Pine Forest Health and Rehabilitation

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the call lights were within reach for two (2) of five (5) residents, Resident #1 and Resident #2. Findings Included:Review of the facility policy titled Call Light Standard with revision date 03.2019 (March 2019) revealed, The purpose of this standard is to assure the facility is adequately equipped with a call light at each resident's bedside .to allow residents to call for assistance .1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light .5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . [...]

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to maintain a safe, functional, and comfortable kitchen environment for staff and failed to ensure the kitchen's air-conditioning system was repaired promptly. The deficient practice had the potential to affect all residents served by the facility's dietary department and all dietary staff required to work in the kitchen while the air-conditioning system remained inoperable.

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to prevent the possibility of spreading infection during Activities of Daily Living (ADL) care for one (1) of four (4) care observations. Resident #7. Findings Include:Record review of facility policy Hand Hygiene with a revision date of 5/2023 revealed, .Staff involved in direct resident contact shall perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. On 5/27/26 at 3:00 PM, an observation of Activities of Daily Living (ADL) care was conducted for Resident #7 with Certified Nursing Assistant (CNA) #1. CNA #1 entered the resident's room carrying supplies and was not wearing a gown. She did not perform hand hygiene upon entering the room. [...]

Inspectors wroteBased on facility policy review, record review and interview the facility failed to notify the Resident Representative (RR) of a change in condition for one (1) of four (4) sampled residents with falls. Resident #1. Findings Included:Record review of the facility provided Nursing Home Residents' Rights, undated, revealed Residents of nursing homes have rights that are guaranteed to them under Federal and State laws. Choice about designating a representative to exercise his or her rights. Right to be Fully Informed of. Changes to the plan of care, or in medical or health status. Record review of the facility policy titled, Resident Rights & Dignity Management with a revision date of September 2025 revealed .3. The resident has the right to be informed of, and participate in, his or her treatment, including c. [...]

Inspectors wroteBased on facility policy review, record review, and interviews the facility failed to evaluate, assess and identify potential injury for one (1) of four (4) residents who experienced a fall. Resident #1. Findings Included:Record review of the facility policy titled Falls Standard with Revision Date February 2018 revealed the policy stated, When a resident is found on the floor the facility is responsible for investing the reason for this. PROCEDURE POST-FALL.Obtain blood pressure and pulse while resident is on the ground. Do neuro-checks (assessment of resident's pupil equality and level of consciousness) for witnessed head injury or unwitnessed fall with or without injury. Move resident in bed or chair only if no obvious injury. Nursing to complete: Fall Risk Assessment form, Incident report. Accident/incident report, Post Fall Investigation report. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the resident environment was free of accident hazards by failing to follow secure a wheelchair during van loading, which resulted in an avoidable accident that caused a scapular fracture and multiple rib fractures for one (1) of three (3) sampled residents (Resident #1). Findings Included:Review of the facility's policy Facility Vehicle Standard revised October 2025, revealed .Van Operation Standard The facility shall provide safe transportation for residents. Procedures.2. Loading and unloading residents. E. Follow manufacturer's instructions for operating the lift. 1. Load wheelchair onto lift.b. Lock brakes. C. In the event of a health emergency, the following steps will be followed: 1. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to implement the care plan for two (2) of (2) sampled residents related to participation in structured activities. (Resident #1 and Resident #2). Findings Include:A record review of the facility policy, Resident Rights & Dignity Management, revised 5/22, revealed on page 30: 1. The resident has a right to a dignified existence, self-determination and .3. Planning and Implementing Care .iv. The right to receive the services and/or items included in the care plan. On 9/3/25, between 9:33 AM and 11:30 AM, the State Agency (SA) observed Resident #1 in a Geri-chair and Resident #2 in a wheelchair sitting in the dayroom with no care planned or structured activity present. [...]

Inspectors wroteBased on observations, interviews, record review and facility policy review, the facility failed to ensure residents were provided with activities designed to meet their physical and mental needs and interest for two (2) of (2) residents reviewed for activities. (Resident #1 and Resident #2).

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to protect the resident's rights to be free from neglect when the resident eloped from the facility unsupervised and unmonitored and made her way to the middle of a busy intersection for (1) of 24 residents sampled. Resident #211 The facility's failure to ensure that Resident #211 was unable to exit the facility unsupervised resulted in her running into the middle of a busy intersection located at an intersection near the facility, placing the resident in a situation that was likely to cause serious injury serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/4/25, when Resident #211 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 6/5/25 at 11:40 AM. [...]

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention for one (1) of twenty-four (24) sampled residents. (Resident #211). This failure resulted in Resident #211 eloping from the building on 6/4/25, for an estimated 600 feet, and being found seated on the back of a trailer in a public intersection surrounded by traffic, thereby placing the resident in Immediate Jeopardy (IJ) for serious injury, harm, impairment, or death. This situation was determined to be IJ and Substandard Quality of Care (SQC), which began on 06/04/25 when Resident #211 eloped from the facility. [...]

