Inspection Reports for
The Pines at Utica Center for Nursing & Rehabilitation
1800 Butterfield Ave, Utica, NY, 13501
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
15.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 5, 2025
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care and treatment, specifically related to wound care and treatment orders for residents.
Findings
The facility failed to ensure residents received treatment and care according to physician orders and professional standards, resulting in actual harm to one resident due to prolonged use of discontinued Unna boots and a subsequent wound infestation with maggots. Documentation and timely wound assessments were inadequate.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences. Resident #1 had physician orders discontinuing Unna boots on 10/03/2025, but the boots remained in place without orders or monitoring, resulting in a new wound with maggot infestation discovered on 10/10/2025.
Report Facts
Residents affected: 3
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #5 | Nurse Practitioner | Documented wound assessment and noted the wound due to Unna boot on 10/10/2025 |
| Wound Registered Nurse #1 | Wound Registered Nurse | Completed wound assessments and provided documentation and interviews regarding wound care |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Documented application of Unna boots and provided interview about wound care |
| Certified Nurse Aide #6 | Certified Nurse Aide | Provided care to resident and reported on dressing status |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Provided treatments and reported presence of Unna boots on 10/09/2025 |
| Licensed Practical Nurse #10 | Licensed Practical Nurse | Removed left leg wrap and discovered wound with maggots on 10/10/2025 |
| Registered Nurse Manager #4 | Registered Nurse Manager | Documented skin and wound evaluation on 10/07/2025 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: Jul 22, 2025
Visit Reason
Multiple quality of care and life safety deficiencies identified, mostly level 2 severity, many corrected by September 20, 2025.
Findings
Multiple quality of care and life safety deficiencies identified, mostly level 2 severity, many corrected by September 20, 2025.
Deficiencies (12)
ADL care provided for dependent residents
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Inappropriate discharge
Infection prevention & control
Label/store drugs and biologicals
Nutrition/hydration status maintenance
Resident allergies, preferences, substitutes
Electrical systems - essential electric syste
Means of egress - general
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jul 22, 2025
Visit Reason
The survey was a recertification and abbreviated inspection conducted from 7/16/2025 to 7/22/2025 to assess compliance with state and federal regulations for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including ineffective discharge planning, incomplete care plans, inadequate assistance with activities of daily living, unsafe resident environment, nutritional deficiencies, improper medication storage, food service inaccuracies, food safety violations, and failure to maintain an effective infection prevention and control program.
Deficiencies (9)
F 0627: The facility failed to develop and implement an effective discharge planning process for Resident #17, who was not updated on their discharge plan status despite expressing the intention to discharge to the community.
F 0656: The facility did not ensure comprehensive care plans for Residents #2, #6, and #50, missing key elements such as management of peripherally inserted central catheter, anticoagulant therapy, and bilateral floor mats for fall prevention.
F 0677: Residents #17 and #31 did not receive necessary assistance with activities of daily living, resulting in poor oral hygiene and long, untrimmed fingernails.
F 0689: Resident #1 required line-of-sight supervision while eating but was observed eating unsupervised in their room, posing a risk of aspiration.
F 0692: Resident #39 experienced significant weight loss without timely re-weighing or notification of family, physician, or dietitian, and no documented verification of weight accuracy.
F 0761: Medications in the 2nd and 4th floor medication carts and 2nd floor medication room were found expired, undated, or improperly labeled, including insulin pens, inhalers, eye drops, and gabapentin.
F 0806: Residents #20, #57, #100, and #112 did not consistently receive food items documented on their meal tickets, including missing fortified pudding, cornbread, milk, and double portions, impacting nutritional status.
F 0812: Food storage and kitchen sanitation were deficient with leaking prep sink, uncovered and undated food in walk-in cooler and freezer, dented cans in dry storage, and outdated bread in the 3rd floor kitchenette.
F 0880: The facility failed to maintain an effective infection prevention and control program; residents with indwelling devices lacked appropriate transmission-based precaution signage and PPE availability, staff failed to wear gowns during central line care, and urinary catheter bags were improperly placed on the floor.
