Pine Forest Care Center For Rehab & Healthcare

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

at approximately 7:10 AM they were informed that Resident #1 was outside on the ground at the back of

the building. Registered Nurse Supervisor #4 went outside and observed Resident #1 to be awake and verbal and 911 was called. The Medical Director was made aware.During an interview on 10/30/2025 at 11:57 AM, the Medical Director stated they were the Primary Care Physician for Resident #1, and they were not made aware of Resident #1's transfer to the hospital on [DATE REDACTED] until Resident #1 was readmitted to the facility on [DATE REDACTED] with multiple fractures. The Medical Director stated they should have been informed

on 10/17/2025.During an interview with Registered Nurse Supervisor #4 stated they wrote the progress note that the Medical Director was made aware of Resident #1's transfer to the hospital on [DATE REDACTED].

Registered Nurse Supervisor #4 stated they made the Medical Director aware via a message on a messaging application. Registered Nurse Supervisor #4 stated they did not follow up to ensure the Medical Director received the message and they should have. Registered Nurse Supervisor #4 stated they did not have documented evidence of the message being sent because the messages disappeared after a certain period of time. Registered Nurse Supervisor #4 stated they should have ensured the Medical Director was informed.During an interview on 11/06/2025 at 11:07 AM, the Director of Nursing Services stated the Primary Care Physician should be informed when there is a change in a resident's condition. The Director of Nursing Services stated they used messaging service to send a message to the Medical Director and

they (the Director of Nursing Services) saw the message Registered Nurse Supervisor #4 sent. The Director of Nursing Services stated it was documented in the Nursing Progress Note that the Medical Director was informed and they (the Director of Nursing Services) recalled speaking to the Medical Director

on 10/17/2025 about Resident #1's accident.During an additional interview on 11/07/2025 at 12:30 PM, the Medical Director stated they normally received a message from the facility, but the staff were told that if they did not get a confirmation to the message, they needed to call them to let them know they had a message.

The Medical Director stated they were not informed of Resident #1 going out the window until Resident #1 returned to the facility on [DATE REDACTED].10 NYCRR 415.3(f)(2)(ii)(a)

Event ID:

Facility ID:

If continuation sheet

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

11/14/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

investigation, Resident #1 tampered with/removed the air conditioner from the window and exited window, resulting in a fall with multiple injuries/fractures requiring hospitalization.The Complaint/Incident Investigation Report, Intake ID 2645865 documented the facility report was completed on 10/17/2025 at 2:23 PM. There was no documented evidence that the New York State Department of Health was notified within the two-hour time frame.During an interview on 10/17/2025 at 1:15 PM, the Director of Nursing Services stated the incident had not been reported yet. The Director of Nursing Services stated the Administrator was working on it now. The Director of Nursing Services stated they did not report the incident within the two-hour time frame because they were dealing with emergency services and interviewing staff for the investigation. The Director of Nursing Services stated they should have reported

the incident within two hours of occurrence.During an interview on 10/17/2025 at 5:36 PM, the Administrator stated the Director of Nursing Services informed them of the incident regarding Resident #1

this morning but could not recall the time. The Administrator stated they did not report this incident within

the two-hour time frame because they did not have access to a computer this morning.10 NYCRR 415.4 (b)(2)

Event ID:

Facility ID:

If continuation sheet

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

11/14/2025

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 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

