Pine Forest Care Center: Infection Control Failures - NY
The November 2025 inspection at Pine Forest Care Center for Rehab and Healthcare in Huntington, New York, turned on that contradiction. Inspectors had observed the supervisor entering the room of Resident 16 without any personal protective equipment. What they found inside the room only deepened the problem.
Resident 12 was on contact precautions for a foot wound. Contact precautions exist for one reason: to stop infectious material from traveling on the hands and clothing of caregivers from one person to the next. A gown is not optional under those circumstances. A sign on the door told staff exactly what protective equipment to wear before entering.
When inspectors interviewed the registered nurse supervisor at 2:05 p.m. on November 4, she told them she had been providing wound care to Resident 12 while wearing a gown, gloves, and a mask. She said she had discarded the gown in the garbage pail inside the room when she was finished. She said that if she had not been wearing a gown, it would be "a very big problem."
Two minutes later, inspectors spoke to Registered Nurse 2, who had been in the same room during the same wound care. That nurse told inspectors neither of them had been wearing a gown. Not the nurse. Not the supervisor. The nurse said they both should have been gowned for wound care on that resident, and said the lapse "can cause an issue with contamination."
The supervisor's account and the nurse's account cannot both be true.
The Director of Nursing Services, interviewed later that afternoon, acknowledged the obvious: all staff should wear appropriate personal protective equipment before entering any room on contact precautions, and the signage on the door is there to make sure they do. She offered no explanation for why it hadn't happened.
The inspection cited a violation under New York State regulation 10 NYCRR 415.19, which governs infection prevention and control in nursing facilities. The level of harm was classified as minimal harm or potential for actual harm, affecting a few residents. That classification reflects the regulatory floor, not a ceiling on what could have happened.
Wound care on a patient under contact precautions is among the highest-risk moments for cross-contamination in a nursing home. The precautions are in place precisely because the wound presents a pathway, and because whatever is on the wound, or on the hands and clothing of the caregiver, can move. A gown catches what gloves and masks do not. Skipping it during an active wound care procedure is not a paperwork failure.
What the inspection record does not resolve is how long this had been happening. Inspectors observed one instance. The nurse's account suggests it was not treated as unusual by either person in the room. The supervisor's initial response to inspectors, insisting she had been gowned, suggests awareness that she should have been.
The Director of Nursing pointed to the door sign as the system's safeguard. The sign was there. The gowns were not.
Resident 12's foot wound remains in the background of this report, unnamed and unresolved, the reason the precautions existed in the first place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pine Forest Car Center For Rehab & Healthcare from 2025-11-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 1, 2026 · Our methodology
Pine Forest Car Center for Rehab & Healthcare in Huntington, NY was cited for violations during a health inspection on November 14, 2025.
The November 2025 inspection at Pine Forest Care Center for Rehab and Healthcare in Huntington, New York, turned on that contradiction.
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.