Pine Forest Care Center For Rehab & Healthcare

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Regular texture, thin consistency diet and GLUCERNA Supplement and well tolerated well. Dietitian following for monitoring of weight status. Weight 171.6 LBS 08/07/25 from 192.4 LBS on 06/02/25 from 187.4 LBS 5/01/25.Continue Bowel Regimen and monitor for BM. Continued Medication including Melatonin at hours of sleet for insomnia with improvement.There are no documented notes from the Dietician or change in plan of care thru 8/18/2025.During an observation with the state agency the resident weigh on 08/19/2025 resident was weight on a standing scale read 171 pounds. During an observation of lunch resident was observed to be served in his room a meal tray which included rice, beans chicken taco milk and a fruit cup. The resident did not consume any of the meal. During observation resident was offered

a sandwich which he was observed to eat half of half the sandwich 25%.The Certified Nurses Accountability was reviewed for July 1-July 31, 2025, and documented resident received setup or clean up assistant with most meals on the 7-3 and 3-11 shift. The Accountability sheet further documented on average resident consumed 51-75% of meals offered during the day 9:00 AM, 1:00PM and 5:00PM.During

an interview conducted on 8/19/2025 with Resident #1 they stated they have lost quite a bit of weight because their pants are falling off and their shirts do not fit. Resident #1 stated he does not like the food, so

he does not eat it. Resident #1 stated that staff gives him a sandwich but thinks it might not be enough.

Resident #1 does not remember if he is provided with a supplement or how often but states he does not drink much. During an interview conducted on 8/18/2025 at 2 pm with Certified Nursing Assistant #1 they stated they are the primary aid for resident #1. They stated that resident #1 has not been eating his meals and is offered a sandwich. Certified nursing Assistant #1 stated they document 50% of meals because Resident #1 eats 1/2 of the sandwich offered. They stated resident #1 does not eat any of the hot meal but will eat some of the sandwich and drink the juice. They stated they have not directly reported it, but everyone knows including the nurse and dietician that the resident is not eating his meals.Multiple attempts were made to reach the dietician and were unsuccessful.During an interview conducted with the Director of Nursing on 8/18/2025 they stated they were notified on 8/18/2025 by the dietician that the Resident had a significant weight loss. The Director of Nursing stated they did not initiate a calorie count because the Certified nursing accountability record documents the resident was eating 50% of their meals. They stated

they were not aware of any new interventions in place.During an interview conducted with the medical Director on 8/18/2025 at 3:00PM they stated they can not recall the resident however if a resident has a significant weight loss they will discuss with the dietician, do a calorie count and will look medically for an underlying cause such as medication like metformin or Ozempic which can 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. 10 NYCRR 415.12(i)(1)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

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 0692

Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, record review and staff interviews during an abbreviated Survey (800072) initiated on 08/19/2025 and completed on 09/11/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of two resident floors (Floor 2) reviewed. Specifically, Floor 2, a locked dementia care unit had a bottle of Isopropyl Alcohol 91% and over 30 pills of brand multivitamins accessible to residents.Findings include:Isopropyl alcohol also known as rubbing alcohol is a clear, colorless liquid.

Widely used as a first aid antiseptic, surface disinfectant and solvent, it is highly flammable, and potentially toxic if absorbed through the skin, inhaled as vapor or ingested. It can lead to dizziness headache nausea, central nervous system depression and loss of consciousnessResident #1 is a [AGE] year-old male admitted to the facility 8/18/23. Medical diagnosis includes dementia anxiety disorder Diabetes type 2.

Minimum Data Set, dated [DATE REDACTED] documents Brief Interview Mental Status score of 5.A comprehensive care plan titled cognition dated 8/2022 documented resident has short and long term memory loss.

Interventions include ensure resident safety. There were no care plans observed for self administration.

There is no documented order that resident may self administer medication.During an observation 08/19/2025 of Resident #1's bedroom, the bedside table was observed with a bottle containing over 30 tablets of brand name multivitamin tablets. Additionally, the resident was observed with 91% isopropyl alcohol 16 ounces about 90% full. During an interview conducted with Resident #1 on 8/19/2025 at 10:30 AM they stated they did not know what the bottle of pills on the bedside table were or where they came from. They further stated possibly a family member brought them to eat because they were concerned about their weigh loss. When asked about the bottle of isopropyl alcohol Resident #1 replied it was water.During an interview on 8/19/2025 at 11:53 AM, License Practical Nurse #1 stated they are the primary nurse for Resident #1. Licensed Practical Nurse #1 stated she provided the resident with their medication in their room in the morning. Licensed Practical Nurse #1 stated the Resident should not have

the alcohol or the bottle of vitamins at the bedside. She further stated she does not know where the resident got it from and would remove it immediately.During an interview on 08/19/2025 at 2:00 PM the Director of Nursing stated the second floor is a designated dementia unit. They further stated there should not be any medication or alcohol at the resident's bedside.10 NYCRR 415.12(h)(1)(2)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet