Inspection Reports for
The Pines at Catskill Center for Nursing & Rehabilitation
154 Jefferson Heights, Catskill, NY, 12414
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
20 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
292% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
40
30
20
10
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 3, 2025
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to investigate complaints related to neglect, misappropriation of resident property, failure to report investigations timely, incomplete care plans, and improper medication labeling at The Pines at Catskill Center for Nursing & Rehab.
Complaint Details
The complaint investigation revealed neglect of Resident #5 resulting in fractures due to failure to follow care plan transfer instructions, misappropriation of Resident #136's property by a Certified Nurse Aide, failure to timely report investigation results to the state agency, incomplete care plans for Residents #5 and #27, and improper medication labeling on the Passport unit medication cart.
Findings
The facility failed to prevent neglect resulting in a resident fall with fractures, did not prevent misappropriation of resident property by a staff member, failed to timely report investigation results to the state agency, did not develop comprehensive care plans for residents, and did not ensure proper labeling and storage of medications.
Deficiencies (5)
F0600: The facility failed to ensure residents were free from neglect when a Certified Nurse Aide transferred Resident #5 without required two-person assistance, resulting in a fall and fractures to both legs.
F0602: The facility failed to protect residents from misappropriation of property when a Certified Nurse Aide took belongings from Resident #136 without permission and was terminated.
F0609: The facility failed to timely report the results of investigations to the state agency within 5 working days for an incident involving misappropriation of Resident #136's property.
F0656: The facility failed to develop and implement comprehensive person-centered care plans for Residents #5 and #27, including failure to document hearing aid use and proper transfer assistance.
F0761: The facility failed to ensure drugs and biologicals were labeled and stored properly, with unlabeled multi-dose insulin vials and unclear opened dates found on medication carts.
Report Facts
Residents reviewed for neglect: 3
Residents reviewed for misappropriation: 3
Employee signatures on in-service: 60
Date of incident: Mar 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in neglect finding for Resident #5 fall and terminated after incident | |
| Licensed Practical Nurse #4 | Assisted during Resident #5 fall incident | |
| Registered Nurse #2 | Assessed Resident #5 after fall | |
| Licensed Practical Nurse #5 | Called hospital to report Resident #5 condition | |
| Certified Nurse Aide #3 | Involved in misappropriation of Resident #136's property and terminated | |
| Administrator #1 | Administrator | Provided statements regarding incident reporting and facility education |
| Administrator #2 | Administrator | Notified of misappropriation concerns and conducted investigation |
| Director of Nursing #1 | Director of Nursing | Provided statements on care plan education and staff expectations |
| Medical Director #1 | Medical Director | Provided statements on Resident #5 incident and root cause analysis |
| Registered Nurse #1 | Provided statements on medication labeling and care plan knowledge | |
| Licensed Practical Nurse #3 | Observed medication cart and discussed labeling issues |
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 10
Date: Jul 3, 2025
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including environmental cleanliness, care planning, communication support, respiratory care, medication labeling, food service safety, waste disposal, and medical record accuracy.
Deficiencies (10)
F 0584: The facility did not maintain a safe, clean, and homelike environment; lighting fixtures and windows were unclean with dirt, debris, and deceased bugs.
F 0655: The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #248, omitting dialysis care instructions.
F 0656: The facility did not develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for Residents #5 and #27, resulting in a fall and inadequate hearing impairment care.
F 0676: The facility did not ensure Resident #7 had consistent access to a communication board to support their language and communication needs.
F 0695: The facility failed to provide safe respiratory care; oxygen tubing was not dated or labeled properly and nebulizer equipment was improperly stored for Residents #41, #128, and #245.
F 0727: The facility did not have a Registered Nurse on duty for at least eight consecutive hours on 1/25/2025 as required.
F 0761: The facility failed to label and store drugs and biologicals properly; insulin vials were unlabeled or lacked clear open dates.
F 0812: The facility did not ensure food was stored, prepared, distributed, or served safely; nutrition rooms and kitchen areas were unclean with dirt, debris, and moisture on equipment and surfaces.
F 0814: The facility did not properly dispose of garbage and refuse; two trash bins had broken lids preventing proper closure and pest-proofing.
F 0842: The facility maintained inaccurate medical records; Resident #120's record documented monitoring a wound vacuum that was no longer present.
Report Facts
Residents reviewed for baseline care plans: 28
Residents reviewed for care plans: 28
Residents reviewed for oxygen administration: 6
Residents affected by deficiencies: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Named in care plan noncompliance and fall incident involving Resident #5 | |
| Director of Nursing #1 | Director of Nursing | Interviewed regarding care plan deficiencies, fall incident, and communication issues |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed regarding oxygen tubing change practices |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication labeling and care plan issues |
| Director of Maintenance #1 | Director of Maintenance | Interviewed regarding environmental cleanliness and trash bin conditions |
| Director of Food Services #1 | Director of Food Services | Interviewed regarding cleanliness of nutrition rooms and kitchen |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding wound vacuum monitoring documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 23
Date: Jul 3, 2025
Visit Reason
Inspection identified multiple standard health and life safety code deficiencies primarily related to quality of care and safety, all corrected by August 21, 2025.
