The Pines at Glens Falls Ctr for Nursing & Rehab

Inspectors wroteBased on record review, observation, and interviews conducted during the survey, the facility failed to ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents reported during interviews that the facility was short-staffed at times, this resulted in call bells not being answered promptly with long wait times for care to be provided. This is evidenced by: The Facility Assessment Exhibit #1- Staffing, dated 07/2025, documented: 2nd Floor Rehabilitation unit desired staffing Day shift: Certified Nursing Assistants five (5) and two (2) Licensed Practical Nurses seven (7) days a week. Evening shift: Certified Nursing Assistants four (4) and two (2) Licensed Practical Nurses (7) days a week. Night shift: [...]

Inspectors wroteBased on observation, record review and interviews conducted during the survey, the facility failed to ensure that drug records were in order; and that an account of all controlled drugs was maintained and periodically reconciled in six (6) of six (6) narcotic books reviewed on Units 2, 3, and 4. Specifically, the shift-to-shift staff signature form for controlled drugs, titled Shift Count did not consistently include the signatures of staff members at each shift change, validating the correct narcotic count. This is evidenced by: A facility policy titled, Controlled Substance Handling (including handling of dropped or refused doses), undated, documented that all controlled drugs would be subject to special receipt, handling, storage, disposal and record keeping. Further documented, in pertinent part, 4. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the survey, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) for eight (8) residents (Resident #s 2, 6, 23, 45, 50, 93, 118, and 137), medications were left at resident bedsides without orders and/or evaluations indicating residents were capable of self-administration; (b.) insulin pens were not individually stored, separating resident pens from comingling; and (c.) Tylenol and Senna (an over-the-counter herbal stimulant laxative used for short-term relief of constipation) pills were loose in medicine cups in one (1) medication cart on the Unit four (4). This is evidenced by: [...]

Inspectors wroteBased on observation, record review and interviews 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 3 of 3 resident unit nutrition rooms and the central kitchen. Specifically, proper food temperature tracking was not tracked, several expired items were identified, and proper dating of open items was not followed. This is evidenced by: During inspection in the central kitchen on 3/10/2026 at 1:00PM the following items were found to be out of compliance with New York State food safety regulations: Review of food temperature logs showed the production temperature logs nor the service logs located on the steam tables had been completed on four shifts since 01/01/2026. The following items were found to be out of their original packages and undated: [...]

Inspectors wroteBased on observations, record review, and interviews during a survey, the facility failed to ensure it maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) (Resident #s 29, 50, 58, 67, and 123) of 30 residents reviewed. Specifically, Resident #s 29 and 67's Foley bag (indwelling urinary catheter collection bag) was hanging under their wheelchair and touched the floor. Resident #s 50, 58, and 123's nebulizer device (coverts liquid medication into a fine mist for direct inhalation) mouthpiece (attached to medication reservoir) and/or mask and tubing were uncovered. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure that comprehensive care plans were developed and implemented according to professional standards for two (2) (Resident #s 38 and 110) of 30 residents revised. Specifically, (a.) Resident #38 had a diagnosis of muscular dystrophy (a group of diseases that cause muscles to become weaker and lose mass over time), ambulated via a power wheelchair, and frequently left the facility unsupervised to attend outside activities. A care plan for leave of absence was not developed and implemented, and (b.) Resident #110 received medications for constipation and a care plan for constipation was not developed and implemented. This is evidenced by: [...]

Inspectors wroteBased on observations, record reviews, and interviews during a survey, the facility failed to ensure residents were treated with dignity and respect for two (2) (Residents #29 and #67) of 30 residents reviewed for dignity. Specifically, for Residents #29 and #67, catheter drainage bags were not covered for privacy. This is evidenced by: The policy and procedure titled Urinary Catheterization, dated 4/24/2024, stated urinary catheter drainage bags should always be covered for privacy. Resident #29 Resident #29 was admitted to the facility with the diagnoses of nondisplaced intertrochanteric fracture (a fracture where the bone is cracked but remains in proper alignment) of right femur, displaced fracture of upper end of left humerus (a break in the left upper arm bone that has moved out of its normal alignment), and retention of urine (inability to fully empty the bladder). [...]

Inspectors wroteBased on record reviews and interviews conducted during the survey, the facility failed to ensure a comfortable homelike environment with reasonable care for protection of residents clothing from loss or theft for one (1) (Resident #42) of two (2) residents reviewed. Specifically, Resident #42 was admitted to the facility with personal clothing that was unable to be located or accounted for after being laundered, there was no documented evidence that an investigation was completed. This is evidenced by: The facility policy titled Misappropriation of Property dated 07/2019 documented on admission a list personal items on personal property including clothing was to be documented on the personal property list form. If a resident claims their property has been lost or misappropriated staff was to conduct an investigation. [...]