Report Facts
Weight loss percentage: 12.39
Weight measurements: 99
Weight measurements: 113
Weight measurements: 112.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Case Manager #9 | Named in discharge planning deficiencies for Resident #17. | |
| Licensed Practical Nurse #4 | Interviewed regarding care plan and medication cart deficiencies. | |
| Registered Nurse Manager #5 | Interviewed regarding care plan, infection control, and nursing supervision. | |
| Certified Nurse Aide #7 | Interviewed regarding infection control and nutritional care. | |
| Licensed Practical Nurse #13 | Interviewed regarding discharge planning and infection control. | |
| Licensed Practical Nurse Unit Manager #18 | Interviewed regarding infection control, medication cart checks, and nail care. | |
| Food Service Director | Interviewed regarding food service deficiencies and kitchen sanitation. | |
| Registered Dietitian #21 | Interviewed regarding nutritional care and weight loss monitoring. |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jul 22, 2025
Visit Reason
The survey was conducted as a recertification and abbreviated survey to assess compliance with care standards for residents unable to perform activities of daily living independently.
Findings
The facility failed to ensure that residents unable to carry out activities of daily living received necessary assistance with nutrition, grooming, and personal and oral hygiene. Two residents were found with long, untrimmed fingernails and poor oral hygiene despite care plans and policies requiring such care.
Deficiencies (2)
F 0677: The facility did not provide adequate assistance with activities of daily living for residents unable to care for themselves. Resident #31 had long, sharp fingernails and poor oral hygiene with foul breath and white film on teeth despite care plans and documented care attempts.
F 0677: Resident #17 was observed with long, yellowed fingernails and brown/black debris under nails on multiple days. Staff failed to provide nail care despite the resident's expressed dislike of long nails and care plans requiring assistance.
Report Facts
Residents reviewed: 5
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #11 | Certified Nurse Aide | Responsible for bathing and grooming Resident #31; did not provide nail or oral care |
| Certified Nurse Aide #12 | Certified Nurse Aide | Responsible for Resident #31's care; did not notice long or sharp nails |
| Dentist #14 | Dentist | Stated importance of daily teeth brushing and noted Resident #31's poor oral hygiene |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Expected nail and oral care to be completed by CNAs; noted Resident #31's nails were sharp |
| Registered Nurse Unit Manager #16 | Registered Nurse Unit Manager | Oversaw hygiene care; noted importance of nail and oral care for Resident #31 |
| Certified Nurse Aide #24 | Certified Nurse Aide | Responsible for morning care of Resident #17; did not perform nail care |
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Stated CNAs responsible for nail care; noted Resident #17's nails needed care |
| Licensed Practical Nurse Unit Manager #18 | Licensed Practical Nurse Unit Manager | Stated nail care should be done after showers; unaware why Resident #17 did not receive nail care |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: Feb 20, 2025
Visit Reason
Quality of care deficiencies including actual harm related to physician visits and medication errors, all corrected by April 21, 2025.
Findings
Quality of care deficiencies including actual harm related to physician visits and medication errors, all corrected by April 21, 2025.
Deficiencies (3)
Free of accident hazards/supervision/devices
Physician visits - review care/notes/order
Residents are free of significant med errors
Inspection Report
Abbreviated Survey
Deficiencies: 8
Date: Feb 20, 2025
Visit Reason
The survey was conducted as an abbreviated survey to investigate compliance with regulations related to resident safety and medication management.
Findings
The facility failed to ensure adequate supervision and accident prevention for a resident who sustained a fall resulting in a hip fracture. Additionally, the facility did not ensure proper physician review and transcription of medication orders for a diabetic resident, leading to significant medication errors and hospitalization for hyperosmolar hyperglycemic state.
Deficiencies (8)
10NYCRR 415.12(h)(I) - The facility did not ensure the resident's environment was free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a resident's unwitnessed fall and delayed medical response.
10NYCRR 415.12(h)(I) - The facility failed to timely notify medical providers and initiate investigations following a resident's fall, resulting in delayed diagnosis of a left hip fracture.
10NYCRR 415.12(h)(I) - Certified Nurse Aide left a resident unattended in a high bed position, violating care plan and facility protocol, contributing to the resident's fall and injury.
10NYCRR 415.12(h)(I) - Registered Nurse Supervisor failed to notify medical providers and initiate an investigation after a resident fall, violating facility policies.
10NYCRR 415.12(h)(I) - The facility failed to ensure proper staff training and supervision regarding bed safety and fall prevention.
10NYCRR 415.12(m)(2)(iii) - The facility failed to ensure the resident's physician reviewed the total program of care, including medications and treatments, resulting in lack of admission orders for routine short-acting insulin and sliding scale insulin.
