Inspection visit
Inspection
7 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, and menu review, the facility failed to follow approved menus for 39 of 40
residents who consume foods orally, and failed to follow the fortified food menu for 5 of 5 sampled residents
who had orders for fortified foods (Residents #13, #14, #35, #10, and #4).
The findings included:
1) Review of the approved menu for Week 4 documented the Monday lunch menu included Turkey Tortilla
Bake, Roasted Corn, and Fruited Gelatin. Review of the approved recipe for the Turkey Tortilla Bake
included the use of cooked seasoned turkey thigh meat, cottage cheese, shredded mozzarella cheese, and
frozen chopped spinach. Review of the Roasted Corn recipe included the use of whole kernel corn. Review
of the Fruited Gelatin recipe included the use of canned fruit mix.
Observation of the lunch meal served on Monday 09/25/23 revealed a tortilla folded in half with thin sliced
up deli meat, a red sauce, and yellow cheese, a soup-like corn item, a chopped salad mix, and a gelatin
dessert without any fruit. Note the chopped salad was not included in the approved menu for that meal.
During an interview on 09/25/23 at 2:40 PM, Staff B, night cook who had come in early to assist with lunch,
confirmed the menu for lunch should have included the Turkey Tortilla Bake, a layered casserole type meal,
layered like a lasagna, as per the recipe. During a side-by-side review of the recipe, Staff B confirmed she
assisted with the lunch prep, and the meat used was thinly sliced turkey deli meat. Staff B stated Staff A,
day cook, prepared the lunch meal, but she did not see any cottage cheese, mozzarella cheese or spinach
in the main dish. When asked if there was any fruit in the gelatin dessert, Staff B stated there was not and
did not know why.
During an interview on 09/25/23 at 3:10 PM, Staff A, day cook, was shown the recipes for the lunch meal.
Staff A confirmed he did not use spinach or cottage cheese in the meat mixture, and did not provide a
reason for the deletion of ingredients. When asked if he used the mozzarella cheese, Staff A stated he did
not because the mozzarella cheese is stringy and could be difficult for the elderly. Staff A volunteered that
he used about a half a pound of cheddar cheese. Upon review of the Turkey Tortilla Bake recipe, it called for
2 cups per 20 x 12 x 2 inch baking pan, and Staff A confirmed he made two baking pans of the meat
mixture, which would have necessitated 4 cups of cheese. When asked why he didn't follow the directions
to make the Turkey Tortilla Bake, Staff A stated, because it would be to heavy for the residents. They are
used to a lighter meal. Staff A was then asked what corn he used for the Roasted Corn, and he reported he
used a large can of creamed corn, which he had further blended up with an immersion blender. When
asked if there was fruit in the gelatin dessert,
(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 11
Event ID:
105835
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Staff A stated there was not, but the gelatin was fruit flavored. When asked why fruit was not added to the
gelatin, Staff A stated they would add it upon request and further stated, There is no recipe or anything and
it's done by the diet techs. When shown the recipe for the Fruited Gelatin, Staff A stated, Oh, they are from
other countries and don't read English. They are doing the best they can. I will try to help them. These are
new menus and we are trying.
Residents Affected - Many
Review of the approved menu for Week 4 documented the Wednesday lunch menu included Asian Ground
Pork over Fried Rice. Review of the Fried [NAME] recipe included chopped onion, soy sauce, and frozen
scrambled eggs. This recipe further instructed while the rice mixture was baking to prepare the scrambled
eggs, and then fold into the rice.
Observation of the prepared foods on the steam table on Wednesday 09/27/23 at 11:17 AM revealed a
large baking pan of white rice with green beans, carrots, corn, and peas. There was no soy sauce or egg
noted. This was confirmed by Staff A, day cook.
2) Observations of the lunch meal on 09/25/23 lacked any obvious fortified foods, such as a cream-based
soup or mashed potatoes.
