AM, Resident #12 was in bed, the bed was in the lowest
position, the resident was receiving oxygen (02) at 3.5 liters per minute via nasal cannula.
On 12/05/23 at 09:34 AM, Resident #12 was not in the facility, the bed was observed to be stripped of linen,
and facility staff stated the resident went to the hospital.
Review of the medical records for Resident #12 revealed, the resident was admitted to the facility on
[DATE]. Clinical diagnoses included but were not limited to: Adult Failure to Thrive, and Pneumonia.
Resident #12 was discharged on 12/05/2023.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 5 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of the Physician's Orders Sheet for December 2023 revealed, Resident #12 had no orders for
oxygen therapy.
Record review of Resident #12 's admission Minimum Data Set (MDS) dated [DATE] revealed, Section C
for Cognitive patterns documented Brief Interview for Mental Status Score was unable to be determined.
Section GG for Functional Status documented resident is Dependent for care, has impairment on both
sides of upper and lower extremities. Section K for Nutritional status documented no unknown weight
loss/gain. Section O for Special Procedures documented no oxygen therapy or special treatments received
while a resident in the last 14 days.
Interview on 12/07/23 at 08:50 AM with the Director of Nursing (DON) it was reported, the nurses are
supposed to be checking on the resident's oxygen (02) concentrators and making sure the 02 is at the
prescribed rate during rounds. The nurses have to check the Electronic Medication Administration Records
(EMAR) for the doctors (MD) orders and make sure the 02 is flowing at the correct rate during their rounds.
DON checked the EMAR orders for Resident #12 and confirmed the resident did not have any orders for
oxygen therapy.
Review of the facility's policy titled Oxygen Administration with a revision date of October 2010, states the
purpose of this procedure is to provide guidelines for safe oxygen administration. Step1-verify that there is a
physician's order for this procedure. Review the physician's orders or facility protocol for oxygen
administration.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 6 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way
that maximizes each resident's well being.
Based on record review and interview, the facility failed to ensure nine out of ten sampled nursing staff
(Staff 1, 2, 3, 4, 5, 6, 8, 9, and 10) received the appropriate competencies and skills sets to provide nursing
and related services to assure resident safety and attain or maintain the highest practicable physical,
mental, and psychosocial well-being of each resident. The facility had no documentation that the staff
received the orientation in-service training including Alzheimer's and Dementia, Abuse, Neglect, and
Exploitation.
The findings included:
Review of the facility's staff records revealed, Staff 1 was hired on 08/14/2023; Staff 2 was hired on
10/02/2023; Staff 3 was hired on 10/23/2023; Staff 4 was hired on 08/15/2023; Staff 5 was hired on
05/14/2023; Staff 6 was hired on 05/23/2023; Staff 8 was hired on 07/14/2023; Staff was 9 hired on
06/26/2023; Staff 10 was hired on 08/15/2023.
Further review of the facility's staffing records relating to new hire orientation revealed, Staff 1, Staff 2, Staff
3, Staff 4, Staff 5, Staff 6, Staff 8, Staff 9, and Staff 10 did not receive their in-service new hire orientation.
Interview on 12/06/2023 at 01:05 PM with the Director of Human Resources (HR) revealed, the staff
received a verbal orientation. She stated, that the facility doesn't have a list of in-service training needed for
the staff to do. The Director of HR also stated that she was new to the job and that she did not know if they
needed to document the trainings the staff received during orientation.
On 12/07/2023 at 2:30PM, during an interview with the Director of Nursing (DON), she stated, During
orientation, they are reminded about abuse and dementia training. We verbally went over all the in-service
training, but I didn't have the list for them to sign. They were made aware. I just don't have the paper to
prove it.
Review of the undated policy and procedures regarding staffing in-service orientation labeled, Staff
Education Plan:
Intent: It is the policy of the facility to provide a Staff Education Plan in accordance to State, Federal and
OSHA [Occupational Safety and Health Act, regulations that is consistent with resident needs based on
Comprehensive Assessments and Care Plans, as well as the Facility Assessment.
Procedure:
1. This staff education plan will be reviewed at least annually by the quality assurance committee and
revised as needed.
2. The facility will ensure this staff education plan includes both pre-service and annual requirements.
9. The facility will ensure that all employees who are expected to, or whose responsibilities require them to,
have direct contact with residents with Alzheimer's disease or a related disorder must, in addition to being
provided the information required, also have an initial training of at least 1
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 7 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0726
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
hour completed in the first 3 months after beginning employment. This training will include, but it is not
limited to, an overview of dementia and must provide basic skills in communicating with persons with
dementia. An individual who provides direct care will be considered a direct caregiver and must complete
the required initial training and an additional 3 hours of training within 9 months after beginning
employment. This training will include, but it is not limited to, managing problem behaviors, promoting the
resident's independence in activities of daily living, and skills in working with families and caregivers.
