Inspection Reports for Tierra Pines Center
7380 Ulmerton Rd, Largo, FL 33771, FL, 33771
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 30, 2025, found deficiencies related to PASARR screening and care plan incorporation, wound care management, assistance with shaving, and kitchen sanitation monitoring. Earlier inspections showed recurring issues with maintenance of equipment and resident environment, including laundry machines, kitchen cleanliness, damaged wheelchairs, and water damage in resident rooms. Prior reports also cited deficiencies in trauma-informed care, medication administration, infection control, and medication storage. Complaint investigations were not listed in the available reports. The pattern of findings suggests ongoing challenges in both resident care and facility maintenance without a clear trend of improvement or worsening.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
5.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
13% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 5
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, PASARR screening, activities of daily living, wound care, and food sanitation at Tierra Pines Center.
Findings
The facility failed to incorporate PASARR Level II recommendations into care plans, had incomplete and outdated PASARR screenings for multiple residents, failed to provide adequate assistance with shaving facial hair for residents, and failed to properly manage wound care and follow physician orders for some residents. Additionally, the facility failed to ensure proper monitoring of sanitation solution for the dish machine in the kitchen.
Deficiencies (5)
Failed to ensure recommendations from PASRR Level II were incorporated into the care plan for one resident.
Failed to complete/update PASARR screenings for residents with mental disorders or intellectual disabilities.
Failed to provide or assist with shaving facial hair for two residents.
Failed to stop bleeding, protect wounds from infection, and promote healing for one resident and failed to follow physician orders related to wound care for another resident.
Failed to ensure proper monitoring of sanitation solution for the dish machine in the facility kitchen.
Report Facts
Residents reviewed for PASARRs: 12
Residents affected by PASARR deficiencies: 8
Residents reviewed for ADL shaving care: 3
Residents affected by ADL shaving care deficiency: 2
Residents reviewed for wound care: 6
Residents affected by wound care deficiencies: 2
Dish machine sanitation level: 50
Dish machine wash temperature: 125
Dish machine rinse temperature: 123
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding PASARR deficiencies, ADL shaving care, wound care, and facility policies | |
| Social Service Director (SSD) | Interviewed regarding PASARR deficiencies | |
| Social Service Assistant (SSA) | Interviewed regarding PASARR deficiencies | |
| Certified Nursing Assistant (CNA) Staff E | Interviewed regarding shaving assistance for residents | |
| Certified Nursing Assistant (CNA) Staff B | Interviewed regarding shaving assistance for residents | |
| Licensed Practical Nurse (LPN) Staff C, Unit Manager | Interviewed regarding shaving assistance for residents | |
| Registered Nurse (RN) Staff D | Interviewed regarding wound care | |
| Licensed Practical Nurse (LPN) Staff H, wound care nurse | Interviewed regarding wound care orders | |
| Physician Assistant (PA) for Resident #73 | Interviewed regarding wound care orders and skin condition | |
| Certified Dietary Manager (CDM) | Interviewed regarding dish machine sanitation monitoring | |
| Dietary Aide Staff F | Interviewed and observed dish machine sanitation | |
| Nursing Home Administrator (NHA) | Interviewed regarding dish machine sanitation monitoring | |
| Licensed Practical Nurse (LPN) Staff I | Interviewed regarding wound care documentation |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 15, 2024
Visit Reason
The inspection was conducted to assess the facility's maintenance of essential equipment, including laundry washers and dryers, kitchen stove cleanliness, exhaust hood condition, and garbage disposal functionality.
Findings
The facility failed to maintain essential equipment as evidenced by one of two laundry washers not working, two of three laundry dryers not working, an unclean gas stove, peeling paint on the exhaust hood, and a leaking garbage disposal. Maintenance issues were compounded by a recent resignation of the Maintenance Director and lack of maintenance requests in the electronic system.
Deficiencies (5)
One of two laundry washers not working
Two of three laundry dryers not working
One unclean gas stove with heavy black debris and drippings
Exhaust hood with peeling paint over stove
Leaky garbage disposal
Report Facts
Laundry washers: 2
Laundry dryers: 3
Laundry washers not working: 1
Laundry dryers not working: 2
Gas stove burners: 6
Peeling paint on exhaust hood: 20
Garbage disposal pan size (inches): 24
Garbage disposal pan size (inches): 18
Garbage disposal pan size (inches): 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Laundry Aid #1 | Interviewed regarding laundry equipment issues |
| Staff B | Laundry Aid #2 | Interviewed regarding laundry equipment issues |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Confirmed unclean stove surface and leaking garbage disposal |
| Senior Dietary Manager | Senior Dietary Manager (SDM) | Participated in kitchen tour |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided information about maintenance staffing and equipment repairs |
| Interim Maintenance Director | Interim Maintenance Director | Provided details on maintenance issues and work orders |
Inspection Report
Deficiencies: 3
Date: Oct 31, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulations regarding the maintenance and cleanliness of resident spaces and equipment, including wheelchairs, over the bed tables, and resident rooms, following observations of damaged and unsanitary conditions.
Findings
The facility failed to ensure resident spaces and equipment were clean and maintained, with twelve of thirty-three wheelchairs having cracked and torn armrests, three of seven over the bed tables with peeled and uneven surfaces, and one resident room exhibiting heavy water saturation damage with biogrowth on walls and ceiling. Maintenance work orders related to some repairs were closed but did not address the current issues observed.