10NYCRR 415.15(b)(2)(iii) - The facility failed to ensure residents were free from significant medication errors, including failure to transcribe hospital discharge orders for insulin and blood glucose monitoring, resulting in hospitalization for hyperosmolar hyperglycemic state.
10NYCRR 415.12(m)(2) - The facility failed to properly transcribe and verify physician orders for blood glucose monitoring and insulin administration, leading to missed fingerstick glucose checks and insulin doses.
Report Facts
Residents Affected: 1
Residents Affected: 1
Blood glucose level: 1192
Hemoglobin A1C: 10.7
Insulin dosage: 10
Insulin dosage: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #8 | Certified Nurse Aide | Issued disciplinary notice for care plan violation related to leaving resident in high bed position |
| Registered Nurse Supervisor #6 | Registered Nurse Supervisor | Issued disciplinary notice for failure to notify medical and initiate investigation after resident fall |
| Nurse Practitioner #15 | Nurse Practitioner | Primary care provider for Resident #1, involved in medication order review |
| Licensed Practical Nurse #23 | Licensed Practical Nurse | Documented resident's elevated heart rate and hospital transfer |
| Director of Nursing #21 | Director of Nursing | Provided interview regarding facility policies and fall prevention |
| Medical Director #14 | Medical Director | Provided interview regarding review of hospital discharge orders and diabetes management |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 12, 2024
Visit Reason
The inspection was a recertification and abbreviated survey conducted from 1/8/2024 to 1/12/2024 to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in providing adequate assistance with activities of daily living for a resident, failure to ensure ordered diagnostic imaging was completed, failure to provide food accommodating resident allergies and preferences, and failure to maintain food service safety standards in the kitchen.
Deficiencies (4)
F 0677: The facility did not ensure residents unable to perform activities of daily living received necessary assistance with bed mobility, incontinence care, and oral and personal hygiene for Resident #54.
F 0684: The facility did not ensure Resident #77 received ordered magnetic resonance imaging to rule out osteomyelitis, resulting in delayed diagnosis and treatment.
F 0806: The facility did not ensure residents received food that accommodated allergies, intolerances, and preferences; Resident #1 did not receive gluten free options as ordered, and Resident #54 was served disliked foods.
F 0812: The facility did not ensure food was stored, prepared, distributed, and served in accordance with professional food service safety standards; the walk-in cooler had a foul odor and food debris, and steam table pans were stacked wet.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Stacks of pans: 8
Depth of pans: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Named in observation and interview regarding Resident #54's care deficiencies |
| Certified Nurse Aide #3 | Certified Nurse Aide | Named in interview regarding failure to provide care to Resident #54 |
| Registered Nurse Unit Manager #12 | Unit Manager | Named in interview regarding oversight of Resident #54's care and meal delivery |
| Licensed Practical Nurse Assistant Unit Manager #1 | Licensed Practical Nurse Assistant Unit Manager | Named in interview regarding Resident #77's wound care and MRI order |
| Nurse Practitioner #5 | Nurse Practitioner | Named in interview and progress notes regarding Resident #77's MRI order and wound care |
| Registered Nurse Unit Manager #7 | Unit Manager | Named in interview regarding MRI order follow-up for Resident #77 |
| Transport Scheduler #9 | Transport Scheduler | Named in interview regarding scheduling of Resident #77's MRI |
| Registered Nurse Unit Manager #10 | Unit Manager | Named in interview regarding communication breakdown for Resident #77's MRI |
| Dietary Aide #19 | Dietary Aide | Named in interview regarding meal service and gluten free diet issues |
| Food Service Director | Food Service Director | Named in interview regarding kitchen sanitation and food preparation |
| Cook #21 | Cook | Named in interview regarding food preparation and gluten free diet issues |
| Registered Dietitian #22 | Registered Dietitian | Named in interview regarding dietary assessments and meal ticket generation |
| Certified Nurse Aide #23 | Certified Nurse Aide | Named in interview regarding meal tray delivery and checking |
| Director of Nursing | Director of Nursing | Named in interviews regarding oversight and communication failures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Jan 12, 2024
Visit Reason
Quality of care and life safety deficiencies identified, mostly level 2 severity, corrected by February 20, 2024.
Findings
Quality of care and life safety deficiencies identified, mostly level 2 severity, corrected by February 20, 2024.
Deficiencies (7)
ADL care provided for dependent residents
Food procurement,store/prepare/serve-sanitary
Quality of care
Resident allergies, preferences, substitutes
Building construction type and height
Electrical equipment - power cords and extens
Illumination of means of egress
Inspection Report
Recertification
Deficiencies: 1
Date: Jan 12, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated survey to assess compliance with care standards for residents, specifically focusing on activities of daily living assistance.
