Pine Forest Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pine Forest Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jun 6, 2025

  Based on observation, interviews, record review, and facility policy review, the facility failed to protect the resident's rights to be free from neglect when the resident eloped from the facility unsupervised and unmonitored and made her way to the middle of a busy intersection for (1) of 24 residents sampled. Resident #211 The facility's failure to ensure that Resident #211 was unable to exit the facility unsupervised resulted in her running into the middle of a busy intersection located at an intersection near the facility, placing the resident in a situation that was likely to cause serious injury serious harm, serious impairment, or death. […]

• Immediate jeopardy, isolatedF689Jun 6, 2025

  Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision, monitoring, and preadmission risk assessment to prevent a resident from exiting the facility unsupervised and without staff awareness or intervention for one (1) of twenty-four (24) sampled residents. (Resident #211). This failure resulted in Resident #211 eloping from the building on 6/4/25, for an estimated 600 feet, and being found seated on the back of a trailer in a public intersection surrounded by traffic, thereby placing the resident in Immediate Jeopardy (IJ) for serious injury, harm, impairment, or death. This situation was determined to be IJ and Substandard Quality of Care (SQC), which began on 06/04/25 when Resident #211 eloped from the facility. […]

• Immediate jeopardy, isolatedF600Dec 5, 2023

  Based on observation, interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from neglect for five (5) of 22 residents reviewed as evidenced by facility staff: 1. Did not provide Pressure Ulcer (PU) assessments and care and treatment to prevent complications and worsening of PUs (Resident #53 and Resident #89) 2. Turn and reposition a resident (Resident #87) 3. Ensure incontinent residents were clean and dry (Resident #1 and Resident #31). […]

• Immediate jeopardy, isolatedF656Dec 5, 2023

  Based on interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions as evidenced by: (1) the failure to develop comprehensive care plan interventions for residents with pressure ulcers (PUs) (Resident #53 and Resident #89), (2) the failure to ensure a resident was turned and repositioned (Resident # 87), (3) the failure to ensure residents were clean and dry (Resident #1 and #31), and (4) the failure to ensure nail care was provided to dependent residents (Resident #23 and Resident #41), for six (6) of 22 care plans reviewed. […]

• Immediate jeopardy, isolatedF657Dec 5, 2023

  Based on interviews, record review, and facility policy review, the facility failed to revise resident-centered comprehensive care plan interventions for residents with Pressure Ulcers (PUs) to prevent worsening or complications from PUs for two (2) of 22 care plans reviewed. (Resident #53 and Resident #89). The facility's failure to revise comprehensive care plan interventions related to PU care put Resident #53, Resident #89, and all other residents with skin breakdown in a situation that was likely to cause serious harm, injury, impairment, or death. […]