Pine Forest Care: 21-Pound Weight Loss Ignored - NY
The resident's weight dropped from 192.4 pounds in June to 171.6 pounds by August. His pants were falling off and his shirts no longer fit.
"I have lost quite a bit of weight because their pants are falling off and their shirts do not fit," the resident told inspectors on August 19. "I don't like the food, so I don't eat it."
During lunch observation that day, inspectors watched staff serve the resident rice, beans, chicken taco, milk and a fruit cup in his room. He consumed none of it. When offered a sandwich, he ate only half.
The resident's primary nursing assistant said everyone knew he wasn't eating his regular meals.
"Resident has not been eating his meals and is offered a sandwich," the aide told inspectors. The assistant documented that the resident consumed 50 percent of meals because he ate half the sandwich offered, even though he touched none of the hot food.
"They have not directly reported it, but everyone knows including the nurse and dietician that the resident is not eating his meals," the aide said.
Records showed the resident received meal setup assistance on most shifts during July. Staff documented he consumed 51 to 75 percent of meals offered at 9 AM, 1 PM and 5 PM. But inspectors found no dietitian notes or care plan changes through August 18.
The resident said staff gave him sandwiches but "thinks it might not be enough." He couldn't remember if he received nutritional supplements or how often, saying he "does not drink much."
The Director of Nursing said the dietitian only notified her about the significant weight loss on August 18 — the day before inspectors arrived. She had not ordered a calorie count because the nursing records showed the resident was eating 50 percent of his meals.
"They were not aware of any new interventions in place," inspectors noted.
Multiple attempts to reach the dietitian were unsuccessful.
The medical director said he couldn't recall this specific resident but described the standard protocol for significant weight loss: discuss with the dietitian, conduct a calorie count, and investigate medical causes like medications that suppress appetite.
"If they find the resident is not finishing meals because of depression or underlying issues they will notify the family and start an appetite stimulant," the medical director explained.
None of these interventions had been implemented despite the 21-pound weight loss over three months.
The resident had been prescribed a regular texture, thin consistency diet with Glucerna supplements, which records indicated he "tolerated well." His care plan included monitoring weight status and continuing bowel regimen.
But the gap between documentation and reality was stark. While nursing assistants recorded meal consumption percentages suggesting adequate intake, the resident was steadily losing weight and telling staff he didn't like the food.
The facility's accountability records showed a pattern of incomplete nutrition monitoring. Staff documented setup assistance and estimated consumption percentages, but failed to recognize or respond to the obvious signs of inadequate nutrition.
By the time inspectors arrived, the resident had lost more than 11 percent of his body weight. His clothes no longer fit. He was surviving primarily on half-sandwiches while staff continued documenting that he consumed half his meals.
The inspection found the facility failed to ensure residents received proper nutrition and hydration to maintain health and well-being. The violation affected few residents but represented minimal harm or potential for actual harm.
The resident's weight trajectory told the story: 187.4 pounds in May, 192.4 pounds in June, then a steady decline to 171.6 pounds by August. Each weigh-in documented the problem getting worse while interventions remained absent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pine Forest Care Center For Rehab & Healthcare from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
PINE FOREST CARE CENTER FOR REHAB & HEALTHCARE in HUNTINGTON, NY was cited for violations during a health inspection on September 11, 2025.
The resident's weight dropped from 192.4 pounds in June to 171.6 pounds by August.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.