documented to administer Quetiapine Fumarate (Seroquel, an antipsychotic medication used to treat mental health conditions) oral tablet 25 milligrams three (3) times a day for a diagnosis of Mild Dementia.Resident #1's Medication Administration Record dated July 2025 documented of 42 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 12 doses.Resident #1's Medication Administration Record dated August 2025 documented of 93 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 40 doses.Resident #1's Medication Administration Record dated September 2025 documented of 90 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 65 doses.Resident #1's Medication Administration Record dated 10/01/2025 to 10/17/2025 documented 70 opportunities for the administration of the Quetiapine Fumarate 25 milligrams Resident #1 refused 23 doses.Psychiatric Progress Notes dated 07/21/2025, 08/11/2025, 09/01/2025, 09/22/2025, 10/06/2025, and 10/27/2025, documented Resident #1 was to continue their current medication regimen and a gradual dose reduction was not recommended because it could lead to behavioral disturbances. The Psychiatric progress notes documented Resident #1's chart was reviewed by the Psychiatric practitioner. There was no documented evidence that the Psychiatric practitioner was aware of or addressed Resident #1's numerous medication refusals.A Psychiatric Progress Note dated 10/31/2025 at 4:25 PM was completed after the practitioner was made aware of the frequency of Resident #1's medication refusals by the surveyor. The Psychiatric Progress Note Documented Resident #1 was evaluated via telehealth. Resident #1 acknowledged non-compliance with her prescribed psychotropic medications. There were no changes recommended to Resident #1's psychotropic regimen. The progress notes documented Resident #1's chart was thoroughly reviewed.During an interview on 10/28/2025 at 2:03 PM, the Medical Director stated they were the Primary Care Physician for Resident #1. The Medical Director stated they were not aware of the number doses of Quetiapine Fumarate (Seroquel) 25 milligrams missed since Resident #1 was admitted . The Medical Director stated the medication would not be effective with the number of missed doses and that would impact Resident #1's judgement.During an interview on 10/31/2025 at 11:57 AM, the Psychiatric Nurse Practitioner stated they treated and prescribed Quetiapine Fumarate (Seroquel) 25 milligrams for Resident #1. The Psychiatric Nurse Practitioner stated the medication was used to treat psychiatric disorders and the nursing staff told them Resident #1 was inconsistent with taking Quetiapine Fumarate (Seroquel) 25 milligrams. The Psychiatric Nurse Practitioner stated they (nursing staff) documented the concern in the medical record, but they did not know how many times Resident #1 refused the medication. The Psychiatric Nurse Practitioner stated the medication worked as it built up in the bloodstream and if the resident did not take it consistently then it would not give the full effect and could lead to behavioral disturbances. The Psychiatric Nurse Practitioner stated there were no changes made to Resident #1's medication because residents have the right to refuse to take their medication. 10 NYCRR 415.15(b)(1)(i)(ii)

Event ID:

Facility ID:

If continuation sheet

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

11/14/2025

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 0742 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

fracture of the right humerus (upper arm bone), and a fracture of the lumbar transverse process (a bony structure located on the back side of each lumbar vertebra in the lower back).There is no documented evidence Resident #1 was assessed by a physician for depression or suicide from 10/23/2025 to 10/29/2025. During an interview on 10/17/2025 at 3:27 PM, Registered Nurse #1 stated Resident #1 and Resident #2 shared a room and after Resident #2 left the facility, Resident #1 frequently came out of their room at about 2:00 AM with their backpack and asked where Resident #2 was. Registered Nurse #1 stated Resident #1 frequently refused their medication and when they did not take the Seroquel, they appeared to become more hyper-concerned about Resident #2 and would ask for Resident #2 more often.During an

interview on 10/28/2025 at 1:18 PM, the Director of Social Work stated Resident #1 and Resident #2 had a relationship before they were admitted in July 2025. The Director of Social Work stated Resident #2 leaving

the facility would have been a significant emotional change for Resident #1 and they did not assess Resident #1's mood after Resident #2 was discharged from the facility on 10/01/2025. The Director of Social Work stated Resident #1 was not assessed for depression or suicide when they were readmitted on [DATE REDACTED] with a new diagnosis of suicide attempt. The Director of Social Work stated 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.During an interview on 10/29/2025 at 11:29 AM with Resident #1, they stated when Resident #2 left

they were very sad. Resident #1 started to cry and was visibly upset and stated they were worried, I will always go looking for Resident #2. During an interview on 10/29/2025 at 12:03 PM, the Director of Nursing stated Resident #1's mood improved when Resident #2 was admitted . The Director of Nursing Services stated when Resident #2 left the facility it would have been a significant emotional change. During an

interview on 10/30/2025 at 11:57 AM, the Medical Director stated when Resident #2 was discharged from