10. The facility will ensure that Risk Management training be a part of the facilities new hire orientation.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 8 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation and interview, the facility failed to implement pharmacy procedures for recording
daily refrigerator temperatures for the refrigerator in the Medication Storage room. There were 45 residents
residing in the facility at the time of the survey.
The findings included:
During the Medication Storage Room observation on 12/07/23 at 7:40 AM with Licensed Practical Nurse
(Staff A) the temperature log for the medication refrigerator in the medication storage room was observed
to be last filled out on 12/5/23 with a recorded temperature of 37 degrees Fahrenheit (F).
Interview on 12/07/23 at 07:53 AM with the Director of Nursing (DON) it was reported, the 11-7pm nurses
are responsible for filling out the refrigerator temperature logs. The DON was shown the temperature log
posted on the refrigerator in the medication room, the DON acknowledged the refrigerator Temperature log
was not filled out since 12/5/23. The DON had Staff A to check the temperature of the refrigerator and
update the log for today,12/7/23. The temperature was recorded as 38 F.
Review of the undated facility's policy titled, Medication Administration states, It is the policy of the facility to
ensure that appropriate infection prevention and control measures are taken to prevent the spread of
infection in accordance with State and Federal Regulations and National guidelines when administering
medications.
Procedures
Step 11 and 12-Refrigerators used to store medications do not include any items other than medications
and temperature is monitored daily and documented.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 9 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure the garbage disposal was
clean and discarded materials were properly disposed and contained on the facility grounds.
Residents Affected - Few
The findings included:
Observation on 12/04/23 at around 09:36 AM showed the outside dumpster area was noted with a large
dumpster for trash and a medium dumpster for card board. The dumpster for the cardboard was observed
to be overflowing, and the lid was unable to closed.
On 12/07/23 at 01:46 PM, during an interview with the Administrator, he stated that he did not see or notice
the dumpster on Monday. He stated, he looked at the dumpster earlier today and saw it was not full at all.
He then stated that he thinks they picked up the trash this morning.
On 12/07/23 at 02:35 PM, the Administrator brought the policy and procedure document and stated, You
remember I told you about the dumpster. it's pretty much empty now. You can go and verify.
Review of the facility's undated policy and procedures relating to Recycling/waste disposal revealed:
Intent: It is the policy of the facility to maintain a safe and sanitary environment.
Procedure:
1. It is the facility policy to discard any disposable material in the proper environment.
2. Staff will attend to proper disposal of items dependent on material requirement.
4. Staff will notify proper responsible party if extra pick up is necessary.
5. If additional pick-up is necessary, the administration or designee will contact contracted company to
schedule service be performed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 10 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to maintain communication with the hospice
provider to ensure continuation of care for 1 (Resident #36) out of 5 residents receiving Hosice services, as
evidenced by no updated hospice communication were notes available in Resident #36's medical records,
and services provided by Hospice were not coordinated and communicated in the written documentation.
The findings included:
Observation on 12/04/23 at 09:56 AM revealed, Resident #36 in bed asleep, Tube Feeding (TF) was
infusing with - Fiber Source at 70ml/hr(milliliters/hour)., Water flush at 30ml/hr., the supplies and equipment
was dated 12/04/23, and the resident was receiving Oxygen (02) at 4 liters per minute (lpm) via trach collar.
On 12/05/23 at 09:36 AM Resident #36 was observed in bed asleep, the TF infusing at 70ml/hr, the
supplies and equipment was dated 12/5/23,. The 02 was on at 4lpm via trach collar.
During Tracheostomy care observation on 12/06/23 at 07:51 AM, Licensed Practical Nurse (Staff C)
12/06/23 07:51 AM gathered tracheostomy care supplies, entered Resident #36's room, the head of bed
was elevated. Staff C stated, the resident's 02 is at 5 liters per minute (lpm). Staff C, completed the Trach
care to resident #36.
Review of resident's # 36 Hospice Agreement revealed, the resident is on Hospice with a start of care on
10/19/2023.
The facility's hospice agreement was signed on 12/01/2016 and 12/15/2016 by the facility and the hospice.
Review of Resident # 36's Hospice Communication Notes revealed, the most recent notes were dated,
10/31/23 for a Interdisciplinary (IDG) meeting and on 11/06/23 for a Hospice Aide Visit.
Review of the medical records for Resident #36 revealed, the resident was admitted to the facility on
[DATE]. Clinical diagnoses included but were not limited to: Acute Respiratory Failure and Anoxic Brain
Damage.
