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Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 165 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
This facility has areas of concern that warrant careful consideration. Registered Nurse hours are 48% of the EveryPlace reference benchmark; ask how RN coverage is allocated across shifts. We recommend asking the administrator directly: "How are you addressing recent staffing shortfalls?" These are not reasons to panic, but they are reasons to ask tough questions and visit in person.
Tierra Pines Center receives highly polarized feedback, with many families praising the facility for its clean environment, friendly administrative staff, and effective physical therapy programs. However, a significant number of reviewers report serious concerns regarding inconsistent nursing care, poor food quality, and understaffing that leads to delayed responses to patient needs. Families should be aware that while many have positive experiences, there is a recurring pattern of complaints regarding basic hygiene and responsiveness.
Quality Themes
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Concerns
Rating Trends
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Distribution · 169 analyzed
This facility actively engages with reviewer feedback.
Personalized based on this facility's data
Key Review Excerpts
“The physical therapy room and the therapists are outstanding. I truly appreciate the care and attention my mother received.”
“Staff are very nice, but very clearly stretched thin. We couldn't get help for our relative that had soiled his clothes for about 20 minutes, and several patients had feces/other fluids that couldn't get help until we let the nurses know.”
“My mom lives here and they take very good care of her (she is 92 and has dementia). The community is clean and unkept. My only complaint would be the food.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
7
measures
6
measures
4
measures
Residents on antipsychotic medication
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Residents whose bladder or bowel control got worse
Residents vaccinated for pneumonia
Residents who lost too much weight
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
Tierra Pines Center has recurring issues across multiple areas, with families filing complaints that triggered inspections regarding equipment safety and living conditions. The facility shows persistent problems with fire safety systems, care planning, and food safety across surveys from 2021-2025. While all deficiencies have correction dates, the pattern of repeated violations in safety systems and basic care areas suggests ongoing operational challenges families should carefully consider.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Emergency Preparedness Deficiencies
Establish policies and procedures including evacuation.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Environmental Deficiencies
Keep all essential equipment working safely.
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Egress Deficiencies
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.
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Federal Penalties
Fine
Jan 30, 2025
$4,147
Tierra Pines Center
for profit
Aston Health
38 facilities nationwide
Chain avg rating: 2.5/5 · Rank 14 of 30
Owners
Tierra Pines Holdco LLC
Owner · Organization
Gabriel Living Center, LLC
Owner (parent company) · Organization
Lce Partners LLC
Owner (parent company) · Organization
Friedman, Leopold
Owner (parent company)
Gutman, Samuel
Owner (parent company)
Key personnel
Contact this facility directly and verify the details that matter most to your family.
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Google Reviews
165 reviews from families & visitors
Official Website
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EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Some summaries, interpretations, suggested questions, and pricing research are AI-generated or AI-assisted and may contain errors or omit important context. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.
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