During an interview on 09/26/23 at 1:00 PM, when asked what fortified foods are utilized in the facility, Staff
B, night cook identified the oatmeal, grits, and cream of wheat in the dry storage, and stated they would
make those items with cream and or butter for fortified foods. Staff B also pointed out a bag of orzo pasta,
and stated the old menu would call for it with cream and or butter. When asked what was currently used for
the lunch and dinner meals, Staff B stated they sometimes make a soup with cream. When asked what was
the fortified food for lunch today, Staff B stated she was the night cook, but that she was here today at
11:30 AM, and did not recall any fortified food.
During an interview on 09/26/23 at 1:11 PM, when asked what fortified foods are utilized in the facility, Staff
A, day cook, explained that the fortified foods were the lighter and softer foods for the elderly. When asked
again, the day cook stated again it was lighter and softer foods, like soup. When told fortified food were
provided to residents who had weight loss and needed extra calories, and asked what was fortified at lunch
today, Staff A stated they had either a shake or magic cup.
Review of the Fortified Food menus provided by the Administrator revealed fortified cereal for breakfast,
fortified soup for lunch, and fortified pudding for dinner.
During the tray line observation on 09/27/23 beginning at 11:17 AM, Staff A, day cook, volunteered that he
had reviewed all of the resident food tickets for the meal, and none were on fortified foods. The survey team
identified the following five sampled residents with ordered fortified foods.
2a) Review of September 2023 Physician Order Sheet documented Resident #13 was ordered fortified
foods at all meals, three times daily. Review of the Annual Nutritional Assessment completed by the
Registered Dietician also documented the use of fortified foods at all meals, along with a nutritional
supplement twice daily.
During an observation on 09/26/23 at 12:42 PM, Resident #13 was eating his lunch that consisted of
lasagna, zucchini, Texas toast, and peaches. The lunch lacked any fortified food and the menu ticket lacked
the documented fortified food order (Photographic Evidence Obtained).
During an interview on 09/27/23 at 3:10 PM, the Registered Dietician (RD) confirmed the fortified
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 2 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
food order for Resident #13. When told the kitchen had not been preparing any fortified food this week, the
RD had no comment.
2b) Review of the record for Resident #14 documented an order dated 07/30/23 for fortified foods all meals.
An observation on 09/26/23 at 12:47 PM revealed the lunch meal for Resident #14 that consisted of
lasagna, zucchini, Texas toast, and peaches. The lunch lacked any fortified food while the menu ticket
documented the order for fortified food (Photographic Evidence Obtained).
2c) Review of the record for Resident #35 revealed an order dated 09/03/23 for fortified foods with all meals
for weight loss.
Observations on both 09/25/23 and 09/26/23 lacked any fortified food on the lunch meal trays. The menu
ticket also lacked the documented order for fortified food.
During an interview on 09/27/23 at 3:18 PM, the RD confirmed the order for fortified food for Resident #35,
stating the resident had been refusing food at times and had been a challenge. The RD explained she puts
in the recommendation for the fortified food, orders are written, the fortified food is added to the diet slip,
and the information is given to the kitchen. The RD was unsure as to why the meal tickets lacked her
recommendation and why the fortified food was not being prepared.
2d) Resident #10, was initially admitted into the facility on [DATE] with diagnoses that included Dementia,
Anxiety, Hypothyroid and Hypertension. Resident #10 was unable to do the Brief Interview for Mental
Status which indicated severe cognitive impairment.
An observation of the lunch meal for Resident #10 on 09/25/23 revealed a chicken tortilla, a soup- like corn
item, a chopped salad mix and a gelatin dessert.
Resident #10's September Physician Orders revealed an order for fortified foods at all meals.
2e) During the initial meal observation conducted on 09/25/23 at 12:33 PM, the surveyor observed
Resident #4's meal ticket stated he was to be receiving fortified foods. The surveyor observed there was a
strawberry flavored milk shake on Resident #4's meal tray, but no soup. The surveyor asked Resident #4 if
he was aware he was to be receiving fortified foods, he stated the doctor told him he was going to get
special foods but that he did not know which foods were special.
Resident #4 was initially admitted to the facility on [DATE] and was last readmitted on [DATE].
Resident #4 had a medical history significant for Stroke, Difficulty Swallowing.