Findings
The facility failed to ensure that residents unable to perform activities of daily living received necessary assistance with nutrition, grooming, and personal hygiene. Resident #54 was not provided required assistance with bed mobility, incontinence care, oral and personal hygiene during the survey period.
Deficiencies (1)
F 0677: The facility did not provide care and assistance to perform activities of daily living for Resident #54 who was unable. The resident was not assisted with bed mobility, incontinence care, oral hygiene, or personal hygiene as required.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #3 | Reported not providing incontinence care, repositioning, or personal hygiene to Resident #54 during their shift | |
| Licensed Practical Nurse #2 | Oversaw certified nurse aides and was unaware Resident #54 had not received care | |
| Registered Nurse Unit Manager #12 | Responsible for oversight and stated staff should check, change, and reposition residents every 2-4 hours | |
| Director of Nursing | Stated staff found resident care information and emphasized risk of skin breakdown if care was not provided |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 2, 2023
Visit Reason
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 24, 2023
Visit Reason
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 17, 2023
Visit Reason
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Apr 3, 2023
Visit Reason
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey identified a level 2 deficiency related to reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Sep 30, 2021
Visit Reason
The inspection was a recertification survey conducted from 9/27/21 to 9/30/21 to assess compliance with regulatory standards for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity during feeding, failure to post survey results, unclean environment and equipment, inadequate assistance with activities of daily living, failure to obtain weekly weights as ordered, unsafe medication administration practices, unsecured service entrance door, failure to post nurse staffing and census daily, improper food storage and sanitation, infection control issues related to urinary catheter care, unsafe and unsanitary environment conditions, and ineffective pest control with presence of fruit flies.
Deficiencies (11)
F 0550: The facility failed to treat Resident #55 with dignity during feeding as staff were observed standing over the resident instead of sitting at eye level.
F 0577: The facility failed to post the results of the most recent survey in a place accessible to residents and families, specifically the 3/23/21 abbreviated survey results were not posted.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment on Units 2, 3, and 4 with unclean floors, equipment, dining areas, and resident rooms.
F 0677: The facility failed to provide necessary assistance with activities of daily living for 5 residents, including timely incontinence care, grooming, oral hygiene, and showering.
F 0684: The facility failed to ensure weekly weights were obtained as ordered for Resident #55, with missing weights documented and staff unaware of the omission.
F 0689: The facility failed to ensure a safe environment and adequate supervision to prevent accidents; Resident #66 was observed with unattended medications on their overbed table and the service entrance door was propped open overnight.
F 0732: The facility failed to post daily nurse staffing and resident census information in a prominent place accessible to residents and visitors for 3 of 4 days reviewed.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards; multiple food items in Unit 3 kitchenette refrigerator were unlabeled, undated, or older than 72 hours.
F 0880: The facility failed to maintain an infection prevention and control program; Resident #45's urinary catheter collection bag was observed resting uncovered on the floor multiple times.
F 0921: The facility failed to provide a safe, clean, and comfortable environment; areas in Unit 3 were in disrepair, equipment was unclean or leaking, and insulated dome plate covers were dirty.
F 0925: The facility failed to maintain an effective pest control program; live fruit flies were observed in the kitchen and dining rooms on Units 2, 3, and 4.
Report Facts
Medication count: 6
Fruit flies count: 10
Weight values: 129.8
Weight values: 120.6
Weight values: 112.6
Weight values: 120.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #14 | Licensed Practical Nurse | Named in medication error finding for leaving medications unattended for Resident #66 and in oral hygiene deficiency |
| RN Unit Manager #15 | Registered Nurse Unit Manager | Named in findings related to dignity during feeding, oral hygiene, catheter care, and medication administration |
| CNA #24 | Certified Nurse Aide | Named in failure to obtain weekly weight for Resident #55 |
| Director of Nursing | Director of Nursing | Named in findings related to posting survey results, medication administration, and nurse staffing posting |
| Food Service Director | Food Service Director | Named in findings related to food storage, cleanliness, and pest control |
| Director of Maintenance | Director of Maintenance | Named in findings related to service entrance door security, pest control, and environmental maintenance |
| NP #36 | Nurse Practitioner | Named in discussion of Resident #55's weight and diuretic management |
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