Findings
Inspection identified multiple standard health and life safety code deficiencies primarily related to quality of care and safety, all corrected by August 21, 2025.
Deficiencies (23)
R14-Activities daily living (adls)/mntn abilities
R14-Baseline care plan
R14-Develop/implement comprehensive care plan
R14-Dispose garbage and refuse properly
R14-Food procurement,store/prepare/serve-sanitary
R14-Free from abuse and neglect
R14-Free from misappropriation/exploitation
R14-Label/store drugs and biologicals
R14-Pasarr screening for md & id
R14-Quality of care
R14-Reporting of alleged violations
R14-Resident records - identifiable information
R14-Respiratory/tracheostomy care and suctioning
R14-Rn 8 hrs/7 days/wk, full time don
R14-Safe/clean/comfortable/homelike environment
RLSC-Corridor - doors
RLSC-Discharge from exits
RLSC-Electrical equipment - testing and maintenanc
RLSC-Ep program patient population
RLSC-Ep testing requirements
RLSC-Illumination of means of egress
RLSC-Sprinkler system - maintenance and testing
RLSC-Utilities - gas and electric
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Mar 18, 2022
Visit Reason
Recertification survey and abbreviated survey conducted from 3/14/2022 through 3/18/2022 to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including baseline and comprehensive care planning, provision of activities of daily living (ADL) care, nutritional monitoring, respiratory care, dementia care, psychotropic medication management, and food service safety. Specific failures included incomplete or delayed care plans, inadequate supervision during meals, missed or inconsistent ADL care, failure to monitor weights timely, oxygen administration not per physician orders, insufficient dementia interventions, lack of documentation for behavior changes prior to medication increases, and food service equipment and sanitation issues.
Deficiencies (8)
Baseline care plans were not developed or implemented within 48 hours of admission for multiple residents, lacking required healthcare information and resident-specific needs.
Comprehensive care plans were incomplete or not implemented for residents, failing to include measurable objectives and timeframes to meet medical, nursing, and psychosocial needs.
Residents dependent on staff for ADLs did not consistently receive necessary care such as incontinence care, shaving, and bathing as documented in their care plans.
Resident with swallowing difficulties was not supervised during meals and was served inappropriate food textures despite broken dentures.
Resident received oxygen at a flow rate higher than the physician's order of two liters per minute.
Resident with dementia did not consistently receive individualized, person-centered non-pharmacological interventions to maximize dignity and socialization.
Psychotropic medication (Zyprexa) was increased without documented evidence of behavioral changes or attempts at non-pharmacological interventions prior to dosage increase.
Food service thermometers were out of calibration and kitchen and unit kitchenettes had maintenance and sanitation deficiencies including damaged flooring, peeling linoleum, and unclean equipment.
Report Facts
Behavior monitoring shifts without documentation: 51
Resident falls: 5
Food thermometer calibration readings: 35
Resident weights: 167.5
Resident weights: 145.8
Resident weights: 83
Resident weights: 82.8
Resident weights: 138.6
Resident weights: 132.6
Resident weights: 133.6
Resident weights: 130.6
Resident weights: 105
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Mar 18, 2022
Visit Reason
Complaint survey found multiple standard health and life safety code deficiencies related to quality of care, all corrected by May 2022.
Findings
Complaint survey found multiple standard health and life safety code deficiencies related to quality of care, all corrected by May 2022.
Deficiencies (10)
R14-ADL care provided for dependent residents
R14-Baseline care plan
R14-Develop/implement comprehensive care plan
R14-Food procurement,store/prepare/serve-sanitary
R14-Free from unnec psychotropic meds/prn use
R14-Free of accident hazards/supervision/devices
R14-Nutrition/hydration status maintenance
R14-Respiratory/tracheostomy care and suctioning
R14-Treatment/service for dementia
RLSC-Electrical equipment - testing and maintenanc
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 24, 2022
Visit Reason
Covid-19 survey identified one standard health citation related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey identified one standard health citation related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
R14-Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 9, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in coordinating assessments for residents with newly evident mental illness, developing comprehensive person-centered care plans for multiple residents, and establishing a policy with time frames for monthly medication regimen reviews.
Deficiencies (3)
F 0644: The facility did not refer a resident with newly diagnosed mental illness for a level II PASRR review as required, failing to ensure a level 1 screen was completed to determine the need for further review.
F 0656: The facility failed to develop and implement comprehensive care plans with measurable objectives and timeframes for four residents, omitting plans for conditions such as blepharitis, pressure sores, constipation, dermatitis, pain management, and nutrition goals.
F 0756: The facility did not have a policy for monthly medication regimen review that included time frames for each step and actions required when irregularities are identified.
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