Pine Forest Car Center for Rehab & Healthcare

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (2633011) the facility failed to ensure that each resident received adequate supervision to prevent accidents. This was identified for ten (10) of 12 residents: Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, reviewed for Accidents. 1) Specifically, Resident #1 and Resident #2 went out on a pass together into the community, signed out by Resident #2 as the responsible party on six (6) different dates in August 2025, and then again on September 30, 2025. On 09/30/2025, Resident #1 and Resident #2 did not return to the facility at the designated time of 3:00 PM. They were found on 10/01/2025 at approximately 10 AM. [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey (Intake ID 2645865) initiated on 10/17/2025 and completed on 11/06/2025, the facility failed to ensure that a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or attain the highest practicable mental and psychosocial well-being. This was identified for one (1) (Resident #1) of twelve (12) sampled residents. Specifically, Resident #1 was assessed as having wandering and exit seeking behavior. Resident #1 had a significant emotional experience after which there was an increase in wandering behavior. [...]

Inspectors wrotei) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in S483.15(c)(1)(ii). [...]

Inspectors wroteNTENT The intent is for the facility to develop and implement policies and procedures that: Provide annual notification to each covered individual of their obligation to comply with the reporting requirements under section 1150B(b) of the Act; Ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Act; and Ensure that all covered individuals, i.e., the owner, operator, employee, manager, agent or contractor, report reasonable suspicion of crimes, as required by Section 1150B of the Act. The facility should provide oversight and monitoring to ensure that implement the required policies and procedures, per 42 CFR S483.12(b). [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (2633011) initiated on 10/27/2025 and completed on 11/06/2025, the facility did not ensure that a comprehensive person-centered care plan was developed and implemented for each resident that included measurable objectives and timeframes to meet each resident's medical and nursing needs. This was identified for eleven (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11) of eleven residents reviewed for accidents. Specifically, 1) the facility's out-of-pass form documented that Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, and Resident #11 went out on pass multiple times and dates. [...]

Inspectors wroteINTENT S483.30(a) The intent of this regulation is to ensure the medical supervision of the care of each resident by a physician and that orders for the resident's immediate care and needs are provided throughout the resident's stay. DEFINITIONS S483.30(a) Attending physician refers to the primary physician who is responsible for managing the resident's medical care. This does not include other physicians whom the resident may see periodically, such as specialists. Non-physician practitioner (NPP) is a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA). Nurse practitioner is a registered professional nurse currently licensed to practice in the State and who meets the State's requirements governing the qualification of nurse practitioners. [...]

Inspectors wroteBased on observations, record review, and interviews during the Abbreviated Survey (Intake ID 2633011 and 2645865) the facility did not ensure all drugs and biologicals were stored in a locked compartment and accurately labeled. This was identified for one (1) of two (2) facility treatment carts. Specifically, the treatment cart on the first floor was noted to be unlocked with the second drawer open in the hallway without any staff members present. The finding is: The facility policy titled Medication Storage reviewed in June 2024 documented all drugs and biologicals will be stored in locked compartments under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments. During a medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart. [...]

Inspectors wroteS483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. S483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: S483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to S483.71 and following accepted national standards; [...]

Inspectors wroteBased on observation, record review and staff interviews during an abbreviated Survey (800072) initiated on 08/19/2025 and completed on 09/11/2025, the facility did not ensure that a resident maintained, to the extent possible, acceptable parameters of nutritional and hydration status. Specifically, Resident #1's weight decreased from 190 pounds in July 2025 to 168 pounds in August 2025, a total weight loss of 22 pounds in one month. This loss of over 11.5% exceeds the Centers for Medicare & Medicaid Services (CMS) guideline for a significant weight loss of 5% in 30 days. Furthermore, there is no documented evidence that the dietician implemented new nutritional interventions to address this decline prior to the survey entrance. [...]

Inspectors wroteBased on observation, record review and staff interviews during an abbreviated Survey (800072) initiated on 08/19/2025 and completed on 09/11/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of two resident floors (Floor 2) reviewed. Specifically, Floor 2, a locked dementia care unit had a bottle of Isopropyl Alcohol 91% and over 30 pills of brand multivitamins accessible to residents.

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00366821), the facility did not ensure that an investigation of alleged abuse was thoroughly and timely investigated to prevent further potential abuse, neglect, exploitation, or mistreatment. This was identified for one (Resident #55) of two residents reviewed for Abuse. Specifically, on 12/28/2024 Resident #55 verbalized that a Certified Nursing Assistant scratched them during the morning care. There was no documented evidence that an investigation to rule out abuse, neglect, or mistreatment was initiated until 12/30/2024. The finding is: The facility Accident/Incident Report reviewed 1/2025 documented all accidents/incidents involving residents must be reported to the Director of Nursing Services and or Assistant Director of Nursing. [...]

