Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pines At Glens Falls Ctr For Nursing & Rehab during CMS and state inspections, most recent first.
The facility did not maintain sufficient CNA and LPN staffing on multiple units and shifts, as compared to its own Facility Assessment, resulting in fewer staff than the desired levels on several day, evening, and night shifts. Residents reported that staffing shortages led to call bells not being answered promptly and long waits for care. Staffing records showed repeated instances of reduced CNA coverage on night shifts, fewer LPNs than specified on day and evening shifts, and occasions when a night nursing supervisor had to function as a floor nurse with minimal CNA support.
Surveyors found that medications were not consistently stored or managed according to professional standards and facility policy. Multiple residents with conditions such as fractures, dementia, COPD, CHF, atrial fibrillation, sleep apnea, chronic pain, and GERD had saline nasal sprays, eye drops, antifungal products, Tums, calcium carbonate, and topical analgesics left at the bedside without required physician orders, documented self-administration evaluations, or explicit authorization to keep medications in their rooms. Insulin pens for several residents were stored loose together in medication cart drawers rather than individually separated, and cups of loose Tylenol and Senna tablets were found in a medication cart drawer. Staff interviews confirmed that orders, evaluations, and secure storage were required but not consistently implemented.
Incomplete Controlled Substance Count Documentation: The facility failed to keep controlled substance records in order and did not consistently obtain both oncoming and off-going nurse signatures on narcotic count books across multiple units. Observation and record review showed repeated missing signatures on shift count forms, and staff interviews confirmed they knew the count was supposed to be completed and signed by two nurses together at each shift change.
Food was not stored, prepared, distributed, or served according to professional standards in the central kitchen and resident unit nutrition rooms. Surveyors found incomplete food temperature logs, undated items removed from original packaging, unlabeled pitchers and opened bottles of thickened juice, expired food items in the walk-in refrigerator, and dietary staff using a stem thermometer without proper sanitizing practices.
The facility failed to follow infection control practices for several residents. Two residents with indwelling catheters had Foley bags hanging under wheelchairs and touching the floor without privacy covers, and three residents had nebulizer mouthpieces, masks, and/or tubing left uncovered instead of being stored as described in policy. Staff interviews confirmed the expected handling and storage of Foley and nebulizer equipment.
A resident who frequently left the facility unsupervised for outside activities had no LOA evaluation, provider order, or care plan, despite staff confirming the resident’s unsupervised outings and the facility’s LOA policy. Another cognitively intact resident received multiple routine and PRN constipation meds, reported frequent constipation, and had no comprehensive care plan addressing the problem, even though nursing staff stated such a care plan should have been in place.
Two residents with indwelling Foley catheters were observed multiple times with their drainage bags uncovered and visible, including one bag hanging under a wheelchair and another under a chair touching the floor. The facility policy required catheter drainage bags to always be covered for privacy, and RN, LPN, and DON interviews confirmed that the bags should be in a privacy bag or otherwise covered so urine could not be seen.
A resident with toxic encephalopathy, DM2, and depression had clothing missing after laundering, and the personal property form did not document the clothing brought in on admission. Family reported several sweaters and long sleeve tops were missing, staff only checked the laundry area, and there was no documented grievance, missing item form, or investigation. Interviews showed the process was handled verbally rather than through documented follow-up.
Port-a-Cath Dressing Left Peeling and Undated: A resident with a Port-a-Cath and diagnoses including DM2 with CKD had a sterile dressing repeatedly observed peeling off, not adhered to the skin, and not labeled with a date or initials. MAR review showed missed documentation for scheduled dressing/site checks, and staff stated the dressing should be intact, clean, dry, and labeled; when peeling, it should be reinforced or changed. During one observation, hydration infusion was running through the port.