Review of the Physician's Orders Sheet for December 2023 revealed, Resident #36 had orders that
included but were not limited to: 10/19/23-Resident is admitted under Hospice at routine level of care.
Record review of Resident #36 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed:
Section C for Cognitive Patterns documented Brief Interview for Mental Status score was unable to be
determined. Section GG for Functional Status documented resident is dependent for all care. Section J for
Health Conditions documented shortness of breath when lying flat and sitting at rest. Section O for special
procedures documented resident received Hospice care, oxygen therapy, suctioning and trach care while a
resident.
Record review of Resident #36 's Care Plans with a Reference Date 10/26/2023 revealed, Resident is
under Hospice care with Do not resuscitate (DNR) orders. Interventions included but not limited to:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 11 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0849
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate care with Hospice to coordinate Care Plans and evaluate resident for Crisis care as needed.
Hospice nurses will assist in coordinating the needs of the residents. Hospice visits with nurses, Chaplain,
and social worker as needed.
Interview on 12/06/23 at 01:04 PM with the Director of Nursing (DON) revealed, hospice Certified Nursing
Assistants (CNAs) come to the facility approximately three times a week and the hospice nurse comes
every other week. The DON reported, there were no notes in the hospice binder for this resident, I believe it
is electronic, and I will see what we have. The DON reported, after the hospice staff visits/see's the
residents they communicate with the assigned nurses.
On 12/06/23 at 02:45 PM, the DON brought some hospice paperwork/communication notes to the
surveyor, and the most recent dated notes was a 10/31/23 IDG meeting and an 11/06/23 Hospice Aide
Visit.
Review of the facility's policy titled Administration-Hospice Services dated January 14, 2022 states: It is the
policy of the facility to provide collaborative care with Hospice providers to ensure that our resident's end of
life preferences and choices are honored.
2. When Hospice care is furnished in the facility through an agreement the following requirements will be
met:
b. - iv. A communication process, including how the communication will be documented between the LTC
facility and the Hospice provider, to ensure that the needs of the resident are addressed and met 24 hours
per day.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 12 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop
corrective plans of action.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interview and record review, the facility failed to demonstrate effective plans of action were
implemented to correct identified quality deficiencies in the problem area related to repeated deficient
practices for F641 Accuracy of Assessment. The facility failed to accurately code Minimum Data Set (MDS)
Section A for one (Resident # 47) out of 23 sampled residents. This deficiency has the potential to affect 45
residents residing in the facility at the time of survey.
The findings included:
Record review of the facility's survey history revealed, during a recertification survey with exit date of
10/06/2022, F641 Accuracy of Assessment was cited related to the accurate coding for MDS Section A for
a Resident.
Interview with Administrator and the Director of Nursing on 12/07/2023 at 1:40 PM, the Administrator stated
that the QAPI (Quality Assurance and Performance Improvement) meetings are held on the last Thursday
of each month.
Record review of the policy and procedure revealed: Our purpose is to provide excellent quality resident
care and services. Quality is defined as meeting or exceeding the needs, expectations and requirements of
the residents cost-effectively while maintaining good resident outcomes and perceptions of care.
[ ] has a Performance Improvement Program which systematically monitors, analyzes and improves its
performance to improve resident outcomes. It recognizes that value in healthcare is the appropriate
balance between good measures, excellent care and services and cost.
Feedback, date systems and monitoring:
a.
QAPI is integrated into the responsibilities and accountabilities of all senior management.
b.
The following date is monitored through QAPI: Input from caregivers, residents, families, and others:
Adverse events; Performance indicators; Survey finding; Complaints.
Process for collecting the above information:
Gather input from caregivers, residents, families and others (Surveys, Council Meetings, written
evaluations, PCP input).
Adverse events (incident reports, 24 hours report)
Performance indicators (Monthly Quality Measure (QM), 5 star rating) Survey findings
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 13 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0867
Complaints.
Level of Harm - Minimal harm
or potential for actual harm
The information gathered is analyzed and compared to benchmarks and/or targets established by the
facility.
Residents Affected - Few
Current scores [NAME] analyzed against benchmarks that have been set quarterly.
Daily interdisciplinary team (IDT) notes are reviewed including adverse events/complaints on daily basis.
We have a mechanism for communicating patters, trends identified during IDT meetings to the broader
QAPI committee.
Consultant reports are compared to goals on a monthly basis.
QAPI team analyze data regularly as part of their project assignments.