Inspectors wroteBased on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00366821) initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet the resident's need was developed and implemented for each resident. This was identified for one (Resident #55) of five residents reviewed for Unnecessary Medications. Specifically, on 9/24/2024 Resident #55 was transferred to the hospital due to unresponsiveness. The resident was readmitted on [DATE] with a diagnosis of Opioid (class of natural, semi-synthetic, and synthetic drugs) Overdose. There was no documented evidence that a comprehensive care plan with appropriate interventions was developed to prevent further potential Opioid Overdose. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure services provided by the facility as outlined in the comprehensive care plan (CCP) must meet professional standards of quality. This was identified for one (Resident # 20) of five residents reviewed for unnecessary medications. Specifically, Resident #20 had a physician's order for Heparin (an anticoagulant) to be administered subcutaneously. The nursing staff were not rotating the injection sites when administering Heparin. Cross Reference: F755- Pharmacy Svcs/Procedures The finding is: The Policy and Procedure for Injection Site Rotation dated October 2023 documented that rotation of the injection site is required. Resident # 20 was admitted with diagnoses that included Functional Quadriplegia. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure pharmaceutical services met the needs of each resident including appropriately administering all drugs and biologicals in accordance with the professional standards of practice. This was identified for one (Resident # 21) of five residents reviewed for unnecessary medications. Specifically, Resident #21 was prescribed Heparin Sodium (Porcine) Injection Solution 5000 units per milliliter and the nursing staff administered the injection without rotating the subcutaneous injection sites. Cross Reference: F658- Services Provided Meet Professional Standards The finding is: The Policy and Procedure for Injection Site Rotation dated October 2023 documents that rotation of the injection site is required. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task. Specifically, 1) several food items were stored in the walk-in refrigerator and walk-in freezer without proper labeling and dating; multiple frozen item bags were observed with ice and frost inside their packaging; Additionally, a plastic container and milk crates in the dry storage area were observed to be dirty. 2) Cold food items including yogurt, milk, chicken salad sandwich, and egg salad temperatures were observed above 41 degrees Fahrenheit.

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that a clean, comfortable, and homelike environment was maintained on one of two resident floors. Specifically, two rooms on the first floor had holes in the wall. 1) Resident #10's room was observed on 1/17/2024 and 1/18/2024 with a nine-inch by nine-inch square hole in the wall behind the room entrance door and a one-inch by half of an inch hole to the bathroom door. 2) Resident #34's room was observed on 1/17/2024 and 1/18/2024 with a one-inch by half-inch hole in the wall behind the door.

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey and Abbreviated Survey (Complaint #NY 00323806) initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health. This was identified for one (Resident #14) of three residents reviewed for Abuse. Specifically, the facility did not report an allegation of verbal abuse to the New York State Department of Health, when Resident #14 complained that Certified Nursing Aide #2 made a derogatory remark towards them. The resident stated the remark left them feeling threatened for their well-being, disrespected, and angry. The finding is: [...]

Inspectors wroteBased on record review and interviews conducted during a Recertification Survey and Abbreviated Survey (Complaint #NY 00323806) initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that all alleged violations are thoroughly investigated in response to allegations of abuse. This was identified for one (Resident #14) of three residents reviewed for Abuse. Specifically, Resident #14 reported on 1/5/2023 to the Director of Nursing Services that they (Resident #14) were verbally abused by Certified Nursing Aide #2 a few months ago. The facility did not initiate an investigation of the allegation according to the facility policy to rule out abuse. The finding is: [...]

Inspectors wroteBased on observations, record review and staff interviews during the Recertification Survey initiated on 1/17/2024 and completed on 1/23/2024, the facility did not ensure that a resident who needs respiratory care is provided such care consistent with professional standard of practice. This was identified for one (Resident #22) of three residents reviewed for Respiratory Care. Specifically, Resident #22 had a Physician's order for Oxygen to be administered at 2 Liters per minutes via nasal cannula. On 1/18/2024 and on 1/19/2024 the resident was observed receiving 4 Liters of Oxygen, not 2 Liters of Oxygen therapy as prescribed by the Physician. The finding is: The facility's Oxygen Administration Policy dated 10/2023 documented an order will be obtained from the Physician for Oxygen use and to adjust the oxygen gauge to the prescribed flow rate as per the Physician's order. [...]

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification Survey initiated on 1/17/2024 and completed 1/23/2024, the facility did not ensure that each residents' environment remains as free of accident hazards as is possible. This was identified for one (Resident #11) of three residents reviewed for Accidents. Specifically, Resident #11 was not assessed to safely self-administer medications. During multiple observations on 1/17/2024 at 11:20 AM, 1/19/2024 at 12:29 PM, and on 1/22/2024 at 10:30 AM Resident #11 was observed with physician ordered medications in their room with no staff member in the vicinity. The finding is: The facility policy titled Medication Administration dated 10/31/2023 documented the nurse will observe the resident's consumption of medication. [...]

Inspectors wroteBased on observations, record review and interviews during the Recertification Survey completed on 2/3/2022 the facility failed to ensure that an Infection Prevention Control Program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for three (Resident #34, #20, and #60) of four residents observed during a medication pass observation conducted on the first-floor Nursing Unit. Specifically, during the medication pass observation the Licensed Practical Nurse (LPN) #1 placed the blood pressure cuff on Resident #34, Resident #20, and Resident #60's bare arms while taking their blood pressure without sanitizing the blood pressure cuff between the residents. The finding is: LPN #1 was observed during a medication pass on the first floor Nursing Unit on 2/1/2022 at 9:30 AM. [...]