Pines at Utica: Wound Care Failures Caused Resident Harm - NY
Federal inspectors cited the facility for actual harm to residents following a complaint inspection completed November 5, 2025.
The problems started on admission, August 27, 2025. The wound registered nurse who spoke with inspectors said the resident's wounds should have been documented in the admission report with type, location, and measurements, and that physician orders for treatment should have been in place within 24 hours. They were not. When asked why, the wound nurse said they were not sure why the wounds went undocumented and not sure why no treatment orders were placed.
Four days passed. Then 24 more. From August 30 through September 23, a stretch of nearly four weeks, no one performed a documented wound assessment on this resident. When inspectors asked why, the wound nurse said the facility had been short-staffed and had lost its unit manager during that period.
The nurse practitioner who saw the resident was equally in the dark. During an interview on the morning of the inspection, Nurse Practitioner #5 told inspectors they had not been aware the resident went more than two days without a treatment order, had not been aware the resident went four weeks without a documented wound assessment, and said plainly that was not timely.
By October 3, staff documented that both lower legs had healed and discontinued the Unna boots, a type of zinc-impregnated compression wrap used to treat leg wounds. Ten days later, on October 7, the wound nurse showed inspectors a photograph taken of the resident's right foot. It showed pink-tinged gauze wrapped from the toes to just below the ankle. The wound nurse identified it as an Unna boot.
There was no physician order for it.
The wound nurse told inspectors they would not have expected an Unna boot to be in place given that no order existed. Nurse Practitioner #5 told inspectors they had not been aware the Unna boots had been discontinued on October 3, and had not been aware that the wrapping applied on or around October 7 had no physician order behind it.
On October 10, the resident was found to have a wound on their left outer ankle. The nurse practitioner's documentation attributed it to the Unna boot. During the inspection interview, they revised that framing: they should have written that the wound occurred while the Unna boot was on, not that the boot caused it. Staff had told the nurse practitioner the resident was non-compliant, that the resident had been scratching at their legs and pushing objects beneath the wrapping to scratch.
Then the nurse practitioner said something that inspectors recorded without elaboration. They were not sure how the resident got an infestation when the Unna boot was in place.
The wound nurse offered the same uncertainty. They had witnessed the resident scratching and inserting things under the boot, but on the question of the infestation, they had no explanation.
What the record shows is a timeline with gaps at every stage. Wounds documented late. Orders placed late, or not at all. Assessments skipped for 24 days while staff cited short-staffing and a missing unit manager. A compression bandage applied to a healing limb with no order, by staff who acknowledged it should not have been there. A wound developing. An infestation following.
The nurse practitioner, who was responsible for ordering treatments and tracking wound progress, learned most of this for the first time from federal inspectors on November 5.
The resident's legs, the wound nurse said, eventually healed. The infestation is not described further in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Pines At Utica Center For Nursing and Rehab from 2025-11-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
THE PINES AT UTICA CENTER FOR NURSING AND REHAB in UTICA, NY was cited for violations during a health inspection on November 5, 2025.
Federal inspectors cited the facility for actual harm to residents following a complaint inspection completed November 5, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.