Medication Pass Error Rate Exceeded Allowed Threshold: Surveyors found an 11% medication error rate during a med pass observation. An LPN selected the wrong eye drop for one resident, another LPN recognized that metoprolol should be held because the resident’s BP was below the ordered parameter, and a third LPN administered a late dose of midodrine and began changing the MAR time to match the scheduled time instead of the actual administration time.
Insufficient Nursing Staff Leading to Delayed Call Bell Response and Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents' needs and to ensure resident safety and the attainment or maintenance of each resident's highest practicable well-being. Residents reported during interviews that the facility was short-staffed at times, which resulted in call bells not being answered promptly and long wait times for care. The facility’s own Facility Assessment, dated 07/2025, specified desired staffing levels for the 2nd floor rehabilitation unit and the 3rd and 4th floors, including specific numbers of CNAs and LPNs for day, evening, and night shifts. Review of facility staffing sheets for multiple dates in March 2026 showed repeated deviations from these desired staffing levels across several units and shifts. On numerous dates, the 2nd floor rehabilitation unit had only two CNAs on night shift instead of the three specified, and the 3rd and 4th floors frequently operated with fewer CNAs and/or LPNs than outlined in the Facility Assessment for day, evening, and night shifts. Examples included shifts with only one LPN where two were specified, and shifts with reduced CNA coverage, including some night shifts with only one CNA. On at least one occasion, the night nursing supervisor had to cover as a floor nurse with only one CNA on the night shift. These documented staffing levels, combined with resident reports of delayed call bell response and long waits for care, formed the basis of the deficiency under 10 NYCRR 415.12(h)(1)(2).
Improper Medication Storage and Unapproved Bedside Self-Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were labeled and stored in accordance with professional standards and facility policy, including requirements for self-administration and bedside storage. Multiple residents were observed with medications at their bedside without corresponding physician orders, self-administration evaluations, or documentation permitting them to keep medications in their rooms. Facility policies required medications to be stored in locked areas, prohibited leaving medications at the bedside, and mandated a self-administration evaluation and specific provider orders before residents could self-administer and store medications in their rooms. Several residents were found with medications at their bedside that lacked appropriate orders or evaluations. One resident with atrial fibrillation, hypertension, and aphasia had saline nasal spray on the bedside table on two separate observations, with no documented physician order or self-administration evaluation. Another resident with fractures and osteoporosis had a calcium carbonate chewable tablet left in a medication cup at the bedside; the resident reported staff left it there because they preferred to take it slowly, but there was no order or evaluation for self-administration. A resident with dementia and cataracts had Refresh Tears eye drops and antifungal powder at the bedside on separate observations, with no documented orders or self-administration evaluation. Additional residents, including those with urinary retention, COPD, CHF, atrial fibrillation, sleep apnea, chronic pain, and GERD, were observed with saline nasal sprays, Flonase, Tums, antifungal powder, Icy Hot spray, and Refresh Tears at the bedside. In several of these cases, there were either no physician orders for the specific medications, no orders authorizing self-administration or bedside storage, or no documented evaluations supporting self-administration, despite some residents having prior self-administration safety screens for certain medications only. The facility also failed to store insulin pens and bulk medications in accordance with professional standards. On one unit, Lantus insulin pens for multiple residents were found loose together in the top drawer of both the south and north side medication carts; although the pens and caps were labeled, they were not stored in individual bags, allowing them to touch each other and creating an opportunity for cross-contamination. LPNs interviewed acknowledged that they knew pens needed to be labeled but were unaware they needed to be stored separately so they were not touching. On another unit, two medication cups labeled “Tylenol” and “Senna” in black ink were found in the top drawer of a medication cart, each containing multiple loose tablets. The assigned LPN confirmed the contents but denied placing them there and then discarded the medications. Staff interviews, including with LPNs, an RN, and the DON, confirmed that residents were supposed to have physician orders and competency evaluations to keep medications at the bedside, that medications should be secured and not left loose on bedside tables, and that certain items like nasal sprays and antifungal powders required orders and proper storage, which was not consistently followed in these instances.
