The Pines at Catskill Center for Nursing & Rehab

In the surveyor’s words

From the most serious findings on record at The Pines at Catskill Center for Nursing & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 3, 2025

  Based on record review and interviews conducted during recertification and abbreviated (Case # NY00376034) survey, the facility failed to ensure residents were free from neglect for one (1) (Resident #5) of three (3) residents reviewed for neglect. Specifically, on 03/24/2025, Certified Nurse Aide #1 did not use a two-person assist for transfer mobility as required in Resident #5's Comprehensive Care Plan while transferring the resident. Certified Nurse Aide #1 attempted to transfer the resident without assistance from another staff member. Resident #5 fell onto the floor and sustained fractures (bone breaks) to both legs. […]

• No harm, potential for more than minimal, widespreadF727Jul 3, 2025

  Based on interview and record review conducted during the recertification survey, the facility did not use the services of a Registered Nurse for at least eight (8) consecutive hours a day, seven (7) days a week. Specifically, a review of staffing revealed a Registered Nurse was not scheduled for eight (8) consecutive hours on 1/25/2025.This is evidenced by:The Facility's Policy and Procedure titled Quality of Life - Accommodation of Needs, issued 9/2024, documented, the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed as needed throughout the residents stay in the facility. […]

• No harm, potential for more than minimal, patternF656Jul 3, 2025

  Based on record reviews and interviews conducted during the recertification survey (NY00376034), the facility did not develop and implemented comprehensive person-centered care plans for each resident that included measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two (2) (Resident #'s 5 and 27) of 28 residents reviewed for care plans. Specifically, (a.) Resident #5 was care planned for 2- person assist for when transfer. Certified Nurse Aide #1 did not follow care plan resulting in Resident #5 falling and breaking both legs; (b.) Resident #27 had difficulty hearing and had hearing aids. […]

• No harm, potential for more than minimal, patternF761Jul 3, 2025

  Based on observation and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for one (1) (Passport unit) of three (3) medication carts reviewed. Specifically, (a.) two (2) open multi-dose Humalog (insulin) vials were not labeled with a resident's name and (b.) one (1) open multi-dose bottle of Lantus (insulin) was not clearly marked with an open date. This is evidenced by:During an observation on 6/30/2025 at 9:07 AM, the medication cart on the Passport unit was reviewed. Two opened multi-dose vials of Humalog were found in the first draw of the medication cart. A labeled multi-dose bottle of Lantus was also found with an unclear opened date. […]

• No harm, potential for more than minimal, patternF812Jul 3, 2025

  Based on observation and interviews conducted during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served following professional standards for food service safety in four (4) of four (4) resident unit nutrition rooms and the central kitchen. Specifically, the area of the main kitchen and resident kitchenettes was not clean. This is evidenced by:During the initial inspection in the central kitchen on 6/26/2025 at 11:20 AM, coffee cups, containers, pots, and trays were put away wet and contained moisture.During an inspection in the central kitchen on 7/02/2025 at 10:45 AM, the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried. […]