Monthly reports/graphs are published-Department manager and/or the QAPI Lead is responsible for
cataloging and maintaining these reports.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 14 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review and interview, the facility failed to implement infection control procedures for two
(Residents #36, and #198) out of 23 sampled residents. As evidenced by a Licensed Practical nurse (Staff
C) not changing gloves during the entire tracheostomy care observation for Resident #36 and not disposing
the used Blood Glucose Monitoring supplies in the sharps container. There were 45 residents residing in
the facility at the time of the survey.
Residents Affected - Few
The findings included:
1. During a Tracheostomy care observation on 12/06/23 at 07:51 AM, Licensed Practical Nurse (Staff C)
gathered tracheostomy care supplies, entered Resident #26's room, the resident was in bed asleep, the
head of the bed was elevated, the resident's oxygen (02) was checked, Staff C stated resident #36 was
receiving 02 at 5 liters per minute (lpm), the resident did not require suctioning. Staff C donned gloves, Staff
C removed the trach gauze, cleaned the trach area with normal saline solution (NSS) with gauze and trach
brush, replaced the trach gauze, replaced the trach collar, re-oxygenated the resident, discarded supplies
in the trash bin, washed hands, exited the resident's room, and signed off on the Trach Care.
Review of the medical records for Resident #36 revealed, the resident was admitted to the facility on
[DATE]. Clinical diagnoses included but were not limited to: Tracheotomy, Acute Respiratory Failure and
Anoxic Brain Damage.
Review of the Physician's Orders Sheet for December 2023 revealed, Resident #36 had orders that
included but were not limited to: Trach care every shift and as needed.
Record review of Resident #36 's Significant Change Minimum Data Set (MDS) dated [DATE] revealed:
Section C for Cognitive Patterns documented Brief Interview for Mental Status score was unable to be
determined. Section GG for Functional Status documented resident is dependent for care. Section J for
Health Conditions documented shortness of breath when lying flat and sitting at rest. Section O for special
procedures documented resident received oxygen therapy, suctioning and trach care while a resident.
Record review of Resident #36 's Care Plans Reference Date 10/26/2023 revealed: Resident has a
potential for alteration in respiratory function related to Tracheostomy. Interventions included but not limited
to: Oxygen as ordered, Head of bed elevated as tolerated, and monitor vital signs as needed and notify MD.
2. During a Blood Glucose Monitoring observation on 12/06/23 at 11:01AM for Resident #198 with Licensed
Practical Nurse (Staff C), the nurse prepared the supplies, entered the room, identified the resident,
washed hands, donned gloves, cleaned the residents left index finger with alcohol pads, checked the Blood
Glucose (BG), the results was 144. Staff C, recleaned the resents left index finger with an alcohol pad,
discarded lancet, blood glucose test strips and used alcohol pads in the garbage in the resident's room.
Staff C reported, no insulin is required at this time, exited room, cleaned blood glucose machine with
sani-wipes, let dry, and signed off on Blood Glucose monitoring.
Interview on 12/06/23 at 08:32 AM with Staff C revealed, Resident #36 usually has a lot of secretions; he
has a prescription for a scopolamine patch for 72 hours that helps with the secretions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 15 of 16
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105057
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pines Nursing Home
301 NE 141 Street
Miami, FL 33161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During the trach care when we go from a dirty to a clean procedure, we are supposed to change our gloves
and wash our hands. I know that I did not change my gloves after cleaning the trach site and before I
placed the clean gauze on the trach site, change the trach collar and the trach mask. I was very nervous; I
am so sorry.
Interview on 12/06/23 at 11:14 AM with Staff C when asked by surveyor, where did she dispose of the used
Blood Glucose Monitoring supplies, Staff C reported, in the garbage, in the room and went back to the
room to retrieve the used supplies. Staff C reported, I need to put them in the sharps container.
During an interview on 12/07/23 at 09:05 AM, the Surveyor discussed the infection control issues observed
with Staff C with the Director of Nursing (DON). The DON stated, she will be conducting in-services and
re-education with all the nurses at the facility.
Review of the facility's policy titled Infection Prevention and Control Program revised October 2018 states:
An Infection Prevention and Control Program is established and maintained to provide a safe, sanitary and
comfortable environment and to help prevent the development and transmission of communicable diseases
and infections.
Prevention of Infection.
Step 3-Educating staff and ensuring that they adhere to proper techniques and procedures.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105057
If continuation sheet
Page 16 of 16
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Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
F726 - Nursing Services
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0345GeneralS&S Dpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
FAQ · About this visit
Common questions about this visit
What happened during the December 7, 2023 survey of PINES NURSING HOME?
This was a inspection survey of PINES NURSING HOME on December 7, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PINES NURSING HOME on December 7, 2023?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.