Pine Forest Care Center for Rehab & Healthcare received an immediate jeopardy citation after the October incident left the resident with a fractured right humerus and lumbar spine injury. The resident was readmitted to the facility on October 23 with a new diagnosis of suicide attempt, but staff still didn't evaluate their emotional state for six more days.
The two residents had shared a relationship before both were admitted to the facility in July. When the roommate was discharged on October 1, staff noticed dramatic behavioral changes but took no action.
Registered Nurse #1 told inspectors the remaining resident would emerge from their room around 2:00 AM carrying a backpack, asking where their former roommate had gone. The resident frequently refused medication, and when they skipped their prescribed Seroquel, they became "more hyper-concerned" about the missing roommate and asked about them more often.
"When Resident #2 left they were very sad," the injured resident told inspectors during an October 29 interview. They began crying and said they were "worried, I will always go looking for Resident #2."
Multiple staff members acknowledged the roommate's departure represented a significant emotional change requiring assessment. None conducted one.
The Director of Social Work admitted they failed to evaluate the resident's mood after the discharge on October 1. When the resident returned from the hospital with a suicide attempt diagnosis on October 23, no mood assessment occurred then either.
"Resident #1's mood should have been assessed on 10/01/2025 and 10/23/2025 to determine if Resident #1 was at risk for harm," the Director of Social Work told inspectors.
The Director of Nursing confirmed the resident's mood had improved when their roommate was initially admitted. The departure "would have been a significant emotional change," she said.
Even the facility's Medical Director acknowledged the oversight. The resident's emotional state "should have been assessed when they were readmitted to the facility with a new diagnosis of suicide attempt on 10/23/2025," the Medical Director stated.
The Medical Director believed the resident "was probably looking for their boyfriend and they did not try to commit suicide." Regardless, they said the resident's mood should have been assessed "to ensure no further harm came to Resident #1."
The facility's Psychiatric Nurse Practitioner agreed the roommate's departure warranted a mood assessment. They described the resident as "confused when they went out the window" rather than suicidal, but said "the facility should have made the Medical Director aware on 10/23/2025 that Resident #1 was readmitted with a new diagnosis of suicide attempt."
The psychiatric nurse practitioner finally saw the resident on October 26, three days after readmission. The social worker didn't assess their mood until October 29, six days later.
No documented evidence exists that any physician evaluated the resident for depression or suicidal thoughts between October 23 and October 29, despite the suicide attempt diagnosis and obvious signs of distress observed by nursing staff.
The resident's nighttime wandering with a packed bag, medication refusal, and persistent searching for their departed roommate all occurred without triggering the facility's assessment protocols. Staff watched the behavioral changes unfold for nearly a month before the window incident sent the resident to the hospital with multiple fractures.
The Director of Nursing acknowledged the failure during a follow-up interview on November 14. The resident "should have been assessed when they were readmitted to the facility on [DATE] with a new diagnosis of suicide attempt," she confirmed.
The inspection report documents no evidence that Pine Forest Care Center has implemented new procedures to prevent similar oversights. The resident remains in care with injuries that required hospitalization and a formal suicide attempt diagnosis that went unaddressed for nearly a week.
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 2025-11-14 including all violations, facility responses, and corrective action plans.
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