Incomplete Controlled Substance Count Documentation
Penalty
Summary
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 of six narcotic books reviewed on Units 2, 3, and 4. The deficiency involved the shift-to-shift controlled substance count records, where the Shift Count forms did not consistently include the signatures of both the oncoming and off-going nurses at each shift change to validate the narcotic count. The facility policy titled Controlled Substance Handling stated that controlled substances were to be specially received, handled, stored, disposed of, and recorded, and that a physical inventory of all controlled drugs was to be made at each shift change by two licensed nurses and documented on an audit record. During observation on 3/13/2026 at 10:00 AM, narcotic sheets on both carts of Unit 3, North and South, were noted to not be consistently signed by two nurses shift to shift. Review of the narcotic books showed multiple missing signatures across Units 2, 3, and 4, including missing oncoming and off-going nurse signatures on numerous dates in the North and South sides of each unit. Interviews confirmed that staff knew the expected process was for two nurses to count the narcotics together and sign the narcotic book at the time of the count. An LPN stated the narcotic count book was supposed to be signed by both nurses at shift change, and other nurses described the same procedure. One LPN stated they did not sign the narcotic book at the change of shift that morning because the book was cumbersome, despite knowing the oncoming and off-going nurses were supposed to sign together. The DON stated the facility became aware during the survey that nurses were not consistently signing the narcotic count book shift to shift and that the procedure should be for two nurses to check the narcotic cards, count the medication together, and sign the narcotic book together every shift change at the time of the count.
Food Storage, Dating, and Temperature Monitoring Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, or served in accordance with professional food service safety standards in the central kitchen and in 3 of 3 resident unit nutrition rooms. During inspection, surveyors found that production temperature logs and service logs on the steam tables had not been completed on four shifts since 01/01/2026. In the central kitchen, several items were found out of their original packaging and undated, including three stacks of American cheese and one portion of sliced ham in the walk-in refrigerator, and two packages of frozen waffles in the walk-in freezer. Surveyors also found multiple items in the dietary refrigerators on each unit that were unlabeled or improperly identified, including pitchers of various unlabeled types of juice and opened bottles of thickened juice of three flavors per unit. In the walk-in refrigerator, expired items were identified, including two quart-size containers of sour cream, one gallon of barbecue sauce, and one 1.36 liter bottle of tomato juice. On the second floor dietary room, dietary staff were observed using a stem thermometer to check food temperatures in the steam tray without using proper sanitizing practices.
Infection Control Lapses With Foley Bags and Nebulizer Equipment
Penalty
Summary
The facility failed to maintain 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 residents. During survey observations, Resident #29 and Resident #67 had Foley drainage bags hanging under their wheelchairs and touching the floor, and the bags were not covered. The facility policy stated that indwelling catheter drainage bags should always be covered and placed below the level of the resident’s bladder, and staff interviews confirmed that Foley bags should be covered and secured off the floor; if found on the floor, the bag was considered contaminated. Resident #50, Resident #58, and Resident #123 had nebulizer equipment with the mouthpiece and/or mask and tubing uncovered. The facility’s nebulizer treatment policy stated that when treatment was complete, the reservoir was to be disconnected, cleaned per manufacturer instructions, and placed in a plastic bag. Staff interviews stated nebulizer equipment should be unplugged when not in use, with the mask and tubing stored in a labeled bag after cleaning and drying. The observations showed the equipment was not stored in the manner described in the facility policies.
