Inspection Reports for
The Pines at Catskill Center for Nursing & Rehabilitation
154 Jefferson Heights, Catskill, NY, 12414
Back to Facility Profile3 Reports · 1 Summary
Inspection Summary
2 inspections covered.
Inspection Reports Summary
Visit Reason
State-compiled facility profile showing 2 inspections from 2022 to 2026 with deficiency and enforcement history.
Complaint Details
The state logged 23 complaints about this facility; 2 led to on-site inspections.
Findings
Across 2 inspections in the reporting period, 41 citations were issued including 25 standard health and 16 Life Safety Code citations. The facility had 23 complaints with 2 on-site inspections and 2 formal enforcement actions totaling $14,000 in fines.
Citations (21)
Activities Daily Living (adls)/mntn Abilities: Standard Health Citation — quality of care with isolated minor potential harm.
Baseline Care Plan: Standard Health Citation — quality of care with isolated minor potential harm.
Develop/implement Comprehensive Care Plan: Standard Health Citation — quality of care with pattern minor potential harm.
Dispose Garbage And Refuse Properly: Standard Health Citation — quality of care with pattern minor potential harm.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation — quality of care with pattern minor potential harm.
Free From Abuse And Neglect: Standard Health Citation — quality of care with isolated actual harm.
Free From Misappropriation/exploitation: Standard Health Citation — quality of care with isolated minor potential harm.
Label/store Drugs And Biologicals: Standard Health Citation — quality of care with pattern minor potential harm.
Reporting Of Alleged Violations: Standard Health Citation — quality of care with isolated minor potential harm.
Resident Records - Identifiable Information: Standard Health Citation — quality of care with isolated minor potential harm.
Respiratory/tracheostomy Care And Suctioning: Standard Health Citation — quality of care with isolated minor potential harm.
Rn 8 Hrs/7 Days/wk, Full Time Don: Standard Health Citation — quality of care with widespread minor potential harm.
Safe/clean/comfortable/homelike Environment: Standard Health Citation — quality of care with isolated minor potential harm.
Corridor - Doors: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Discharge From Exits: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Electrical Equipment - Testing And Maintenanc: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Ep Program Patient Population: Life Safety Code Citation — NFPA requirements with widespread minor potential harm.
Ep Testing Requirements: Life Safety Code Citation — NFPA requirements with widespread minor potential harm.
Illumination Of Means Of Egress: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Utilities - Gas And Electric: Life Safety Code Citation — NFPA requirements with pattern minor potential harm.
Report Facts
Inspections on page: 2
Total violations/deficiencies cited: 41
Violations with inspections: 1
Violations without citations: 1
Complaints total: 23
Complaints on-site inspections: 2
Enforcement actions: 2
Total fines: 14000
Individual Reports
One document per inspection visit.
Inspection Report — Jul 3, 2025
Annual Inspection
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.
Citations (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 — Mar 18, 2022
Annual Inspection
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.
Citations (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 — Sep 9, 2019
Annual Inspection
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.
Citations (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.
4 CMS Surveys
CMS Survey — Jul 3, 2025
Jul 3, 2025
CMS Survey — Sep 9, 2019
Sep 9, 2019
CMS Survey — Mar 18, 2022
Mar 18, 2022
CMS Survey — Jul 3, 2025
Jul 3, 2025
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