Deficiencies (3)
Twelve of thirty-three wheelchairs observed with cracked and torn armrests.
Three of seven resident room over the bed tables observed with peeled surfaces and uneven surfaces.
One resident room observed with heavy water saturation damage with biogrowth on both the door wall and the ceiling.
Report Facts
Wheelchairs with cracked armrests: 12
Over the bed tables with peeled surfaces: 3
Work orders related to room repairs: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding maintenance work orders and facility repairs | |
| Nursing Home Administrator | Provided maintenance work order report and facilitated interview | |
| Director of Nursing | Provided maintenance work order report | |
| Regional Nurse Consultant | Provided Maintenance Service policy and procedure |
Inspection Report
Routine
Deficiencies: 10
Date: Dec 8, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication management, infection control, staffing competencies, food safety, call system functionality, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to implement trauma-informed care plans for residents with PTSD, inadequate respiratory care and oxygen management, lack of staff competencies related to trauma care, failure to provide rationale for disagreement with pharmacist recommendations, improper medication administration practices, unsanitary kitchen conditions including malfunctioning dishwashing sanitizer and ice buildup in freezers, improper use and storage of clean linen carts, failure to ensure staff wore appropriate PPE during a COVID-19 outbreak, and malfunctioning resident call light systems in multiple rooms and bathrooms.
Deficiencies (10)
Failure to implement trauma-informed care plans for residents with PTSD diagnosis.
Failure to provide safe and appropriate respiratory care including not notifying physician of respiratory distress and not following oxygen orders.
Failure to ensure staff possessed competencies and skills to meet behavioral health needs related to trauma/PTSD.
Failure to ensure attending physician provided rationale for disagreeing with pharmacist recommendations.
Failure to follow proper medication administration practices including handling pills with ungloved hands and not sanitizing blood pressure cuffs between residents.
Failure to maintain kitchen in sanitary manner including malfunctioning dishwashing sanitizer delivery, inadequate wash temperatures, ice buildup in walk-in freezer, and black bio growth on kitchen wall.
Failure to ensure clean linen carts were free of staff belongings and resident hygiene products.
Failure to ensure staff wore appropriate PPE during COVID-19 outbreak and infection control lapses including improper mask use and failure to sanitize equipment.
Failure to ensure residents understood arbitration agreements and their rights to refuse.
Failure to ensure functioning call light systems were available in resident rooms, bathrooms, and bathing areas.
Report Facts
Pharmacist recommendations: 4
Residents positive for COVID-19: 15
Call light audit date: Dec 6, 2022
Dish washing machine wash temperature: 115
Dish washing machine rinse temperature: 120
Ice buildup size: 7
Ice buildup size: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff H | Licensed Practical Nurse | Observed with stained mask, improper PPE use, and medication administration lapses. |
| Staff K | Certified Nursing Assistant | Observed failing to don PPE entering isolation room and not performing hand hygiene. |
| Staff O | Certified Nursing Assistant | Interviewed regarding care of Resident #73 with PTSD and lack of training. |
| Staff E | Registered Nurse/Unit Manager | Interviewed regarding behavior monitoring and infection control practices. |
| Regional Clinical Director | Interviewed regarding Resident #73's care and trauma history. | |
| Nursing Home Administrator | Interviewed regarding arbitration agreements and facility policies. | |
| Dietary Manager | Interviewed regarding kitchen sanitation and dishwashing machine issues. | |
| Staff I | Dietary Aide | Observed operating dishwashing machine without sanitizer. |
| Staff J | Dietary Aide | Observed operating dishwashing machine without sanitizer. |
| Staff G | Registered Nurse | Interviewed regarding isolation precautions and call light system issues. |
| Staff C | Licensed Practical Nurse/Unit Manager | Interviewed regarding call light system audit and maintenance. |
| Staff L | Registered Nurse | Observed medication administration lapses and improper sanitization. |
| Consultant Pharmacist | Interviewed regarding medication regimen review process. |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 9, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening, care plan implementation, medication storage, and other resident care standards at Tierra Pines Center.
Findings
The facility failed to ensure appropriate PASARR level II referrals for residents with mental illness, did not fully implement care plans for wandering and contracture management, and improperly stored controlled medications in an unlocked refrigerator without a permanently affixed locked box.
Deficiencies (3)
Failed to ensure residents were referred to the appropriate state designated authority for PASARR level II review when mental illness was evident after admission.
Failed to implement care plans for two residents related to adult monitoring device use and contracture management, including lack of documentation and non-use of prescribed splints.
Did not ensure that 4 vials of Lorazepam, a Schedule IV medication, were stored in a permanently affixed locked compartment separate from other medications in a locked refrigerator.
Report Facts
Residents sampled: 32
Residents affected: 4
Residents affected: 2
Vials of Lorazepam: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Licensed Practical Nurse (LPN) | Reported Resident #87 often wandered and had an order for an adult monitoring device |
| Staff B | Certified Nursing Assistant (CNA) | Reported not responsible for checking the adult monitoring device |
| Staff C | Registered Nurse (RN) | Reported no order or documentation for checking adult monitoring device functioning |
| Director of Nursing (DON) | Reported family concerns about Resident #60 not wearing splints and acknowledged missing splint | |
| Director of Therapy (DOT) | Reported Resident #60 had bruising and family requested to hold off on splint use | |
| Consultant Pharmacist | Noted improper storage of controlled substances and planned to work with facility to correct |
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