Inspection·April 22, 2025

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the admission packet, record reviews, and interviews, the facility failed to refund to the resident or resident representative all refunds due to the resident within 30 days from the resident's date of death / discharge from the facility, for 3 of 3 sampled residents, Resident #1, Resident #2, and Resident #3. Residents Affected - Some The findings included: The facility's admission packet stated that the facility will refund any overpayment within 30 days. 1. Record review revealed Resident #1 expired on [DATE] and had a refund amount of greater than $1040.00 owed to the resident. During an interview with Resident #1's daughter on [DATE], at 12:00 PM, the daughter said that the family received the check last Thursday ([DATE]) for the amount of money owed to her. That was approximately 3 months and 8 days after the resident's expired from the facility. Review of documents provided by the Business Office Manager (BOM), showed a refund to the Resident / Payer, Resident #1, which was processed on [DATE], in the amount $30.00. There was an additional refund to the Resident / Payer Resident #1 processed on [DATE] in the amount $1057.15. Photographic Evidence Obtained. 2. Record review revealed Resident #2 was discharged on [DATE]. Documentation provided by the BOM showed a refund processed on [DATE] in the amount $23,857.87. This was approximately 3 months and 19 days after the resident's discharge from the facility. Photographic Evidence Obtained. 3. Record review revealed Resident #3 expired on [DATE]. Documentation provided by the BOM showed a refund processed on [DATE] for the amount $664.63. This was approximately 3 months and 19 days after the resident's discharge from the facility. Photographic Evidence Obtained. An interview was conducted with the BOM on [DATE] at 12:50 PM, who was asked to describe the refund process. She explained that when a patient is discharged (or expired), the facility has 30 days to refund any money that was due to the resident or to their family. She said she provided a package for each resident to the corporate office who in turn processes their refunds. The BOM stated on [DATE] at approximately 2:50 PM, that the requested reports of the refunds were just sent to the facility by the corporate office. The surveyor and the BOM reviewed the refund dates (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 2 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 04/22/2025 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)