Hilaire Rehab & Nursing

F-F658- Services Provided Meet Professional Standards

The finding is:

The Policy and Procedure for Injection Site Rotation dated October 2023 documents that rotation of the injection site is required.

The pdr.net/drug summary/ Heparin Sodium injection website for Heparin subcutaneous injection administration documented to rotate the injection site frequently.

The National Library of Medicine; National Center for Biotechnology Information: Nursing Skills 2nd edition 2023 documented it is important to rotate Heparin sites to avoid bruising in one location.

Resident # 20 was admitted with diagnoses that included Functional Quadriplegia. The Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period.

The current Physician's order documented to administer Heparin Sodium (Porcine) Injection Solution 5000 units per milliliter subcutaneously two times a day for prophylactic measures.

The Medication Administration Record for January - February 2025 documented Resident #20 received Heparin injections to their lower left abdomen on consecutive days twice daily on the following days: 1/4/2025, 1/9/2025 to 1/10/2025, 1/28/2025- 1/29/2025, 2/2/2025, and 2/4/2025 to 2/7/2025. There was no documented evidence that the injection site was rotated to other sites on these dates.

During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 335040 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335040 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Forest Care Center for Rehab & Healthcare 9 Hilaire Drive Huntington, NY 11743

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated Heparin injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse Level of Harm - Minimal harm or #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason. potential for actual harm

During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of Residents Affected - Few Heparin administration should be documented accurately and the injection site should be rotated. If the Heparin injection site is not rotated, it can cause tissue damage and discomfort for the resident.

During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of Heparin is not rotated bleeding, pain, and tissue damage can occur.

10 NYCRR 415.11(c)(3)(i)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 335040 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335040 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Forest Care Center for Rehab & Healthcare 9 Hilaire Drive Huntington, NY 11743

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 45349

Residents Affected - Few Based on observation, interviews, and record review conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the Kitchen task. Specifically, 1) several food items were stored in the walk-in refrigerator and walk-in freezer without proper labeling and dating; multiple frozen item bags were observed with ice and frost inside their packaging; Additionally, a plastic container and milk crates in the dry storage area were observed to be dirty. 2) Cold food items including yogurt, milk, chicken salad sandwich, and egg salad temperatures were observed above 41 degrees Fahrenheit.

The findings are:

A facility policy and procedure titled Food Storage effective 10/2024, documented food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. A date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high-risk food. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. Plastic containers with tight-fitting covers must be used for storing broken lots of bulk foods. All containers must be legible, accurately labeled, and dated. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Refrigerated food storage: all foods should be covered, labeled, and dated.

A facility policy and procedure titled Cleaning and Sanitation of Dining and Food Service Areas, effective 10/2024, documented the food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Tasks shall be designated to be the responsibility of specific positions in the department. All staff will be trained on the frequency of cleaning necessary.

During an initial tour of the kitchen on 2/3/2025 at 9:26 AM, the walk-in refrigerator was observed with multiple food items (tapioca pudding, and beet salad) not properly labeled and dated. The walk-in freezer was observed with multiple food items (corn, French toast, chicken nuggets, French fries, turkey burger, beef burger, pork chops, and frankfurters) not properly labeled and dated. The bags of turkey burgers, beef burgers, pork chops, and frankfurters were observed to have ice/frost build up on the inside of the packaging. There were also two packages of Perogies and a corned beef outside of their original delivery pack without a delivery date. A plastic container of jelly was not dated in the reach-in refrigerator; the edges and the lid of

the container had remnants of peanut butter on it.

The Food Service Director was immediately interviewed and stated the cooks are responsible for labeling and dating food returned to the freezer. The Food Service Director stated the cooks should ensure that the food packages are sealed to prevent freezer burn. The container of jelly should have been dated and the edges should have been cleaned.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 335040 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335040 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Forest Care Center for Rehab & Healthcare 9 Hilaire Drive Huntington, NY 11743

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview on 2/3/2025 at 9:35 AM, [NAME] #1 stated the cooks are responsible for labeling and dating food packages when returning to the freezer. [NAME] #1 stated food with freezer burn cannot be Level of Harm - Minimal harm or served and should be discarded. potential for actual harm

During a tour of the dry storage area on 2/3/2025 at 9:40 AM, a plastic tub of beef soup base was observed Residents Affected - Few with black dust on the lid. The plastic tub was stored on top of milk crates which were observed with a buildup of the soup base powder along the top and edges. The Food Service Director stated that the container and the milk crates should have been cleaned.

During an interview on 2/6/2025 at 3:21 PM, the Administrator stated that stored food should be labeled and dated. The Administrator stated they were not aware the kitchen was not following the food storage procedure.

2) A facility policy and procedure titled Food Temperatures effective 3/2022 last reviewed 1/2025, documented it is the policy to record food temperatures daily to ensure food is at the proper serving temperature(s) before trays are assembled. Food temperatures will be checked on all items prepared in the dietary department. Potentially hazardous cold food temperatures will be kept at or below 41 degrees Fahrenheit. No food will be served that does not meet the food code standard temperatures. Place cold menu items such as ham salad or egg salad over an ice bath in a pan and not beside a heated steam table.

The Cook's Temperature Log Sheet maintained by the facility did not include evidence of cold food temperature monitoring.

