The Pines at Utica Center for Nursing and Rehab

In the surveyor’s words

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

• Actual harm, isolatedF684Nov 5, 2025

  Based on record review and interviews during an abbreviated survey (iQIES ID# 2648127), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (1) of three (3) residents (Resident #1). Specifically, Resident #1 had physician orders discontinuing their Unna boots (gauze bandage soaked in a wound treatment, wrapped from toes to knees that provided compression and remained in place for up to one week) on 10/03/2025, and there was documented evidence the Unna boots remained in place for seven (7) days without an order and without monitoring. […]

• Actual harm, isolatedF711Feb 20, 2025

  Based on record review and interviews during the abbreviated survey (NY00309249) the facility did not ensure the physician reviewed the total program of care, including medications and treatments, for one (1) of four (4) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge orders included routine short-acting insulin and sliding scale (the amount of insulin administered was based on the results of blood glucose finger sticks) short-acting insulin. The resident did not have admission orders for routine short-acting insulin and sliding scale short-acting insulin as recommended. Subsequently, Resident #1 was hospitalized for hyperosmolar hyperglycemic state (severely high blood glucose levels with severe dehydration and confusion). […]

• Actual harm, isolatedF760Feb 20, 2025

  Based on record review and interviews during the abbreviated survey (NY00309249), the facility failed to ensure residents were free of significant medication errors for one (1) of four (4) residents (Resident #1) reviewed. Specifically, Resident #1's hospital discharge orders included routine short acting insulin and sliding scale (the amount of insulin administered is based on the results of blood glucose finger sticks) short acting insulin. The resident's admission physician orders included long-acting insulin and blood glucose monitoring before and after meals, and at bedtime. The physician orders were not transcribed to the Medication Administration Record and the resident did not have blood glucose level readings completed for 10 days. […]

• No harm, potential for more than minimal, patternF880Jul 22, 2025

  Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025 - 7/22/2025, the facility failed to establish and 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 (5) of five (5) residents (Residents #2 #11, #13, #17 and #80) reviewed. Specifically:Resident #11's urinary catheter (drains urine from the bladder) collection bag was directly on the ground without a barrier, and the resident did not have appropriate transmission-based precaution signage posted.Registered Nurse Unit Manager #5 did not wear appropriate personal protective equipment when providing central line catheter… […]

• No harm, potential for more than minimal, patternF584Sep 30, 2021

  Based on observation and interview during the recertification and abbreviated surveys (NY 580) conducted 9/27/21-9/30/21, the facility failed to provide residents with a safe, clean, comfortable, and homelike environment for 3 of 3 resident units (Units 2, 3, and 4) reviewed. Specifically, there were unclean floors in unit dining rooms, unclean door handles, baseboards, unclean fall mats in resident room 220, the window sills in the unit dining rooms were unclean with bugs, dining tables in unit dining rooms were unclean, food carts were unclean with uncovered food items, light fixtures within the unit dining rooms were unclean and contained bugs, dining room floors and resident floors were unclean with food debris and spills, and there was unclean resident equipment including bedframes,… […]