Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Pines At Utica Center For Nursing And Rehab during CMS and state inspections, most recent first.
A resident with venous ulcers did not receive timely wound assessments or appropriate discontinuation of Unna boots after physician orders. The boots remained in place for seven days without an order or monitoring, leading to the development of a new wound with maggot infestation. Staff interviews and documentation revealed lapses in wound care assessment, documentation, and adherence to physician orders, resulting in harm to the resident.
Two residents who were dependent on staff for ADLs did not receive necessary assistance with nail and oral care, resulting in long, untrimmed fingernails with debris and poor oral hygiene. Staff interviews revealed confusion about responsibilities and inconsistent provision of care, despite care plans and facility policy requiring regular grooming and hygiene support.
A resident with type 2 diabetes was discharged from the hospital with orders for both long-acting and short-acting insulin, including a sliding scale. However, the facility failed to implement orders for short-acting insulin and did not monitor blood glucose levels, leading to the resident's hospitalization for hyperosmolar hyperglycemic state. Interviews revealed a lack of follow-through in ensuring all necessary orders were implemented.
A resident with Type 2 diabetes was admitted to an LTC facility with hospital discharge orders for insulin and blood glucose monitoring. However, the facility failed to transcribe these orders into the Medication Administration Record, resulting in the resident not receiving necessary insulin and monitoring for 10 days. This led to the resident being hospitalized for hyperosmolar hyperglycemic state, with a critically high blood glucose level.
A resident with a history of falls and dementia experienced an unwitnessed fall from a high bed position, leading to a delayed diagnosis of a hip fracture. The facility failed to follow protocols for fall prevention and incident reporting, resulting in a lack of timely medical notification and investigation.
Failure to Discontinue Unna Boots and Timely Assess Wounds Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident with a history of lymphedema, morbid obesity, and venous ulcers did not receive wound care in accordance with professional standards, physician orders, and the comprehensive care plan. Upon admission, the resident had multiple wounds, but there was no documented evidence specifying the type, number, or location of these wounds, nor were physician-ordered treatments obtained in a timely manner. The initial wound assessment was incomplete, and there was a lack of documentation regarding wound care orders within the first 24 hours of admission, as required by facility protocol. The resident had physician orders for Unna boots to be applied to both legs, which were later discontinued by physician order. However, documentation and staff interviews revealed that the Unna boots remained in place for seven days after the discontinuation order, without a current physician order and without appropriate monitoring or assessment. During this period, there was no evidence of wound assessments being performed, and the resident's wounds were not evaluated weekly as required. Staff interviews confirmed that the dressings remained in place and were not removed or changed as ordered. On the day the resident complained of severe left leg pain, the Unna boot was removed, revealing a new open wound on the left outer ankle with an infestation of maggots. The resident was subsequently sent to the hospital due to the wound and intractable pain. The facility also lacked a policy addressing non-pressure injury wounds, and staff acknowledged lapses in documentation, assessment, and timely acquisition of physician orders for wound care. These failures resulted in harm to the resident, though the situation was not classified as Immediate Jeopardy.
Failure to Provide Adequate ADL Assistance for Grooming and Oral Hygiene
Penalty
Summary
Surveyors found that the facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in the areas of grooming and oral hygiene, for two residents who were unable to perform these tasks independently. The facility's policy required staff to assist residents with ADLs such as showering, toileting, dressing, and grooming, as documented in each resident's care plan. However, observations and interviews revealed that these services were not consistently provided as required. One resident with a history of cerebral infarction, aphasia, and hemiplegia was observed multiple times with long, sharp fingernails and poor oral hygiene, including foul-smelling breath and a white film on their teeth. Despite documentation indicating that oral care was provided twice daily, both family and staff interviews confirmed that oral and nail care were not consistently performed. Staff expressed confusion about their responsibilities, with some believing that only licensed staff should perform nail or oral care for this resident due to their medical condition, while others simply did not notice the need for care. Another resident, who required maximum assistance for most ADLs due to renal abscesses, osteomyelitis, and discitis, was repeatedly observed with long, yellowed fingernails and brown or black debris under the nails. The resident expressed dissatisfaction with the lack of nail care, stating they could not get anyone to trim their nails. Staff interviews confirmed that nail care was not performed as needed, despite the resident not refusing care and the expectation that such care should be provided on shower days or as needed. Nursing staff acknowledged the deficiency but could not explain why the care was not completed.