An Annual Minimum Data Set was done on 09/13/23 and showed Resident #4 had a Brief Interview of
Mental Status score of 15, which indicates he was cognitively intact.
Review of Resident #4's weights documented his readmission weight taken on 08/14/23 was 134.4 pounds
and his weight taken on 09/09/23 was 125.4 pounds. This indicates Resident #4 suffered a 6.7% weight
loss in less than one month.
Review of the physician orders revealed the Dietitian wrote an order on 09/19/23 for fortified
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 3 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0803
foods all meals with the indication weight loss.
Level of Harm - Minimal harm
or potential for actual harm
Review of the Nurse's Note written on 09/19/23 (untimed) stated the following: resident seen by nutritionist
new order for fortified foods all meals, MVI (multivitamin) /mineral 1 tab PO (orally) daily. Dx (diagnosis)
weight loss. Order fax to pharmacy, slip given to dietary.
Residents Affected - Many
Review of the most recent Nutritional Assessment (undated) documented by the Dietitian stated the
following: being assessed for annual. IDT (interdisciplinary team) reports good appetite and no GI
(gastrointestinal)distress. Noted significant weight change x30 days. Recommend 1) fortified foods with all
meals, 2) multivitamin with minerals daily. Magic cup TID (three times daily)-lunch, dinner, HS (bedtime)
snack already in place. RD (registered dietitian) following will continue to monitor and adjust POC (plan of
care) PRN (as needed). Met with resident at bedside, observed edentulous state. IDT reports dentures lost
as resident cannot find it. Care plan updated. Will adjust POC PRN.
Additional observations conducted during the meals of the survey week revealed Resident #4's meal tickets
documented he was to be receiving fortified foods, but he was unable to tell the surveyor which foods were
fortified.
Interviews conducted with the kitchen staff and the dietitian revealed there was a lack of knowledge
regarding what fortified foods are and that fortified foods were not being made/distributed to the residents
who had orders for fortified foods. Because of this, Resident #4 failed to receive fortified foods 3 times per
day as ordered by the Dietitian and had the potential to suffer greater weight loss if not for surveyor
intervention during the survey week.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 4 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation and interview, the facility failed to provide food in proper form for 12 of 40 residents
who consume mechanical soft diets, including sampled residents #4 and #13, and for 5 of 40 residents who
consume pureed diets.
The findings included:
During the lunch observation on 09/25/23 in the dining area adjacent to the nurse's station, seven residents
were observed, three of whom had menu tickets that documented a mechanical soft diet. Residents on a
mechanical soft diet were served the same lunch as residents on a regular textured diet. The lunch served
was a tortilla with meat, sauce, and cheese, soupy looking creamed corn, and a side chopped salad. Staff
were having difficulty cutting up the tortilla and the lettuce in the salad was cut into large chunks
(Photographic Evidence Obtained). Sampled residents #4 and #13 had orders for mechanical soft diets.
During an interview on 09/25/23 at 2:40 PM, when asked the difference between the regular texture lunch
diet and the mechanical soft diet, Staff B, night cook who was assisting with the lunch meal stated they
were both served the same meal. Staff B stated she had suggested to Staff A, day cook, to serve the meat
and tortilla separately for the mechanical soft, but he did not. Note that the chunks of lettuce still would not
have been appropriate for a mechanical soft diet.
An observation of the lunch tray line was made on 09/27/23 beginning at 11:17 AM. The first meal tray
prepared was for a resident who required a pureed diet. Staff A, day cook, took a ladle and poured the
pureed foods onto a divided plate. The food had no form and poured like soup. The pureed food spread out
and filled the divided plate (Photographic Evidence Obtained).
Review of the recipes for the pureed Asian Ground Pork and Fried [NAME] documented the use of only 1
tablespoon of broth per serving, which would have provided a proper consistency of pureed foods.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 5 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) During an
observation on 09/26/23 at 12:42 PM, Resident #13 was eating his lunch. Review of the menu ticket
documented to provide apple juice. The tray contained a red juice (Photographic Evidence Obtained). When
asked about his drinks, Resident #13 stated, I like apple juice. Upon tasting the punch, the resident
hesitated, stated it was OK, but that he preferred the apple juice.