the facility that it would have been a significant emotional change for Resident #1 and Resident #1's mood should have been assessed at that time.The Medical Director stated Resident #1'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 they felt Resident #1 was probably looking for their boyfriend and

they did not try to commit suicide; however, their mood should have been assessed when they were readmitted to ensure no further harm came to Resident #1.During an interview on 10/31/2025 at 11:57 AM,

the Psychiatric Nurse Practitioner stated Resident #2 leaving the facility would have been a significant emotional change for Resident #1 and Resident #1's mood should have been assessed when Resident #2 left the facility. The Psychiatric Nurse Practitioner stated they did not think Resident #1 was suicidal, but

they were confused when they went out the window. The Psychiatric Nurse Practitioner stated 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 and an assessment should have been completed upon readmission by the nursing or social work staff. During an additional interview on 11/14/2025 at 10:49 AM, the Director of Nursing stated Resident #1 was seen by the psychiatric nurse practitioner on 10/26/2025 but was not assessed by the social worker for their mood until 10/29/2025. The Director of Nursing stated Resident #1's mood should have been assessed when they were readmitted to the facility on [DATE REDACTED] with a new diagnosis of suicide attempt.10 NYCRR 415.12(f)(1)

Event ID:

Facility ID:

If continuation sheet

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

11/14/2025

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observations, record review, and interviews during the Abbreviated Survey (Intake ID 2633011 and 2645865) the facility did not ensure all drugs and biologicals were stored in a locked compartment and accurately labeled. This was identified for one (1) of two (2) facility treatment carts. Specifically, the treatment cart on the first floor was noted to be unlocked with the second drawer open in the hallway without any staff members present. The finding is: The facility policy titled Medication Storage reviewed in June 2024 documented all drugs and biologicals will be stored in locked compartments under proper temperature controls. Only authorized personnel will have access to the keys to locked compartments.

During a medication pass, medications must be under the direct observation of the person administering medication or locked in the medication storage area/cart.During an observation on 11/04/2025 at 2:00PM a treatment cart was observed outside Resident #12's room. The treatment cart was unlocked, and the second drawer was open about three inches and treatment medications were visible to the surveyors.

Registered Nurse #2 exited Resident #12's room and stated they were using the treatment cart.During an

interview on 11/04/2025 at 2:06 PM, Registered Nurse #2 stated that the treatment cart was unlocked, and

the lock was broken. Registered Nurse #2 stated they accepted the treatment cart with the broken lock at

the beginning of their shift and that the lock had been broken for a while. Registered Nurse #2 stated they should not have accepted a treatment cart without a functioning lock because residents could get into the treatment cart and take a medication.During an interview on 11/04/2025 at 4:08PM, with Director of Nursing Services they stated that all treatment carts should be locked and if they are unlocked the nurse should be present at the cart. The Director of Nursing Services stated that if the lock was not working, the cart should not have been in use because a resident could potentially obtain and ingest a treatment medication from the cart. 10 NYCRR 415.18(e)(1-4)

Event ID:

Facility ID:

If continuation sheet

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

11/14/2025

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

resident #16 without any personal protective equipment on. During an interview on 11/04/2025 at 2:05pm with Registered Nurse Supervisor #2 they stated they were providing treatment care to resident #12 and stated they were wearing a gown, gloves and a mask. They stated the resident is on contact precautions for their foot wound. They stated they discarded their gown in the garbage pail inside Resident #12's room if

they were not wearing a gown, it would be a very big problem. During an interview on 11/04/2025 at 2:07pm with Registered Nurse #2, they were not wearing a gown when providing care to Resident #12.

They stated the staff member (registered nurse supervisor #2) in the room with them, was also not wearing

a gown. They stated they both should have been wearing a gown when providing wound care to Resident #12. They stated this can cause an issue with contamination. During an interview on 11/04/2024 at 4:08pm with Director of Nursing Services they stated the signage on the door will let the staff know what personal protective equipment to wear. They stated that all staff should wear appropriate personal protective equipment before entering a room that is on contact precautions. 10 NYCRR 415.19(a) (1-3)

Event ID:

Facility ID:

If continuation sheet