Failure to Implement Insulin Orders Leads to Resident Hospitalization
Penalty
Summary
The facility failed to ensure that a resident's physician reviewed the total program of care, including medications and treatments, as required. Specifically, a resident with type 2 diabetes and multiple sclerosis was discharged from the hospital with orders for both long-acting and short-acting insulin, including a sliding scale for insulin administration based on blood glucose levels. However, upon admission to the facility, there were no documented orders for the short-acting insulin or the sliding scale insulin, as recommended in the hospital discharge orders. The resident's hospital discharge summary indicated poorly controlled diabetes, and the plan included specific insulin regimens to manage the condition. Despite this, the facility's admission orders only included the long-acting insulin, and there was no evidence of blood glucose monitoring or administration of short-acting insulin. This oversight led to the resident being hospitalized for a hyperosmolar hyperglycemic state, characterized by severely high blood glucose levels and severe dehydration. Interviews with facility staff revealed that hospital discharge orders were initially reviewed by nursing staff and nurse practitioners, but there was a lack of follow-through in ensuring all necessary orders were implemented. The medical director and nurse practitioner acknowledged the importance of monitoring blood glucose levels and administering appropriate insulin, but there was no documented evidence that this was done for the resident. The deficiency resulted in actual harm to the resident, though it was not classified as Immediate Jeopardy.
Failure to Transcribe Insulin Orders Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, leading to actual harm. The resident, who had a history of poorly controlled Type 2 diabetes and multiple sclerosis, was admitted with hospital discharge orders that included both long-acting and short-acting insulin, as well as blood glucose monitoring. However, the facility did not transcribe the physician orders for blood glucose monitoring and short-acting insulin into the Medication Administration Record (MAR). As a result, the resident did not receive the necessary blood glucose level readings or the recommended insulin for 10 days. The facility's policy required medication reconciliation at the time of admission and within 24 hours, but this process was not effectively carried out. The resident's admission orders included long-acting insulin and blood glucose monitoring, but there was no evidence of orders for routine short-acting insulin and sliding scale insulin. The lack of proper transcription and monitoring led to the resident being hospitalized for hyperosmolar hyperglycemic state, a condition characterized by severely high blood glucose levels, severe dehydration, and confusion. Interviews with facility staff revealed that there was a failure in the transcription process, where orders were not correctly entered into the electronic system, preventing them from appearing on the MAR. This oversight was not caught by the facility's second-check system, which was supposed to verify the accuracy of entered orders. The resident's condition deteriorated due to the lack of appropriate monitoring and insulin administration, resulting in hospitalization with a critically high blood glucose level of 1192 mg/dL.
Failure to Prevent Fall and Delay in Medical Notification
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for Resident #2, who had a history of dementia, falls, and unsteady balance. The resident experienced an unwitnessed fall from a high bed position, which was not immediately reported to medical staff or investigated for potential abuse or neglect. The resident complained of pain the following day, but the medical provider was not notified until two days later, delaying necessary medical evaluation and treatment. The facility's policies on fall prevention and accident/incident reporting were not followed. The resident's care plan required the bed to be in a low position and for staff to remain with the resident during care. However, a certified nurse aide left the resident unattended in a high bed position, leading to the fall. The incident was not documented or investigated in a timely manner, and the medical provider was not informed of the resident's increased pain, resulting in a delayed diagnosis of a left hip fracture. Interviews with staff revealed a lack of adherence to protocols and communication failures. The certified nurse aide involved was unaware of the policy against leaving residents in high bed positions, and the registered nurse supervisor did not initiate an investigation or notify medical staff promptly. The facility's failure to follow established procedures and ensure proper supervision and reporting contributed to the resident's injury and delayed treatment.
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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.
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Nursing homes near Utica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grand Rehabilitation And Nursing At Utica | 0.3 mi | — | 0 | 0 |
| Oneida Center For Rehabilitation And Nursing | 0.7 mi | — | 0 | 0 |
| Utica Rehabilitation & Nursing Center | 1.1 mi | — | 9 | 0 |
| Mvhs Rehabilitation And Nursing Center | 1.2 mi | — | 0 | 0 |
| Charles T Sitrin Health Care Center Inc | 2.6 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.