The Pines at Utica Center for Nursing and Rehab

Inspectors wroteBased 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. On 10/10/2025, the resident complained of left leg pain and upon removal of the Unna boot, they were found with a new open wound on the left outer ankle that contained an infestation of maggots. [...]

Inspectors wroteBased 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 (intravenous access site) care to Resident #2. [...]

Inspectors wroteBased on interview and record review during the recertification survey conducted 7/16/2025-7/22/2025 the facility did not develop and implement an effective discharge planning process that focused on the resident's discharge goals for one (1) of three (3) residents (Resident #17) reviewed. Specifically, Resident #17 expressed the intention to be discharged to the community and was not updated on the status of their discharge plan.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025- 7/22/2025, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for three (3) of three (3) residents (Residents #2, #6 and #50) reviewed. Specifically, Resident #6 did not have a comprehensive care plan for the use of anticoagulants (blood thinners); Resident #2 did not have a comprehensive care plan for managing their peripherally inserted central catheter (intravenous line); and Resident #50 did not have bilateral floor mats as care planned.

Inspectors wroteBased on observations, record review, and interviews during the recertification and abbreviated (NY00368679) surveys conducted 7/16/2025-7/22/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two (2) of five (5) residents (Residents #17 and 31) reviewed. Specifically, Resident #17 had brown debris behind long, untrimmed fingernails and Resident #31 had long, sharp fingernails and poor oral hygiene.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of two (2) residents (Resident #1) reviewed. Specifically, Resident #1 had a physician order to provide line-of-sight supervision for all intakes, and the resident was observed eating unsupervised in their room without staff in the vicinity.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure residents maintained acceptable parameters of nutritional status for one (1) of four (4) residents (Resident #39) reviewed. Specifically, Resident #39 had weight loss not addressed by the physician or dietitian and there was no documented verification of the resident's actual weight.

Inspectors wroteBased on observations and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for two (2) of three (3) medication carts (2nd floor low end medication cart and the 4th floor low end medication cart) and one (1) of two (2) medication rooms (2nd floor medication room) reviewed. Specifically, the 2nd floor low end medication cart had one expired inhaler and one opened and undated insulin pen; the 2nd floor medication room had one opened, undated bottle of liquid gabapentin (seizure medication); and the 4th floor low end medication cart had one bottle of expired multidose eye drops and one open and undated insulin pen.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025 - 7/22/2025, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences for four (4) of four (4) residents (Residents #20, #57, #100, and #112) reviewed. Specifically, Residents #20, #57, #100, and #112 did not receive items documented on their meal tickets.

Inspectors wroteBased on observations, record review, and interviews during the recertification survey conducted 7/16/2025 - 7/22/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for one (1) of one (1) main kitchen. Specifically, in the main kitchen the preparation sink was leaking with a puddle underneath; the walk-in cooler had a black substance on the back wall, the cooler contained personal items, undated and/or uncovered food, and expired food; the walk-in freezer had uncovered food items; and the dry food storage area had dented cans. Additionally, the 3rd floor kitchenette had outdated bread.

Inspectors wroteBased 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). This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased 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. Additionally, the resident did not have admission orders for routine short acting insulin and sliding scale short acting insulin as recommended. [...]

Inspectors wroteBased on record review and interviews during the abbreviated survey (NY00308422), the facility did not ensure the residents' environment remained free of accident hazards and residents received adequate supervision to prevent accidents for 1 of 1 resident (Resident #2) reviewed. Specifically, Resident #2 had an unwitnessed fall and complained of pain the following morning. The medical provider was not notified until 2 days after the fall, an x-ray was not completed until 2 days and 17 hours after the resident complained of pain, and an investigation was not initiated timely to rule out abuse. Subsequently, the resident was hospitalized and was diagnosed with a left hip fracture.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00320208 and NY00323561) surveys conducted 1/8/2024-1/12/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #54) reviewed. Specifically, Resident #54 was not provided assistance with bed mobility, incontinence care, and oral and personal hygiene.

Inspectors wroteBased on observation, record review, and interview during the recertification survey conducted 1/8/2024-1/12/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #77) reviewed. Specifically, Resident #77 did not receive a magnetic resonance imaging (a test to view images of the anatomy) to their left heel as ordered to rule out osteomyelitis (bone infection).

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted from 1/8/2024-1/12/2024, the facility did not ensure each resident received food that accommodated resident allergies, intolerances, and preferences for 2 of 4 residents (Residents #1 and #54) reviewed. Specifically, Resident #1 did not receive gluten free (a protein found in some grain products) options as ordered; and Resident #54 was not provided their food preference for 2 meals.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted 1/8/2024- 1/12/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the main kitchen walk-in cooler had a foul odor and food debris on the floor; and steam table pans were stacked wet inside one another and not air dried as required.

Inspectors wroteBased on observation and interview during the recertification and abbreviated surveys (NY00279580) 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 [ROOM NUMBER], 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, commodes, and IV (intravenous) poles.

Inspectors wroteBased on observation, record review, and interview during the recertification and abbreviated (NY00250508, NY00277730, NY00282556 and NY00279580) surveys conducted from 9/27/21-9/30/21, the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 5 of 8 residents (Residents #10, 25, 36, 45, and 50) reviewed. Specifically, Residents #10 and 36 were not assisted with grooming according to their preferences; Resident #25 was not assisted with incontinence care timely; Resident #45 did not receive oral hygiene as care planned; and Resident #50 was not showered as care planned.

Inspectors wroteBased on observation, interview, and record review during the recertification and abbreviated (NY00279580) surveys conducted 9/27/21-9/30/21, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 units (Unit 3) observed. Specifically, areas were in disrepair, and equipment was not clean or working properly and insulated dome plate covers were observed to be unclean.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted on 9/27/21-9/30/21, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 3 of 3 resident units (Units 2, 3, and 4) and the kitchen. Specifically, there was evidence of live fruit flies within the kitchen and the dining rooms on Units 2, 3, and 4.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 9/27-9/30/21, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life for 1 of 1 resident (Resident #55) reviewed. Specifically, staff were observed standing over Resident #55 while assisting the resident with feeding.

Inspectors wroteBased on record review and interview during the recertification survey conducted 9/27-9/30/21, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 3 residents (Resident #55) reviewed. Specifically, weekly weights were not completed as ordered for Resident #55.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted from 9/27/21-9/30/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #66) and for 1 of 5 entrances (service entrance) reviewed. Specifically, Resident #66 was observed with a medicine cup containing 5 pills on their over bed table on a unit that had wandering residents. Additionally, the facility's side service entrance door was propped open during the overnight shift.

Inspectors wroteBased on observation, interview, and record review during the recertification survey conducted from 9/27/21-9/30/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 3 nursing units (Unit 3). Specifically, multiple food items in the Unit 3 kitchenette refrigerator which were unlabeled, undated, and older than 72 hours.

Inspectors wroteBased on observation, record review and interview during the recertification survey and Focused Infection Control Survey (FICS) conducted 9/27/21-9/30/21, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #45) reviewed. Specifically, Resident #45's urinary catheter collection bag was observed resting on the floor on multiple occasions.

Inspectors wroteBased on observation and interview during the recertification survey conducted 9/27/21-9/30/21, the facility failed to post on a daily basis the current resident census and the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in a prominent place readily accessible to residents and visitors for 3 of 4 days reviewed. Specifically, the facility did not post the resident census and nurse staffing information daily, as required.

Inspectors wroteBased on observation, record review and interview during the recertification survey conducted 9/27-9/30/21, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Specifically, the facility did not post results from the 3/23/21 abbreviated survey.