HUNTINGTON, NY - Pine Forest Care Center for Rehab & Healthcare faced multiple health and safety citations during a February 2025 federal inspection, with violations ranging from improper medication administration to food storage and temperature control failures.
Injection Site Rotation Violations Lead to Resident Bruising
The most serious violation involved improper administration of blood-thinning medication to a quadriplegic resident. Federal inspectors found that nursing staff repeatedly failed to rotate injection sites when administering Heparin, a critical blood-thinning medication used to prevent dangerous blood clots.
Resident #20, who has functional quadriplegia, was prescribed Heparin sodium injections twice daily as a preventive measure. However, medication administration records revealed that staff consistently administered the injections to the same location on the resident's lower left abdomen over multiple consecutive days throughout January and February 2025.
During the inspection, surveyors observed a quarter-size bruise on the resident's lower left abdomen where the repeated injections had been given. The resident told inspectors they "do not monitor where they get their injections," highlighting their dependence on staff to follow proper protocols.
The facility's own policy, dated October 2023, clearly required rotation of injection sites. This standard practice is essential because Heparin injections administered repeatedly in the same location can cause tissue damage, excessive bruising, and potential complications that could affect the medication's effectiveness.
Medical Significance of Proper Injection Technique
Heparin is a powerful anticoagulant medication that prevents blood clots, which can be life-threatening for immobilized residents like those with quadriplegia. The subcutaneous injection must be rotated to different sites on the abdomen, arms, or thighs to prevent localized tissue damage and maintain proper medication absorption.
When injection sites are not rotated, several serious complications can occur. The repeated trauma to the same tissue area can cause hardening of the tissue, making it difficult for the medication to be properly absorbed into the bloodstream. This can reduce the drug's effectiveness in preventing blood clots, potentially putting the resident at higher risk for pulmonary embolism or deep vein thrombosis.
The bruising observed during the inspection indicates tissue damage from repeated needle trauma. Beyond causing discomfort, this type of localized tissue injury can lead to the formation of lumps or hardened areas under the skin, permanent discoloration, and in severe cases, tissue death.
The facility's Director of Nursing Services acknowledged to inspectors that "if the Heparin injection site is not rotated, it can cause tissue damage and discomfort for the resident." A physician consulted during the inspection confirmed that failure to rotate injection sites "can result in bleeding, pain, and tissue damage."
Food Safety Violations Compromise Resident Health
Federal inspectors also identified significant food safety violations that put residents at risk of foodborne illness. The violations involved both improper food storage and temperature control failures that violated professional food service standards.
Storage and Labeling Failures
In the facility's walk-in refrigerator and freezer, inspectors found multiple food items without proper labeling and dating, including tapioca pudding, beet salad, corn, French toast, chicken nuggets, and various meat products. Several frozen meat packages showed ice and frost buildup inside the packaging, indicating compromised storage conditions that could lead to freezer burn and food quality deterioration.
Staff members acknowledged their responsibility for proper food labeling but admitted the protocols were not being followed consistently. The Food Service Director told inspectors that "cooks are responsible for labeling and dating food returned to the freezer" and should ensure food packages are properly sealed to prevent deterioration.
Critical Temperature Control Violations
More concerning were the temperature control failures that directly threatened resident safety. Cold foods including yogurt, milk, chicken salad sandwiches, and egg salad were found to be stored and served at temperatures well above the safe limit of 41 degrees Fahrenheit.
During the inspection, dietary staff measured food temperatures that revealed significant violations: - American cheese sandwich: 60 degrees Fahrenheit - Chicken salad sandwich: 50 degrees Fahrenheit - Yogurt: 50 degrees Fahrenheit - Milk: 50 degrees Fahrenheit - Egg salad: 60 degrees Fahrenheit
These temperatures are in the "danger zone" where harmful bacteria can multiply rapidly, potentially causing foodborne illness in vulnerable nursing home residents whose immune systems may already be compromised.
Breakdown in Food Safety Protocols
The temperature violations occurred because staff were not following established procedures for cold food handling. Dietary staff told inspectors they did not routinely measure temperatures of cold food items and were not keeping sandwiches on ice during preparation as required by the facility's own policies.
One dietary aide revealed that their cooler for keeping cold items was broken and "was never replaced," forcing staff to work without proper equipment to maintain safe food temperatures. This equipment failure, combined with inadequate temperature monitoring, created conditions where residents were regularly served potentially contaminated food.
The facility's policy clearly states that "potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit" and that "no food will be served that does not meet the food code standard temperatures." However, inspectors found that temperature logs maintained by the kitchen staff did not include evidence of cold food monitoring.
Health Risks for Vulnerable Residents
These food safety violations pose particularly serious risks for nursing home residents, who often have weakened immune systems due to age, chronic conditions, or medications. Foodborne illnesses that might cause mild symptoms in healthy adults can lead to severe complications, hospitalization, or death in frail elderly residents.
Bacteria like Salmonella, E. coli, and Listeria multiply rapidly in the temperature range observed during the inspection. Contaminated dairy products, egg-based items, and prepared sandwiches can cause symptoms ranging from digestive upset to severe systemic infections. For nursing home residents with compromised health, these infections can be life-threatening.
The violations also indicate broader systemic problems in the facility's food safety management, including inadequate staff training, insufficient equipment maintenance, and lack of proper oversight by management.
Administrative Awareness and Oversight Issues
A concerning aspect of both violations was the apparent lack of administrative awareness of these serious safety issues. The facility's Administrator told inspectors they were not aware that kitchen staff were failing to follow food storage procedures or temperature monitoring requirements.
This disconnect between policy and practice suggests inadequate oversight systems and quality assurance measures. While the facility had written policies addressing both injection site rotation and food safety, the failure to implement and monitor these policies put residents at unnecessary risk.
Additional Issues Identified
Beyond the major violations, inspectors documented additional concerns with facility cleanliness and sanitation. In the dry storage area, food containers and milk crates were observed with buildup of food residue and contamination that should have been cleaned according to the facility's sanitation protocols.
These findings reflect broader challenges in maintaining professional standards across multiple operational areas, from clinical care to food service to housekeeping functions that all contribute to resident safety and quality of life.
The violations identified during this inspection highlight the critical importance of consistent implementation of established healthcare protocols, proper staff training, and effective management oversight in nursing home operations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hilaire Rehab & Nursing from 2025-02-07 including all violations, facility responses, and corrective action plans.
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