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to implement a comprehensive care plan for two (2) of 24 residents reviewed. Resident # 41 and Resident #98.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection during Percutaneous Endoscopic Gastrostomy (PEG) care for Resident #14 and during suprapubic catheter care for Resident #62 for two (2) of five (5) care observations.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide wound care in a manner to promote healing and prevent infection for one (1) of three (3) residents reviewed for wound care. Resident #98. Findings Include: A record review of the facility's policy titled Skin Management Standards, revised April 2021, revealed Bacteria are present on all skin surfaces. When the primary defense provided by intact skin is lost, bacteria will reside on the wound surface. Follow infection control policies to prevent self-contamination and cross-contamination in individuals with pressure ulcers. Record review of the facility policy Skin Management Standards dated 04/2021 revealed .Protocol .3. Change dressing as ordered per physician . [...]

Inspectors wroteBased on record reviews and interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place in December 2023. This was for two (2) recited deficiencies originally cited in December 2023 on an annual recertification survey. The deficiencies were in the area of the care plan not being followed and infection control. The continued failure during two surveys shows a pattern of the facility's inability to sustain an effective QAPI Committee for two (2) of seven (7) deficient practice citations. Findings Include: Record review of the facility's policy, Quality Assessment and Performance Improvement, September 2019, revealed, .It is the standard of this facility to .c. Develop and implement appropriate plans of action to correct identified quality deficiencies . F656: [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to provide incontinent care in an appropriate manner to related to bowel and bladder care for one (1) of 24 residents reviewed. Resident #98.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical abuse for one (1) of five (5) sampled residents when Certified Nurse Aide (CNA) #1 used physical force with Resident #1, who was cognitively impaired and had right hemiparesis, was observed with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead following an incident in which CNA #1 admitted to pressing down on Resident #1's left arm (the only functional arm) and using physical force on his face to prevent the resident from hitting her. Findings Included: [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure comprehensive care plan interventions were implemented regarding a resident's behavior during care for one (1) of five (5) sampled residents when Certified Nurse Aide (CNA) #1 used physical force with Resident #1, who was cognitively impaired and had right Hemiparesis, was observed with purplish-red discoloration under the right eye, abrasions on the nose, and a hematoma on the forehead following an incident in which CNA #1 admitted to pressing down on Resident #1's left arm (the only functional arm) and using physical force on his face to prevent the resident from hitting her during care.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to secure a resident in a mechanical lift and maintain necessary supervision during a transfer resulting in a laceration requiring staples and Emergency Department (ED) visit for one (1) of seven (7) sampled residents.

Inspectors wroteBased on observation, interviews, and record review, the facility policy review, the facility failed to ensure the call lights were within reach for two (2) of seven (7) residents, Resident #3 and Resident #6. Findings Included: A review of the facility policy titled Call Light Standard, dated 03/2019, revealed, .The purpose of this standard is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance .Policy Explanation and Compliance Guidelines .5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed . Resident #3 On 1/15/25 at 6:13 AM, an observation and interview revealed Resident #3 was awake and resting in bed. The resident's call light was on the floor by her bed. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to acknowledge grievances, make prompt efforts to resolve grievances, and communicate progress toward resolution with families and residents for two (2) of seven (7) sampled residents. Resident #2 and Resident #3 Findings Included: A review of the facility's policy titled Resident & Family Grievances, revised 1/2025, revealed .Definitions: ; Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. Procedure 1. The Administrator is ultimately responsible for the Grievance Program. Social Service staff has been designated as the Grievance Official .8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member of Grievance Official .d. [...]

Inspectors wroteBased on observations, record review, policy review and interviews the facility failed to implement a resident's individualized care plan for Activities of Daily Living (ADL) care related to personal hygiene for four (4) of seven (7) sampled residents. Residents #1, Resident #5, Resident #6, and Resident #7.

Inspectors wroteBased on observations, interviews, facility policy review,and record review, the facility failed to ensure dependent residents received necessary services to maintain adequate grooming, related to nail care and removal of unwanted facial hair for four (4) of seven (7) sampled residents. Residents #1, Resident #5, Resident #6, and Resident #7