Missing Care Plans for Unsupervised Leave and Constipation
Penalty
Summary
Comprehensive care plans were not developed and implemented according to professional standards for two residents. The facility’s policy stated that after the comprehensive assessment, a person-centered care plan would be developed, reviewed, and implemented, with goals, interventions, and responsible staff identified for each problem. The cited deficiency involved one resident who frequently left the facility unsupervised for outside activities and another resident who routinely received multiple medications for constipation, yet neither resident had a corresponding comprehensive care plan addressing those needs. Resident #38 had muscular dystrophy, depression, and hypertension, was cognitively intact, and used a power wheelchair. Record review showed the resident repeatedly left the facility for outside activities, including hockey games and a bank visit, and returned later the same day. Nursing notes documented these outings, and the resident stated they frequently left the facility on their own and sometimes returned when no receptionist was present. Staff interviews confirmed the resident left unsupervised and that nursing and social work were responsible for the leave-of-absence care plan, but no leave-of-absence evaluation, provider order, or care plan was found in the record. Resident #110 had COPD, chronic kidney disease, and peripheral vascular disease, was cognitively intact, and reported being constipated often and using medications to relieve it. The February and March 2026 MARs showed routine and PRN constipation medications, including Miralax, psyllium, senna plus, milk of magnesia, Dulcolax tablets, and Dulcolax suppositories. Staff interviews stated nursing was responsible for care plan development and that the resident should have had a constipation care plan, but the record contained no comprehensive care plan addressing constipation.
Uncovered urinary catheter drainage bags
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for two residents whose urinary catheter drainage bags were left uncovered. The facility policy titled Urinary Catheterization, dated 4/24/2024, stated urinary catheter drainage bags should always be covered for privacy. Resident #29 was admitted with diagnoses including a nondisplaced intertrochanteric fracture of the right femur, a displaced fracture of the upper end of the left humerus, and urinary retention. The resident’s MDS dated 03/09/2026 documented severe cognitive impairment, while also noting the resident was able to be understood and understood others. A physician order dated 03/04/2026 directed an indwelling Foley catheter to straight drainage for retention. Resident #29 was observed on 03/10/2026 at 12:22 PM, 03/12/2026 at 9:49 AM, and 03/12/2026 at 2:00 PM with the urinary catheter drainage bag hanging under the wheelchair without a privacy cover, including in the hallway and physical therapy gym. Resident #67, admitted with diagnoses including atrial fibrillation, orthostatic hypotension, and dementia, had an MDS documenting severe cognitive impairment and ability to be understood and understand others. Resident #67 was observed on 03/10/2026 at 11:21 AM and 12:06 PM with the urinary catheter drainage bag uncovered, and on 03/16/2026 at 10:00 AM with the bag uncovered under the chair and touching the floor. RN #4, LPN #8, RN #1, and the DON each stated that urinary catheter drainage bags should be covered with a privacy bag or leg bag so urine could not be seen.
Missing resident clothing was not documented or investigated
Penalty
Summary
The facility failed to ensure a comfortable homelike environment with reasonable care for protection of a resident’s clothing from loss or theft for one resident. Resident #42 was admitted with toxic encephalopathy, type 2 diabetes mellitus, and depression, and the MDS dated 02/04/2026 documented that the resident could be understood, understand others, and was cognitively intact. The facility’s policy stated that personal items, including clothing, were to be documented on the personal property list form at admission, and that if a resident claimed property was lost or misappropriated, staff were to conduct an investigation. Review of the resident’s personal property form dated 11/17/2025 did not document the clothing the resident had upon admission. The resident’s family reported that clothing brought in at admission was collected by staff, and that several sweaters and long sleeve tops were later missing after laundering. The family stated they checked the laundry area with staff, but the clothing was not located and there was no further follow-up after that search. Staff interviews showed that missing clothing was handled by verbally notifying laundry and looking in the laundry area, but there was no documented missing item form, grievance, or investigation for the resident’s missing clothing. The RN, Director of Social Services, Administrator, and CNAs all described verbal communication as the process for missing clothing, and acknowledged there were no missing item forms for the resident’s clothing. The report also states there was no documented evidence of a search for, or the location of, the missing clothing.