Review of the current Minimum Data Set (MDS) assessment revealed Resident #13 had a Brief Interview
for Mental Status (BIMS) score of 15 on a 0 to 15 scale, indicating the resident was cognitively intact.
During an observation on 09/26/23 at 1:10 PM, Staff B, night cook, was asked what juices were available
for the residents. Staff B went into the walk-in refrigerator and identified a red punch. When asked if they
had cranberry or apple juice, Staff B stated they had run out of both. Staff B stated she had told the
Administrator (NHA) they needed three cases of each with the last order, but only one case arrived. Staff B
stated they had been out of cranberry and apple juices for several days.
The NHA provided the most current invoice for their delivery from the previous week, that documented only
one case of each. When asked about the quantity of juices, the NHA denied the need for three cases and
stated they had some left and she thought it was concentrated so they didn't need as much. The NHA was
made aware they were out of both cranberry and apple juices, and had no comment.
Based on observation, interview and record review, the facility failed to provide dietary options per resident
preferences for Residents #24 and #13, which had the potential to affect 39 of 40 residents who consume
food orally.
The findings included:
1) Resident #24 was admitted to the facility on [DATE] with diagnoses that included Cerebral Palsy,
Asthma, and Morbid Obesity. The quarterly minimum data set with an assessment reference date of
08/17/23 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was
cognitively intact. Resident #24's diet order dated 08/15/23 was a regular diet, double portion for lunch only.
Resident #24 does not ambulate and stated on 09/25/23 at 10:42 AM that he has reservations about being
in his wheelchair and does not get out of bed most of the time. Resident #24 further stated that he does not
like gravy and received gravy on his food for lunch and dinner and at times he cannot discern what the food
is. He stated if he does not know what the food is, he won't eat it. He stated 2 weeks ago, when did not
know what the food was for lunch, he ordered a grilled cheese sandwich, but he never received it and did
not eat lunch. Resident #24 stated that he likes cranberry juice but is receiving fruit punch in a glass on his
tray. He stated fruit punch is too sweet for him so he does not drink it so he drank the water.
An addition interview was conducted with Resident #24 on 09/28/23 at 10:34 AM. The resident was asked if
he was given a menu so to be able to make choices for his meals. He stated he is not given a menu but
would like to be given a menu so he knows ahead of the meal what is being served. Resident #24 was also
asked if he received a double portion of food at lunch and he replied he does not know was a normal
portion would be so he doesn't know.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 6 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0806
Level of Harm - Minimal harm
or potential for actual harm
An interview was conducted with the Registered Dietician (RD) on 09/27/23 at 3:07 PM. The RD stated that
she is not aware of how residents who can't have access to the menu in the lobby are able to know what is
on the menu. She does not know the process about getting meal preferences on the meal ticket, she thinks
the nurses do that.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 7 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation and interview, the facility failed to store, prepare, and serve food in a sanitary
manner, as evidenced by open and expired food, ceiling and walls in disrepair, rust-laden surfaces, not
holding cold foods at required minimum temperature of 41 degrees Fahrenheit, lack of hand hygiene, and
observation of pests, potentially affecting 39 of 40 residents who consume food orally.
The findings included:
1) During the initial kitchen tour on 09/25/23 at 9:25 AM, the following was observed (Photographic
Evidence Obtained):
a) Dented cans of creamed corn in the dry storage area, with no designated area identified for the storage
of dented cans to be returned.
b) Two bags of au gratin potatoes being stored in open zip lock bags, and expired as of 08/22/23.
c) A 5 pound bag of blueberry muffin mix opened with no cover or seal.
d) The lower shelf of a food preparation table covered with old food debris, used to store three large 25
pound containers of soup base.
e) Live crawling insects noted throughout the kitchen, to include on the floors, walls, shelving, food
preparation and serving surfaces, and inside of old ovens that were out of service. Decorative tiles used as
the base border were missing, exposing gaps in the base of the wall with insects crawling nearby.
f) The ceiling vent over the working oven was rust laden with debris falling onto table surfaces.
g) Multiple dinner plates and serving trays were chipped.
