Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mohawk Meadows during CMS and state inspections, most recent first.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure that its services met professional standards of quality, as observed during the survey. The report does not specify particular actions, residents, or incidents involved in this deficiency.
A resident with chronic respiratory conditions used a BiPAP machine for several months without a physician's order, despite facility policy and staff expectations requiring such orders for respiratory interventions. The oversight was discovered during a review of medical records and confirmed through staff interviews.
The facility failed to complete required hiring procedures for new staff, including reference checks, criminal background checks, and physical examinations. This was confirmed through a review of employee files and an interview with the HR Director, revealing multiple instances of missing documentation despite existing policies.
A resident with severe cognitive impairment and a risk for falls was found with their call bell out of reach on two occasions. The facility's policy required the call bell to be within reach, which was confirmed by the LPN and interim DON. The resident's care plan also included this intervention due to their dependency on staff for daily living activities.
A resident with moderately impaired cognition and multiple diagnoses did not receive their preferred two showers per week, as documented in the facility's shower logbook. Despite the facility's policy to honor resident choices, the resident received only 2 out of 11 scheduled showers. Interviews with staff confirmed the expectation for bi-weekly showers, but the facility's administration did not provide further information when concerns were raised.
A resident was observed in a wheelchair with a seatbelt device, which was used without proper authorization or documentation. The resident, who had memory problems and arm contractions, was acknowledged by an LPN to be using the seatbelt for safety, but a nurse confirmed it was not appropriate. The facility's policy requires physician notification and orders for restraints, which were not present in this case.
A resident did not receive the prescribed medication, Abemaciclib, for breast cancer due to the facility's pharmacy not delivering it on time. The medication was ordered but not available, and the resident confirmed not receiving it since admission. The facility's interim DON stated the pharmacy was out of stock and referred them to another pharmacy, with the medication expected to arrive three days later. The facility's policy mandates timely administration of medications.
A facility failed to document the urinary output of a resident with an indwelling urinary catheter as per physician's orders. The resident, who had severe cognitive impairment and was admitted with conditions including urinary tract infection and urine retention, had their catheter output last recorded on the date the order was issued. An LPN confirmed the absence of documentation, citing an incorrectly entered order. The facility's policy required monitoring and documenting output, which was not followed.
A facility failed to maintain complete medical records for a resident with severe cognitive impairment and multiple diagnoses, including dementia and schizoaffective disorder. Despite regular psychiatric visits, notes from May, July, and October were missing from the resident's records, contrary to the facility's policy requiring documentation within three days.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or incidents involved. No further information about the circumstances, individuals affected, or specific events leading to the deficiency is provided in the report.
Failure to Obtain Timely Physician Order for BiPAP Use
Penalty
Summary
A deficiency was identified when a resident with a history of acute and chronic respiratory failure, chronic obstructive pulmonary disease (COPD), and other respiratory conditions was found to be using a BiPAP machine without a physician's order for an extended period. The resident had been admitted with the BiPAP device, and documentation showed use of the machine since November of the previous year. However, a review of the medical record revealed that a physician's order for the BiPAP was not obtained until several months later, despite the resident's ongoing use of the equipment. Interviews with nursing staff and facility leadership confirmed that the expectation was for all respiratory interventions, such as BiPAP, to have a corresponding physician's order. The care plan for the resident included the use of BiPAP as ordered, but the lack of a timely order was not identified or addressed until it was brought to the attention of the Director of Nursing and the Licensed Nursing Home Administrator during the survey. Facility policy required verification of complete and accurate physician orders for all interventions, which was not followed in this instance.
Failure to Complete Required Hiring Procedures
Penalty
Summary
The facility failed to ensure that proper hiring procedures were followed for newly hired staff, as evidenced by the lack of completed reference checks, criminal background checks, and physical examinations for several employees. Specifically, seven out of ten newly hired staff did not have reference checks completed, four out of ten did not have criminal background checks, and two out of ten did not have physical examinations prior to their start date. This was confirmed through a review of ten randomly selected new employee files, which revealed multiple instances of missing documentation. The Human Resources Director confirmed the deficiencies during an interview with the surveyor, acknowledging that the required checks and examinations were not completed for the employees in question. The facility's policy on the hiring process, dated October 2024, mandates that all new applicants undergo criminal background investigations and reference checks before employment, and that new hires obtain a physical examination prior to their first day. Despite these policies, the facility did not adhere to the established procedures, leading to the identified deficiencies.
Resident Call Bell Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call device was readily accessible, which was identified as a deficiency during a survey. On two separate occasions, a surveyor observed a resident lying in bed with the call bell positioned behind the headboard, out of reach. Interviews with the LPN and LPN/Supervisor confirmed that the call bell should be within the resident's reach, and the LPN subsequently placed the call bell next to the resident's right hand. The resident involved had been admitted with unspecified dementia and severe cognitive impairment, as indicated by a BIMS score of 0 out of 15. The resident was dependent on staff assistance for daily living activities and was at risk for falls due to poor safety awareness. The comprehensive care plan for the resident included an intervention to keep the call bell within reach. The interim DON acknowledged the deficiency, and the facility's policy required staff to ensure the call bell was within reach before leaving the room.