Inspectors wroteBased on observation and interviews conducted during the survey, the facility failed to ensure that residents were provided with treatment and care according to professional standards for one (1) (Resident #91) of 30 residents reviewed. Specifically, Resident #91 had a Port a Cath (implanted venous access device) with a sterile dressing that was undated and not adhered to skin creating a risk for Central Line Blood Stream Infection. This is evidenced by: The facility policy titled Implanted Venous Port Accessing dated 01/2022 documented a sterile dressing would be changed at least every seven (7) days and with any complications. The dressing was to be labeled with the date, time, and nurse initials. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure that its medication error rate did not exceed five (5) percent for three (3) (Resident #s 57, 67, and 137) of four (4) residents observed during a medication pass for a total of 27 observations. This resulted in a medication error rate of eleven (11) percent. This is evidenced by: The facility's policy and procedure titled, Medication Pass Policy, revised 9/23/2024, documented, acceptable medication pass time is one (1) hour before and one (1) hour after the scheduled time for most medications. Always observe residents until they have swallowed all medications that have been administered. Do not leave medication in medication cup at the bedside or on tableside. Remember the six (6) rights of medication pass: [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 03/16/23 through 03/22/23, the facility did not ensure food was stored, prepared, distributed or served in accordance with professional standards for food service safety for three (3) of 3 resident unit kitchenettes and the main kitchen. Specifically, in the main kitchen, the microwave oven, slicer, mixer, thermometer holder, ceiling and ceiling lights, wall by kitchen door, and fire extinguishers were soiled with food particles; the framing around the window by the 3-compartment sink was peeling; and the walls behind and around the dishwashing machine were peeling and soiled with black mold. In the 2nd floor, 3rd floor, and 4th floor kitchenettes, the refrigerator door gaskets were soiled with food particles. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure preadmission screening for individuals with a mental disorder and individuals with intellectual disability was performed for 1 (Resident #13) of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR). Specifically, for Resident #13, the facility did not ensure a comprehensive Level 2 assessment and determination/recommendations were completed prior to admission to the facility, following a positive Level 1 determination on the DOH-695 Preadmission Screen form on 11/16/2021. This was evidenced by: Resident #13 Resident #13 was admitted to the facility with diagnoses of bipolar disorder, schizoaffective disorder, and chronic kidney disease. [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 03/16/23 through 03/22/23, the facility did not ensure garbage and refuse was disposed properly. Specifically, the metal plate back piece and metal plate bottom piece of the large dumpster was pulled away creating two 2-foot by 3-inch holes and the drain plug was missing in the small dumpster. This is evidenced as follows: During observations on 03/16/23 at 11:44 AM, the metal plate back piece and metal plate bottom piece of the large dumpster was pulled away creating two 2-foot by 3-inch holes; the drain plug was missing in the small dumpster. During an interview on 03/16/23 at 11:47 AM, the Administrator stated that the vendor will be contacted to replace the large dumpster and to provide a drain plug for the small dumpster. 10 NYCRR 415.14(h)

Inspectors wroteBased on observation, record review and interviews during the recertification survey the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 6 (Resident #'s 29, 34, 60, 71, 78 and #91) of 22 residents reviewed for comprehensive care plans (CCPs). Specifically, for Resident #29, the CCP for anticoagulation therapy did not include an indication or diagnosis for the therapy and the CCP for psychotropic medications did not include person-centered, non-pharmacological interventions; [...]

Inspectors wroteBased on interviews and record review conducted during the recertification survey, the facility did not provide proper treatment and assistive devices to maintain the hearing ability for 1 (Resident #34) of 1 resident reviewed for communication. Specifically, for Resident #34, the facility did not ensure the resident, who had impaired hearing, was provided with an audiologist consultation to be evaluated for hearing aids. This is evidenced by: Resident #34: Resident #34 was admitted to the facility with the diagnoses of cerebral infarction, schizoaffective disorder and epilepsy. The Minimum Data Set (MDS - an assessment tool) dated 8/19/20, documented the resident had moderately impaired cognition, could usually understand others and could make self understood. The Minimum Data Set (MDS) documented the resident had moderate difficulty hearing. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure acceptable parameters of nutrition were maintained for 1 (Resident # 87) of 4 residents reviewed for nutrition. Specifically, for Resident #87, the facility did not ensure re-weights were obtained per facility protocol, the physician was notified of the resident's significant change in weight, and the nutrition care plan included person-centered approaches to maintain acceptable parameters of the resident's nutritional status. This is evidenced by: Resident #87: Resident #87 was admitted to the facility with the diagnoses of intestinal obstruction, atrial flutter, and dysphagia. The Minimum Data Set (MDS - an assessment tool) dated 9/29/20 documented the resident was cognitively intact, could understand others and could make self understood. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #28) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #28, the facility did not ensure a PRN antianxiety medication (lorazepam) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #28: Resident #28 was admitted to the facility with the diagnoses of end stage renal disease, diabetes, and congestive heart failure. [...]

Inspectors wroteBased on observation, staff interview, and record review during the recertification survey, the facility did not adhere to adopted food safety regulations. The safe and sanitary operation of a professional kitchen is to include particular methods of operation. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and floors are required to be kept clean and in good repair. Specifically, the automatic dishwashing machine was not operating within the manufacturer's specifications required to sanitize food contact surfaces, and floors were covered in food debris and missing grout. This is evidenced as follows. [...]