h) A repaired ceiling area from a water leak, approximately 2 feet by 4 feet, with peeling paint noted. This
area was near the tray line assembly area where the silverware and trays were stored.
i) The floor of the walk-in freezer was rust laden, with nearly the whole floor a copper color over the
concrete.
j) Silverware in the designated holder had silverware with the handles down, which would contribute to
contamination when staff grabbed the silverware at the non-handle end/eating surface. There was a sign on
the silverware holder that documented, HANDLES UP HANDLES UP.
k) The burners of the working stove top and oven had carbon build up.
l) The shelving storage area for the clean bowls and plastic containers was soiled and dirty.
m) The baking and muffin trays were soiled with carbon build up.
n) A ceiling light with debris seen through the cover.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 8 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
During the initial tour, the Kitchen Manager was unavailable and Staff A, day cook was busy. After the tour,
when asked about the chipped dishes, Staff A, day cook, confirmed they were chipped and stated there
were no others to use. When asked about the dented cans, Staff A was unaware they were not to be used.
When shown the walk-in freezer floor, Staff A stated it had been like that for a long time. When shown the
baking pans, Staff A stated they needed to be scoured. When shown the silverware storage area, Staff A
stated he had told the dietary aides in the past, of the improper storage.
During an interview on 09/25/23 at 10:17 AM, when told of the observations in the kitchen, the
Administrator (NHA) stated they had cleaned the kitchen on Saturday, and were supposed to clean it every
night. When asked what she meant by cleaning the kitchen, the NHA stated they did a routine cleaning on
Saturday, and cleaned the ovens on Friday.
During an interview on 09/25/23 at 2:40 PM, Staff B, night cook, volunteered the oven takes four hours to
heat up. The cook stated they turn it on first thing in the morning and keep it on all day. Staff B also
volunteered the steam table gets hot, but they are unable to regulate the temperature as the knobs under
the steam table don't function. Staff B stated the Kitchen Manager was aware of the issues, and that they
have been like that for 6 to 8 months. During this interview, Staff B confirmed the items in the dry storage
should be covered and sealed closed. The night cook confirmed the baking pans that needed to be scoured
clean were currently being used.
2) A lunch service observation was made on 9/27/23 beginning at 11:17 AM. The steam table was hot and
set up with the lunch meal. Silverware was wrapped in napkins, with extra silverware again observed in the
holder with the handles down. The chipped trays were set up with meal tickets on each one. Staff C, dietary
aide obtained glasses with juice, water, and milk, along with prepared apple sauce from the refrigerator and
added ice to both. Staff A, day cook, brought out a box of 23 individual milk containers, while Staff D,
dietary aide brought out a box of magic cups and nutritional shakes. Staff failed to add ice to these
additional items.
During observation of the lunch service line, Staff A, day cook, changed his gloves between kitchen tasks
at 11:28 AM, 11:32 AM, 11:50 AM, 12:02 PM, and 12:13 PM, without washing his hands. Staff C, dietary
aide, took trays out to the residents, returning to kitchen at 11:49 AM, and donned gloves without washing
her hands. Staff D, dietary aide, spilled juice onto the floor at 12:14 PM, mopped the floor, removed her
gloves and rinsed her hands for about 3 seconds in the kitchen prep sink without any soap, turned off the
faucets, walked over to the hand washing sink to obtain paper towels, then donned gloves.
After the lunch service on 09/27/23 at 12:19 PM, Staff D, dietary aide, started toward the walk-in
refrigerator with the left-over milk, nutritional shakes, and magic cup desserts. When asked, Staff D
confirmed she was returning these milk products to the refrigerator for use at another time. Temperatures
taken with the facility's calibrated thermometer revealed the milk was at 52 degrees Fahrenheit, the
nutritional shakes were at 58 degrees Fahrenheit, and the magic cup nutritional desserts were at 60
degrees Fahrenheit. There were 23 milk containers, 12 nutritional shake containers, and multiple magic cup
nutritional desserts. During this interview, Staff D confirmed she wrapped the silverware earlier that day.
When asked about the storage of the silverware with the handles down, Staff D stated, But I used gloves.