Failure to Honor Resident's Bathing Preferences
Penalty
Summary
The facility failed to ensure that a resident's choice for bathing was honored, specifically the preference for two showers per week. During an interview, the resident expressed that they had not received a shower in weeks, despite their preference and the facility's policy. The resident, who has diagnoses including major depression, type 2 diabetes mellitus, and bipolar disorder, was assessed to have moderately impaired cognition and required setup assistance with bathing. The facility's records did not include a physician's order for showers twice per week, but the shower logbook indicated that the resident was scheduled for showers on specific days, which were not consistently provided. Interviews with facility staff, including an LPN and a CNA, revealed that all residents were supposed to receive showers twice a week, and this information was maintained in a notebook at the nursing station. However, the review of the shower logbook showed that the resident received only 2 out of 11 scheduled showers over a period of more than a month. The facility's policy on ensuring resident choices emphasized the importance of honoring resident preferences to improve autonomy and mental well-being. Despite being informed of the surveyor's concerns, the facility's administration did not provide further comments or information regarding the resident's showers.
Failure to Ensure Resident's Freedom from Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, as evidenced by the observation of a resident seated in a wheelchair with a seatbelt device around their waist. The resident, who was unable to respond to inquiries due to memory problems, was observed with contractions in both arms. The Licensed Practical Nurse (LPN) acknowledged that the seatbelt was used for safety and to prevent falls, but the Registered Nurse later confirmed that the resident should not have been wearing the seatbelt device. A review of the resident's records, including the Admission Record and the Quarterly Minimum Data Set, did not show any physician's order or care plan documentation authorizing the use of a seatbelt or restraint. The facility's policy on restraints requires that the attending physician be notified and provide an order for such use, which was not done in this case. The Licensed Nursing Home Administrator confirmed there was no documentation to justify the use of the seatbelt, and no further information was provided during the survey team's discussion with the facility's administration.
Failure to Administer Prescribed Medication for Breast Cancer
Penalty
Summary
The facility failed to ensure that a resident received a prescribed medication, Abemaciclib, for breast cancer according to the physician's order. During a medication administration observation, it was noted that the medication was not available because the facility's pharmacy had not delivered it. The resident confirmed that they had not received the medication since admission. A review of the resident's medical records showed a physician's order for the medication dated two days prior to the observation. The facility's interim Director of Nursing stated that the pharmacy initially contacted did not have the medication and referred them to another pharmacy. The medication was expected to be received three days after the order was placed. The pharmacy confirmed they informed the facility of the unavailability of the medication the day after the order was received. The resident's physician was made aware of the missed doses two days after the order was placed. The facility's policy requires that physician orders be verified and medications administered timely.
Failure to Document Urinary Output for Resident with Catheter
Penalty
Summary
The facility failed to document the urinary output of a resident with an indwelling urinary catheter as per the physician's orders. This deficiency was identified during a survey when a resident, who had severe cognitive impairment and was admitted with diagnoses including urinary tract infection, sepsis, and urine retention, was observed with a catheter. The physician's order dated 10/2/24 required the recording of the resident's urinary catheter output, but the Treatment Administration Record showed that the output was last recorded on the same date, indicating a lack of ongoing documentation. During interviews, an LPN, who was the regular day shift nurse for the resident, acknowledged the absence of recorded urinary output in both electronic and paper charts, attributing it to an incorrectly entered physician's order. The facility's policy on Foley catheter care required monitoring and documenting the resident's output, which was not adhered to. The interim Director of Nursing and the Licensed Nursing Home Administrator were informed of these findings, and they acknowledged the mistake.
Incomplete Medical Records for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to maintain complete and readily accessible medical records for a resident, identified as Resident #86, who had severe cognitive impairment and multiple diagnoses including dementia, schizoaffective disorder, and major depressive disorder. The resident was on several medications for these conditions, and the care plan indicated a need for regular psychiatric consultations. However, during a review of the hybrid medical records, it was found that the most recent psychiatry consult notes were from March 2024, despite the psychiatrist visiting the facility weekly and the resident reportedly being seen in June 2024. The Registered Nurse Supervisor confirmed the absence of recent psychiatry notes in the resident's medical record, and the facility's policy did not address the documentation of psychiatric consults. The Licensed Nursing Home Administrator stated that documentation should be in the resident's medical records within three days of a visit. Upon further investigation, it was revealed that the psychiatrist had left notes for visits in May, July, and October 2024, which were not found in the resident's medical record during the surveyor's review.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 259 citations issued within 25 miles in the last 12 months — including the 7 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Barn Hill | 3.4 mi | ★★★★★ | 12 | 0 |
| Valley View Rehabilitation And Healthcare Ctr | 3.4 mi | ★★★★★ | 0 | 0 |
| United Methodist Communities At Bristol Glen | 3.5 mi | ★★★★★ | 10 | 0 |
| Homestead Rehabilitation & Health Care Center | 6.2 mi | ★★★★★ | 5 | 2 |
| Dwelling Place At St Clares | 12.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.