Inspection Reports for Pine Forest Center for Rehabilitation and Healthcare

The abbreviated survey was initiated based on complaints regarding failure to notify physicians of significant resident changes, failure to report incidents timely, inadequate care planning, inadequate supervision leading to accidents, and infection control breaches. Substantiation status is not explicitly stated.

The facility was found deficient in multiple areas including failure to promptly notify physicians of significant resident changes, failure to timely report suspected abuse and incidents to authorities, inadequate development and implementation of comprehensive care plans, inadequate supervision to prevent accidents resulting in immediate jeopardy, failure to ensure residents were under physician care with appropriate orders, failure to provide appropriate treatment for residents with mental disorders, failure to secure medications properly, and failure to maintain an effective infection prevention and control program.

Inspection identified two standard health deficiencies related to accident hazards and nutrition/hydration status, both Level 2 severity and isolated scope.

The facility failed to ensure a resident maintained acceptable nutritional and hydration status, evidenced by significant unaddressed weight loss, and failed to maintain a safe environment free of accident hazards, as a dementia care unit resident had access to potentially harmful substances including isopropyl alcohol and multivitamins at bedside.

Multiple standard health and life safety code deficiencies identified, all Level 2 severity and mostly isolated scope, with some widespread and pattern scopes. All deficiencies were corrected by March or April 2025.

The complaint involved Resident #55 alleging that a Certified Nursing Assistant scratched them during care on 12/28/2024. The facility did not initiate an investigation until 12/30/2024. Interviews with involved staff and the resident revealed conflicting accounts. The Director of Nursing Services and Nurse Practitioner assessed the resident on 12/30/2024 and initiated an investigation. Registered Nurse #2 failed to document the assessment or start an investigation timely.

The facility failed to ensure a timely and thorough investigation of alleged abuse involving Resident #55, specifically a delayed investigation of an alleged scratch by a Certified Nursing Assistant. Additionally, the facility did not develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes to address Resident #55's opioid overdose and prevent further occurrences.

The facility failed to ensure timely and thorough investigation of alleged abuse for Resident #55, did not develop a comprehensive care plan addressing opioid overdose for Resident #55, failed to rotate injection sites for Heparin administration for Resident #20, and did not maintain proper food storage, labeling, and cold food temperatures in the kitchen.

Complaint #NY 00323806 initiated the survey due to allegations of verbal abuse by Certified Nursing Aide #2 towards Resident #14. The complaint was substantiated as the facility failed to report the incident and conduct a proper investigation according to policy.

The facility failed to timely report and thoroughly investigate an allegation of verbal abuse made by Resident #14 against Certified Nursing Aide #2. The investigation was incomplete, no occurrence report was documented, and the incident was not reported to the New York State Department of Health as required. Additionally, the facility failed to ensure Resident #11's environment was free from accident hazards by allowing medications to be left unattended at the bedside without proper supervision or physician orders for self-administration.

The facility was found deficient in maintaining a safe, clean, and homelike environment due to holes in resident rooms; failure to timely report and investigate an allegation of verbal abuse; and failure to provide respiratory care consistent with physician orders, specifically administering oxygen at a higher flow rate than prescribed.

One standard health deficiency related to accident hazards with Level 3 severity and isolated scope, corrected by June 23, 2023.

The facility failed to ensure the effectiveness of a window restrictor screw, allowing Resident #1, who had a history of elopement and suicidal ideation, to open the window and jump out, sustaining multiple fractures and actual harm. The facility's policies on accident prevention and maintenance were reviewed, but daily window checks were inadequately documented and the window was found to be damaged, allowing it to open beyond the safety limit.

One standard health deficiency related to abuse and neglect with Level 2 severity and isolated scope, corrected by June 24, 2022.

The facility failed to maintain an effective Infection Prevention Control Program, as evidenced by a Licensed Practical Nurse not sanitizing the blood pressure cuff between residents during medication pass observations.