Additional observations in and about the lunch service line area revealed numerous live crawling insects
(Photographic Evidence Obtained).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 9 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and review of exterminator service inspection reports, the facility failed to maintain
an effective pest control program, as evidenced by observed crawling insects in the kitchen and guest
bathroom, documented roach activity by the exterminator during the past six months, and voiced resident
confirmation during the resident council meeting.
Residents Affected - Many
The findings included:
During the initial kitchen tour on 09/25/23 beginning at 9:25 AM, live crawling insects were noted
throughout the kitchen, to include on the floors, walls, shelving, food preparation and serving surfaces, and
inside of old ovens that were out of service. Decorative tiles used as the base border were missing,
exposing gaps in the base of the wall with insects crawling nearby (Photographic Evidence Obtained). Upon
conclusion of the initial tour, the pests were pointed out to Staff A, day cook, who agreed with the issue.
After the initial tour on 09/25/23 at 10:17 AM, the Administrator (NHA) was informed of the live crawling
insects. The NHA stated she was aware of the issue and had increased the pest services to weekly.
During an observation of the lunch line service on 09/27/23 beginning at 11:17 AM, numerous live crawling
insects were again noted (Photographic Evidence Obtained).
The NHA was asked to locate and provide evidence of pest service for the past six months. Review of the
Service Inspection Reports from the exterminator revealed the following:
On 02/27/23 the exterminator was targeting pests to include ants, roaches, silverfish, and spiders. The
exterminator had identified dirty floor drains and food spillage or residue in the kitchen, and instructed the
facility to clean the areas. This inspection rated the severity of the situation needing attention as high.
On 03/06/23, 03/22/23 and 04/17/23, the exterminator continued to target roaches and other pests
throughout the facility, to include the kitchen, office, bathrooms, laundry, and hallway.
On 05/01/23 the exterminator documented excessive moisture and water collecting underneath the dish
washing equipment and in the hot water heater pan, dirty floor drains, and spoilage or food residue in the
kitchen. The exterminator instructed the facility to repair any leaks and keep the area as dry as possible,
and to clean the drains and spoiled or food residue. The exterminator documented the collection of water
was reported to the facility on [DATE] and remained at a medium severity. The dirty drains and spoiled or
food residue had been reported on 02/27/23 and remained at a high severity level.
On 05/24/23 roach activity had been reported in the kitchen, and the areas including cracks and crevices
where roaches could be seen was treated.
On 06/15/23 the exterminator inspected and treated the interior for possible cockroach sightings. This
inspection report documented the kitchen food spoilage or residue continued and was again reviewed with
the facility staff.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 10 of 11
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
105835
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Trail Nursing and Rehab Center
4445 Pine Forest Dr
Lake Worth, FL 33463
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 0925
On 06/30/23 the exterminator continued to target German cockroaches.
Level of Harm - Minimal harm
or potential for actual harm
On 07/24/23 the Service Inspection Report documented, German roaches have been reported in kitchen.
Clean out for German roaches is recommended in order to fully eradicate the German roach population.
Residents Affected - Many
On 08/28/23 the Service Inspection Report documented that visit as the second of two services for the
month of August.
Review of an invoice dated 09/05/23 documented the initiation of weekly service. The facility did not provide
any Service Inspection Reports for the month of September.
Review of the Pest Sighting Log for September 2023 documented roaches were seen in one room on
09/17/23, in four additional rooms on 09/18/23, and in the kitchen on 09/22/23.
During the surveyor resident council meeting on 09/25/23 at 11:40 AM, residents voiced they are still
seeing roaches, to include under a game in the activity room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105835
If continuation sheet
Page 11 of 11
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
7 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.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0222GeneralS&S Dpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0355GeneralS&S Dpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
FAQ · About this visit
Common questions about this visit
What happened during the September 28, 2023 survey of PINE TRAIL NURSING AND REHAB CENTER?
This was a inspection survey of PINE TRAIL NURSING AND REHAB CENTER on September 28, 2023. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PINE TRAIL NURSING AND REHAB CENTER on September 28, 2023?
Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed ..."
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.