During an interview on 2/6/2025 at 12:25 PM, [NAME] #2 stated they only measure the temperature of cold entrees but do not take the temperature of the other cold food items that are placed on the individual resident tray such as milk, yogurt, sandwiches, etc.

During the Kitchen observation on 2/6/2025 at 12:32 PM, two trays of sandwiches were not kept in an ice bath.

During an observation and interview on 2/6/2025 at 12:33 PM, [NAME] #3 stated they did not keep the sandwiches (such as American cheese, egg salad, tuna salad) on ice during preparation, nor did they take

the temperatures of the sandwiches. [NAME] #3 measured the temperatures of the sandwiches. The American cheese sandwich temperature was measured at 60 degrees Fahrenheit, and the chicken salad sandwich temperature was measured at 50 degrees Fahrenheit. [NAME] #3 stated the temperature of the sandwiches should be below 40 degrees Fahrenheit.

During an interview on 2/6/2025 at 12:40 PM, the Food Service Director stated the proper serving temperature for cold food should be 41 degrees Fahrenheit or below. The Food Service Director stated they do not routinely measure the temperature of cold food items such as sandwiches, milk, and yogurt.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 335040 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335040 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Forest Care Center for Rehab & Healthcare 9 Hilaire Drive Huntington, NY 11743

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an interview and observation on 2/6/2025 at 12:45 PM, Dietary Aide #1 stated that they do not measure the temperature of the cold food items before they place the food items on the individual resident Level of Harm - Minimal harm or trays. Dietary Aide #1 stated they usually kept cold items in a cooler, but the cooler was broken and was potential for actual harm never replaced. Dietary Aide #1 measured the temperature of cold food items, finding yogurt at 50 degrees Fahrenheit, milk at 50 degrees Fahrenheit, and a cup of egg salad at 60 degrees Fahrenheit. Dietary Aide #1 Residents Affected - Few stated the temperature of the cold food should be less than 41 degrees Fahrenheit.

During an interview on 2/6/2025 at 3:21 PM, the Administrator stated they were aware of the food temperature standards and cold food should be maintained at a temperature of 41 degrees Fahrenheit or below. The Administrator stated they did not know the Food Service Director was not monitoring the temperature of the cold food items served to the residents.

10 NYCRR 415.14(h)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 335040

F-F755- Pharmacy Svcs/Procedures

The finding is:

The Policy and Procedure for Injection Site Rotation dated October 2023 documented that rotation of the injection site is required.

Resident # 20 was admitted with diagnoses that included Functional Quadriplegia. The Minimum Data Set (MDS) assessment dated [DATE REDACTED] documented the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident's cognition was intact. The Minimum Data Set assessment documented Resident # 20 received anticoagulants and injections 7 of 7 days in the look-back period.

The current Physician's order documented to administer Heparin Sodium (Porcine) Injection Solution 5000 units per milliliter subcutaneously two times a day for prophylactic measures.

The Medication Administration Record for January - February 2025 documented Resident #20 received Heparin injections to their lower left abdomen on consecutive days twice daily on the following days: 1/4/2025, 1/9/2025 to 1/10/2025, 1/28/2025- 1/29/2025, 2/2/2025, and 2/4/2025 to 2/7/2025. There was no documented evidence that the injection site was rotated to other sites on these dates.

During an observation and interview on 2/7/2025 at 1:54 PM, Resident #20 was observed in bed with their abdomen exposed (resident preference). A quarter-size ecchymosis (bruising) to the lower left abdomen was observed. Resident # 20 stated they do not monitor where they get their injections.

During an interview on 2/7/2025 at 2:00 PM, Registered Nurse #1, the medication nurse, stated Heparin injection should be administered subcutaneously and the injection site should be rotated. Registered Nurse #1 stated the injection site for Resident #20 was not rotated as required and was unable to state the reason.

During an interview on 2/7/2025 at 2:27 PM, the Director of Nursing Services stated the injection site of Heparin administration should be documented accurately and the injection site should be rotated. If the Heparin injection site is not rotated, it can cause tissue damage and discomfort for the resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 335040 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335040 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Forest Care Center for Rehab & Healthcare 9 Hilaire Drive Huntington, NY 11743

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During an interview on 2/7/2025 at 12:48 PM, Physician #1 stated if the injection of Heparin is not rotated bleeding, pain, and tissue damage can occur. Level of Harm - Minimal harm or potential for actual harm 10 NYCRR 415.11(c)(3)(i)

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 335040 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335040 B. Wing 02/07/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Forest Care Center for Rehab & Healthcare 9 Hilaire Drive Huntington, NY 11743

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 17585

Residents Affected - Few Based on observation, record review, and interviews conducted during the Recertification survey initiated on 2/3/2025 and completed on 2/7/2025, the facility did not ensure pharmaceutical services met the needs of each resident including appropriately administering all drugs and biologicals in accordance with the professional standards of practice. This was identified for one (Resident # 21) of five residents reviewed for unnecessary medications. Specifically, Resident #21 was prescribed Heparin Sodium (Porcine) Injection Solution 5000 units per milliliter and the nursing staff administered the injection without rotating the subcutaneous injection sites.

Cross Reference: