Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 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.
Infection control precautions were not maintained for multiple residents with indwelling devices and isolation needs. An RN did not wear PPE during central line care for a resident with osteomyelitis and ESBL, a resident with a urinary catheter had the drainage bag on the floor and later dragging in the hallway, and several residents lacked proper precaution signage or readily available PPE. A resident on contact isolation had no gowns or gloves available, and housekeeping entered without gown and gloves.
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 renal abscesses, vertebral osteomyelitis, and discitis wanted to return home, but discharge planning was not kept current or tied to the resident’s stated goal. Records showed the resident needed max assist or dependence for most ADLs, later required 2-person assist and could not ambulate, and had ongoing needs including nephrostomy care and IV antibiotics. The resident asked about the discharge plan and said no one was helping with therapy or discharge toward home, while staff acknowledged they did not follow up after the last care conference and waited for quarterly meetings to discuss discharge planning.
Incomplete and unimplemented care plans were identified for three residents. One resident with a PICC for IV antibiotics did not have the line or related monitoring included in the care plan, another resident with stroke and fall risk was care planned for bilateral floor mats but only one mat was in use, and a third resident on apixaban for atrial fibrillation did not have anticoagulant therapy or monitoring included in the care plan. Staff interviews confirmed these items should have been addressed in the residents’ care plans.
Failure to provide required line-of-sight supervision during meals: A resident with stroke-related deficits, dysphagia, and severely impaired cognition had orders and a care plan for direct supervision while eating, along with modified diet and feeding strategies. Surveyors observed the resident eating in bed without staff in sight, and on another occasion a CNA set up the meal tray and left the room, after which the resident ate unsupervised and coughed several times while drinking.
A resident with severe cognitive impairment and emphysema had unintended weight loss documented in the care plan, but the facility did not verify a low weight with a timely reweight or document provider notification. Staff reported the resident’s weight was entered by an aide who did not actually weigh the resident that day, and the LPN was unsure why the weight loss was not rechecked or reported in the record.
Medication Storage and Labeling Deficiencies: Surveyors found expired and improperly labeled medications in multiple medication storage areas, including an expired inhaler, opened and undated insulin pens, an opened and undated bottle of liquid gabapentin, and an expired bottle of multidose eye drops. Staff stated that all medications should be dated when opened and discarded if expired or not dated, but these items remained in the carts and medication room.
Meal trays were missing foods listed on meal tickets for several residents with significant nutritional needs. A resident with multiple myeloma did not receive ordered items such as a dinner roll, cornbread, and fortified pudding; a resident with dementia and weight loss did not receive a PB&J sandwich that was part of the meal plan; and a resident with ESRD and severe malnutrition did not receive the expected double portion at lunch. Staff interviews confirmed that missing items and unavailable substitutions were occurring, and that tray accuracy checks were inconsistent.
Food storage and sanitation practices were not maintained in the kitchen and a unit kitchenette. Surveyors observed a leaking prep sink with standing water, a dirty walk-in cooler wall, uncovered and undated food, expired food, personal items stored with food, uncovered freezer items, dented cans, and outdated bread on the unit. The FSD stated food should be covered, dated, and discarded when past use-by dates, and that the leaking sink had been reported to maintenance.
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.
Infection Control Precautions Not Maintained
Penalty
Summary
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 residents reviewed. The deficiency involved transmission-based and enhanced barrier precautions, personal protective equipment use, and handling of indwelling devices and isolation signage for residents with central lines, urinary catheters, nephrostomy tubes, colostomy, and wounds. Resident #2 had diagnoses including osteomyelitis of the right foot/ankle and extended spectrum beta lactamase resistance, and the 6/9/2025 MDS documented intact cognition and central intravenous access. During care, RN Unit Manager #5 did not wear appropriate PPE when providing central line catheter care. Resident #11 had end stage renal disease, extended spectrum beta lactamase resistance, and heart disease, and the 6/26/2025 MDS documented severely impaired cognition and an indwelling urinary catheter. The care plan directed enhanced barrier precautions and keeping the urinary collection bag off the floor, yet the bag was observed directly on the floor mat without a barrier and later dragging on the floor behind the resident in the hallway. Resident #11 also had enhanced barrier precautions signage posted, but no PPE was readily available at the room entrance. Resident #13 had a urinary catheter and colostomy and did not have appropriate transmission-based precaution signage posted. Resident #17 had urinary catheter and nephrostomy tubes and also did not have appropriate signage posted. Resident #80 had a contact isolation sign on the door, but no gowns or gloves were available, and housekeeping entered the room without donning gown and gloves. The Infection Prevention Consultant stated enhanced barrier precautions were for residents with urinary catheters, wounds, or central lines, and that staff should read the signage, wash hands, and put on appropriate PPE before entering rooms on precautions.
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 Maintain Ongoing Discharge Planning for a Resident Seeking Community Discharge
Penalty
Summary
The facility did not develop and implement an effective discharge planning process that focused on the resident’s discharge goals for one resident who wanted to return to the community. The resident had diagnoses including renal abscesses, osteomyelitis of the vertebra, and discitis. The resident’s MDS documented intact cognition, moderately severe depression, no behavioral symptoms, maximum assistance or dependence for most ADLs, and no active discharge planning. The care plan identified a need for a safe and appropriate discharge plan to return home, with interventions to assess discharge needs from admission and throughout the stay. Record review showed the resident’s discharge plan repeatedly changed or remained unclear. Weekly discharge planning notes documented the resident needed skilled care for nephrostomy tubes, pressure wounds, surgical wounds, and training on nephrostomy care, with home as the expected discharge location. Later updates documented the resident required two-person assistance, was unable to ambulate, and it was uncertain whether the resident could return home because of living conditions. A care conference documented the resident’s interest in therapy and being up in a chair more, but there was no updated documentation regarding the discharge plan. Subsequent notes documented the resident’s discharge plan was unclear, the resident exhausted Medicare Part A, and the resident was receiving IV antibiotics three times daily and could not manage them at home. The resident later asked what the discharge plan was and stated they were agreeable to complete IV therapy and then see if they could return home. A later care conference documented the resident did not wish to be long term care, but there was no further documentation showing discharge planning continued toward the resident’s goal of returning home. During interviews, the resident stated no one was helping them work toward going home and that they needed more therapy. Staff interviews indicated discharge discussions were not followed up after the last care conference, that the resident’s wish for therapy and discharge was known, and that the resident wanted to discharge but needed 24-hour care that the family could not provide. The Director of Social Services stated they should not have waited until the quarterly care conference to discuss discharge planning with the resident.
Incomplete and Unimplemented Care Plans
Penalty
Summary
The facility did not ensure that comprehensive person-centered care plans were developed and implemented for three residents. The facility policy stated care plans were to include information necessary to properly care for the resident and be kept current by all disciplines on an ongoing basis. During the survey, the care plans for Resident #2, Resident #6, and Resident #50 were found to be incomplete or not followed as documented. Resident #2 had diagnoses including acute osteomyelitis of the right ankle and foot, was cognitively intact, had intravenous access, and received IV medications. Physician orders included care and maintenance of a PICC line, including dressing changes, tubing changes, needleless connector changes, external catheter length measurement, and saline flushes. The comprehensive care plan addressed antibiotic therapy but did not include the PICC line or interventions for its management and monitoring. During observation, the resident had a PICC in the left upper arm with a dressing dated 7/6/2025. Staff interviews confirmed the PICC should have been included in the care plan because it required ongoing assessments, care, and frequent monitoring. Resident #50 had diagnoses including stroke with right-sided hemiplegia and hemiparesis and falls, and the care plan documented bilateral floor mats for fall prevention. The resident care instructions also stated the resident was a high fall risk and required two bilateral floor mats. However, observations showed only one floor mat in use on the left side of the bed, while the second mat was standing upright and not being used on the floor. Staff interviews confirmed the resident was supposed to have bilateral floor mats and that only one was in use. Resident #6 had atrial fibrillation, moderately impaired cognition, and was prescribed apixaban for anticoagulation. The comprehensive care plan did not include anticoagulant therapy or monitoring for its effects, and staff interviews confirmed anticoagulant therapy should have been included in the care plan.
Failure to Provide Required Line-of-Sight Supervision During Meals
Penalty
Summary
The facility did not ensure the resident environment remained free of accident hazards and did not provide adequate supervision for one resident who had a physician order for line-of-sight supervision during all intakes. The resident had diagnoses including right-sided paralysis and weakness following a stroke, dysphagia, and acute respiratory failure with hypoxia. The resident’s MDS documented severely impaired cognition, a mechanically altered diet, no swallowing disorder, and set-up assistance for eating. The physician order dated 5/15/2024 directed a house diet with regular/whole texture, moderately thick consistency, staff to cut solids into bite-sized pieces, open containers and condiments, follow dining strategies, and provide line-of-sight supervision for intake. The resident’s care plan documented the need for direct supervision, line-of-sight, while eating, along with positioning and feeding strategies. During observations, the resident was seen eating lunch in bed with the tray across their lap and no staff in the room or in line-of-sight. On another observation, a CNA brought the lunch tray into the resident’s room, set it up, and left; the resident then ate without line-of-sight supervision, and coughed several times while drinking. Staff interviews confirmed that a resident requiring eye-line supervision should not be left alone with a meal tray, that the resident was unaware to staff as needing this supervision, and that the resident should not have been left alone in the room with the tray.
