Pine Forest Car Center for Rehab & Healthcare

In the surveyor’s words

From the most serious findings on record at Pine Forest Car Center for Rehab & Healthcare, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 14, 2025

  Based on observation, record review, and interviews during an abbreviated survey (2633011) the facility failed to ensure that each resident received adequate supervision to prevent accidents. This was identified for ten (10) of 12 residents: Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, reviewed for Accidents. 1) Specifically, Resident #1 and Resident #2 went out on a pass together into the community, signed out by Resident #2 as the responsible party on six (6) different dates in August 2025, and then again on September 30, 2025. On 09/30/2025, Resident #1 and Resident #2 did not return to the facility at the designated time of 3:00 PM. They were found on 10/01/2025 at approximately 10 AM. […]

• Immediate jeopardy, isolatedF742Nov 14, 2025

  Based on record review and interviews during the abbreviated survey (Intake ID 2645865) initiated on 10/17/2025 and completed on 11/06/2025, the facility failed to ensure that a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or attain the highest practicable mental and psychosocial well-being. This was identified for one (1) (Resident #1) of twelve (12) sampled residents. Specifically, Resident #1 was assessed as having wandering and exit seeking behavior. Resident #1 had a significant emotional experience after which there was an increase in wandering behavior. […]

• Actual harm, isolatedF689May 3, 2023

  Based on observation, interviews and record review conducted during an abbreviated survey NY00313378 the facility failed to provide the resident's environment remain as free of accident hazards for one of four residents reviewed for accidents (Resident #1). Specifically, the facility did not ensure the effectiveness of the screw that was installed in the resident's window track as a restrictor to limit how far the window would open. Subsequently, Resident #1, who had a history of elopement and suicidal ideation prior to admission, was able without manipulating the window in their room open and jumped out the window hitting a concrete surface. Resident #1 sustained multiple fractures of the spine, left ribs, left acetabulum, left scapula, and left sacrum. […]

• No harm, potential for more than minimal, isolatedF580Nov 14, 2025

  i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in… […]

• No harm, potential for more than minimal, isolatedF609Nov 14, 2025

  NTENT The intent is for the facility to develop and implement policies and procedures that: Provide annual notification to each covered individual of their obligation to comply with the reporting requirements under section 1150B(b) of the Act; Ensure reporting reasonable suspicion of crimes against a resident or individual receiving care from the facility within prescribed timeframes to the appropriate entities, consistent with Section 1150B of the Act; and Ensure that all covered individuals, i.e., the owner, operator, employee, manager, agent or contractor, report reasonable suspicion of crimes, as required by Section 1150B of the Act. The facility should provide oversight and monitoring to ensure that implement the required policies and procedures, per 42 CFR S483.12(b). […]