Port-a-Cath Dressing Left Peeling and Undated
Penalty
Summary
Resident #91 had a Port-a-Cath with a sterile dressing that was repeatedly observed to be peeling off, not adhered to the skin, and not dated or labeled with a signature or initials. The resident was admitted with diagnoses including cholecystitis, Type 2 diabetes mellitus with chronic kidney disease, and chronic kidney disease stage 3B. The Minimum Data Set dated 01/24/2026 documented that the resident could be understood, understand others, and was cognitively intact. Record review showed the facility’s medication administration records documented weekly sterile membrane dressing changes and supervisor checks of the intravenous site on specified evenings, but there was no documented evidence of a Port-a-Cath dressing change on 02/25/2026 and no documented evidence of several scheduled site checks in February and March 2026. The records also did not show any medication administration order to check the vascular access device every two hours during continuous infusion or every shift when not in use. The care plan for intravenous therapy documented monitoring the site for placement and signs or symptoms of infection every shift and changing the dressing every seven days and as needed. During observations on 03/10/2026, 03/16/2026, and 03/17/2026, the dressing at the Port-a-Cath site on the resident’s right upper chest was noted to be peeling off and not adhered to the skin. On 03/17/2026, hydration infusion was running via infusion pump. The resident stated the dressing frequently peeled off and nurses sometimes placed tape over the bottom if they noticed it. The Nurse Educator and RN stated they would expect the dressing to be intact and labeled, and that if it was peeling it should be reinforced or changed. The DON stated the Port-a-Cath dressing should always be clean, dry, intact, and labeled with a date, and that if it was not intact it would be a potential for infection.
Medication Pass Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that its medication error rate remained below 5 percent during a medication pass observation involving 27 medication administrations for four residents. Surveyors determined the facility’s medication error rate was 11 percent based on observed errors involving three residents. The facility’s Medication Pass Policy, revised 9/23/2024, stated acceptable medication pass time is one hour before and one hour after the scheduled time for most medications, that residents must be observed until all medications are swallowed, and that medications should not be left at the bedside or tableside. Resident #137 had diagnoses including atrial fibrillation, chronic pain, and GERD without esophagitis, and was documented as cognitively intact. During observation, an LPN reviewed the MAR and stated the resident was to receive carboxymethylcellulose sodium ophthalmic solution at 9:00 AM, but the bottle pulled from the cart was Lumigan eye drops. The surveyor identified the discrepancy, and the LPN stated the wrong medication had been selected in error and replaced the Lumigan eye drops. Resident #57 had diagnoses including atrial fibrillation, hip fracture, and depression, and was documented as significantly cognitively impaired. During observation, an LPN reviewed the MAR and prepared metoprolol tartrate for the resident at 9:50 AM after checking vital signs that showed a blood pressure of 99/66. The order required holding the medication for systolic blood pressure less than 100, and the LPN recognized the parameter and stopped administration, documenting the medication as held. Resident #67 had diagnoses including atrial fibrillation, orthostatic hypotension, and dementia, and was documented as severely cognitively impaired. During observation, an LPN administered midodrine hydrochloride 2.5 mg oral tablet scheduled for 7:30 AM at 9:17 AM, then began changing the administration time in the electronic record to 7:28 AM instead of the actual time. The surveyor stopped the time change, and the LPN stated they had been told to back date late medications to the due time, while other nurses stated they documented the actual time given and notified the provider or nurse manager.
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What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Glens Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fort Hudson Nursing Center Inc | 3.6 mi | ★★★★★ | 0 | 0 |
| Glens Falls Center For Rehabilitation And Nursing | 4.6 mi | ★★★★★ | 0 | 0 |
| Warren Center For Rehabilitation And Nursing | 4.9 mi | ★★★★★ | 21 | 0 |
| Washington Center For Rehab And Healthcare | 9 mi | ★★★★★ | 11 | 0 |
| Slate Valley Center For Rehabilitation And Nursing | 16.7 mi | ★★★★★ | 0 | 0 |
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