Unverified weight loss and missing provider notification
Penalty
Summary
Resident #39 had documented diagnoses including adjustment disorder and emphysema, with severely impaired cognition and dependence for all activities of daily living. The resident’s care plan identified unintended weight loss related to varied oral intake and included interventions to monitor weight changes and report significant loss to the physician, dietitian, family, and physician. The facility policy required monthly weights and verification of significant weight changes for accuracy, with notification and care plan revision if the change was confirmed. During the survey, Resident #39 was observed sitting at a dining room table and being encouraged to eat but not physically assisted. The resident’s weight history showed a documented weight of 99 pounds on 7/7/2025 and a reweight of 107.5 pounds 11 days later after the dietitian reviewed the weights and noted a severe decline over the prior month. Staff interviews indicated the aide who entered the weight did not weigh the resident that day, another aide weighed the resident and informed an LPN of the weight loss, and the LPN was unsure why there was no documentation that the provider was notified or that the resident was reweighed. The dietitian stated the resident should have been reweighed when weight loss was noticed and that follow-up was not documented in the electronic record.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles in the 2nd floor low end medication cart, the 2nd floor medication room, and the 4th floor low end medication cart. Surveyors found an expired inhaler and an opened, undated insulin pen in the 2nd floor low end medication cart, and an opened, undated bottle of liquid gabapentin in the 2nd floor medication room refrigerator. The facility policy stated medications would expire on the manufacturer’s date unless a shorter opened-date expiration was specified on the label, but the policy did not include instructions for labeling multidose vials or discarding expired medications.
Meal Trays Missing Ordered Foods and Nutritional Items
Penalty
Summary
The facility did not ensure that residents received foods documented on their meal tickets, including items tied to allergies, preferences, and nutritional support needs. During the recertification survey, surveyors observed that multiple residents did not receive items listed for them on meal tickets, and the report states there was no documented facility policy regarding accuracy of meal trays. Staff interviews confirmed that missing items were occurring on resident trays and that substitutions were not always made when items were unavailable. Resident #20 had multiple myeloma, moderately impaired cognition, and required set-up assistance for eating. The resident’s care plan and RD notes documented nutritional concerns, including fortified cereal, fortified pudding, and liquid supplements to support weight gain and maintenance. On one observation, the resident’s lunch ticket listed a dinner roll and 2% milk, but neither item was on the tray. On another observation, the ticket listed cornbread, fortified chocolate pudding, and 2% milk, but the tray did not include those items. The resident stated they wanted the cornbread and pudding and would eat them if available. A CNA later provided cornbread, but the pudding was not addressed during that interaction. Resident #57 had dementia, abnormal weight loss, and moderate protein-calorie malnutrition, with care plan interventions to honor food preferences and provide supplements. The resident’s RD note documented weight decline and interventions including a peanut butter and jelly sandwich at lunch and dinner. During observation, the resident’s lunch tray was missing the peanut butter and jelly sandwich listed on the meal ticket, and the resident stated they would eat it if they had it. Staff interviews confirmed that this resident often did not eat the main entree and relied on the sandwich for protein and calories, but it was not always on the tray. Resident #112 had end stage renal disease and severe protein-calorie malnutrition, with a care plan for malnutrition and RD documentation of a low BMI and increased nutritional needs. The resident reported attending dialysis and returning in time for lunch, and stated they were trying to gain weight by eating more. During observation, the lunch ticket listed one pound of meat sauce with spaghetti noodles, but the tray contained only a single portion. The resident stated they were still hungry and said they never received double portions, despite staff and RD interviews indicating double portions were intended for this resident and were expected to be provided.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards in the main kitchen and a 3rd floor kitchenette. During observations in the main kitchen, the preparation sink was leaking and creating puddles on the floor, and there was no documented work order for the leak. The walk-in cooler contained employee personal items, uncovered and undated food items, food past its use-by date, and food stored without dates, including pudding, chicken noodle soup dated 7/9/2025, deli turkey, cooked pasta, diced cooked potatoes, sliced black olives, sliced oranges dated 7/2/2025 with a use-by date of 7/5/2025, and uncovered gelatin. The walk-in freezer contained uncovered food items, and the dry storage area contained dented cans of tuna and cranberry sauce. The back wall of the walk-in cooler also had a black substance on the paneling. In the 3rd floor kitchenette, bread was observed with outdated dates, including a loaf dated 5/22/2025 and later a 1/4 loaf dated 5/21/2025. A Foodservice Aide stated toast was made with the bread that morning and said staff were responsible for checking dates and discarding items past their use-by date, but they were unaware the bread had a use-by date on it. The Food Service Director stated food should be used by the best used by date or expiration date, items transferred to another container should be used within 3 days, all food should be covered, dented cans should be discarded, and the walk-in cooler and freezer should be cleaned daily. The director also stated the leaking sink had been brought to maintenance attention and that pooling water could attract pests.
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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Illustrative
What surveyors actually found near you
We read the 168 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — 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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 1 | 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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