Inspectors wroteBased on observations, interviews, record review, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee as evidenced by two (2) re-cited deficiencies, originally cited in December 2023, on an annual recertification survey.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from neglect for five (5) of 22 residents reviewed as evidenced by facility staff: 1. Did not provide Pressure Ulcer (PU) assessments and care and treatment to prevent complications and worsening of PUs (Resident #53 and Resident #89) 2. Turn and reposition a resident (Resident #87) 3. Ensure incontinent residents were clean and dry (Resident #1 and Resident #31). The facility's neglect to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions as evidenced by: (1) the failure to develop comprehensive care plan interventions for residents with pressure ulcers (PUs) (Resident #53 and Resident #89), (2) the failure to ensure a resident was turned and repositioned (Resident # 87), (3) the failure to ensure residents were clean and dry (Resident #1 and #31), and (4) the failure to ensure nail care was provided to dependent residents (Resident #23 and Resident #41), for six (6) of 22 care plans reviewed. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to revise resident-centered comprehensive care plan interventions for residents with Pressure Ulcers (PUs) to prevent worsening or complications from PUs for two (2) of 22 care plans reviewed. (Resident #53 and Resident #89). The facility's failure to revise comprehensive care plan interventions related to PU care put Resident #53, Resident #89, and all other residents with skin breakdown in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility, and was not assessed by a qualified nurse or practitioner until 9/18/23, causing a PU to worsen. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed and received care and treatment for Pressure Ulcers (PUs) to prevent complications and worsening of PUs for two (2) of four (4) residents reviewed for PUs. Resident #53 and Resident #89. The facility's failure to provide wound assessments, documentation, and wound care treatment resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 8/29/23 when Resident #53, who had existing PUs, was admitted to the facility and was not assessed by a qualified nurse or practitioner until 9/18/23, causing the wound to worsen. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the clinical staff were educated and trained on staging Pressure Ulcers (PUs), providing complete and accurate wound assessments, and implementing appropriate treatments for identified wounds for two (2) of four (4) residents reviewed for PU care. Resident # 53 and Resident #89. The facility's failure to ensure staff were competent with PU assessments, documentation, and treatments resulted in harm to Resident #53 and Resident #89 and put all other residents at risk for skin breakdown in a situation that was likely to result in serious harm, injury, impairment, or death. [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to honor residents' rights or choices, as evidenced by the resident having to remain in his room despite his request to get up to socialize and participate in activities for one (1) of twenty-two (22) sampled residents.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to provide adequate and appropriate Activities of Daily Living (ADL) care for two (2) of twenty-two (22) sampled dependent residents. Residents #23 and #41.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide the care and services necessary for a resident with limited range of motion as evidenced by failure to apply a right elbow extensor splint to a resident's arm for one (1) of 22 sampled residents. Resident #87. Findings Include: During an observation on 11/27/23 at 10:27 AM, revealed Resident #87 lying in bed with the head of bed elevated and lying on his back at a 45 degree angle. Resident #87's right arm was bent and had no splint or any device on his arm. During an interview on 11/28/23 at 9:00 AM, with Resident #87's sister she complained that the facility has not been putting the resident's right arm extensor splint on. The sister said she is afraid Resident #87 will decline. The State Agency (SA) observed the splint in the chest of drawers in the resident's room. [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to provide food that accommodates food preferences and options of similar nutritive value to residents who prefer not to eat food that is initially served or who request a different meal choice for two (2) of 22 residents reviewed for food preferences: Resident #23 and #67.

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to provide proper incontinent care to prevent infection, ensure catheter bags were not lying on the floor and staff were wearing proper Personal Protective Equipment (PPE) when entering a COVID-19 positive resident's room for three (3) of 22 residents reviewed. Resident #63, Resident #75 and Resident #249 Findings Include: Review of the facility's policy, Standard Precautions Infection Control, dated 5/2023 revealed It is our standard to assume that patients are potentially infected or colonized with an organism that could be transmitted during providing patient care services and therefore our facility applies the Standard Precautions, infection control practices . Review of the facility's policy Infection Control Standard dated 5/2023 revealed Component: Hand Hygiene- Practices: [...]

Inspectors wroteBased on interviews, record review and facility policy review the facility failed to ensure dependent residents received the COVID-19 vaccine in a timely manner for four (4) of 22 sampled residents reviewed for COVID-19. Resident #11, #43, #87 and #89.

Inspectors wroteBased on observations, interviews, record review, policy review, dietary meal slips, and Resident Rights, the facility failed to honor resident choices related to food preferences for one (1) of 17 residents, Resident #46.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review the facility failed to maintain safekeeping of resident's belongings for one (1) of 17 residents, Resident #29.

Inspectors wroteBased on staff and resident interviews, record reviews, and facility policy review the facility failed to report an allegation of marijuana use in a timely manner to local police department and the Attorney General's Office for one (1) of 17 residents reviewed, Resident #25.

Inspectors wroteBased on staff and resident interviews, record reviews, and facility policy review the facility failed to report an allegation of marijuana use in a timely manner to the State Agency for one (1) of 17 residents, Resident #25.

Inspectors wroteBased on observation, staff interview, record review, Resident' s Rights, and the Certified Nursing Assistant Job Description, the facility failed to provide Activities of Daily Living (ADL) care for two (2) of 17 residents observed for ADL care, Residents #46 and #55.

Inspectors wroteBased on staff interviews, record reviews, facility policy review, the facility failed to supervise residents, as evidenced by a resident testing positive for cannabis on 1/3/21 for one (1) of 17 residents, Resident #25.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to have a less than five (5) percent medication error rate by failure to administer respiratory inhalers per manufactures guidelines for two (2) of 25 medication administration observations resulting in a 8.8% medication rate for Residents #42 and #63.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to prevent the possible spread of infection for one (1) of four (4) incontinent care observations, Resident #44.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review the facility failed to ensure equipment was maintained in a safe manner for one (1) of 17 room observations, Resident #40.