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 Mvhs Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A facility failed to ensure residents had access to grievance forms, a clear grievance process, or a way to file anonymous complaints. During a resident group meeting, all 8 anonymous residents said they did not know where to get forms, how to file anonymously, or who the grievance official was. Staff interviews and observations found no grievance forms or drop boxes in resident-accessible areas, and the facility policy did not include an anonymous grievance process.
Failure to Provide Hot Beverages Listed on Meal Tickets: Multiple residents were not served hot beverages that were listed on their meal tickets during breakfast service, including coffee, tea, and hot chocolate. Staff gave conflicting accounts of whether nursing or dietary was responsible for pouring drinks, and the CNM stated all ticketed items should be offered because they were part of the residents’ nutritional plan.
Improper refrigeration of food items in the meat and dairy cooler was identified during survey observations. The cooler’s thermometer readings were inconsistent, and multiple foods such as butter, cheese, milk, eggs, ham, and bologna were found above the acceptable temperature range. Staff relied on an inaccurate thermometer, did not routinely check internal food temperatures, and were unaware how long the items had been out of temperature.
A resident was admitted without documented evidence of a required Level I PASRR screen completed before admission. Staff stated the PASRR form was often not in the chart until after admission, and the Admissions Coordinator printed hospital documents labeled PAI and screen but not the required DOH-695 form. The DON confirmed the facility did not have the PASRR form on file for the resident.
Insufficient nursing staffing led to delayed resident care and prolonged call bell response times. Residents reported frequent short staffing, with only 2 CNAs on some units and long waits for toileting and assistance, resulting in incontinence and frustration. Survey observations showed call bells left unanswered for 35 to 78 minutes, and staff confirmed that when staffing was low, toileting, showers, repositioning, and other care were delayed.
Failure to Follow Enteric Pathogen Precautions: A resident with active C. diff, diarrhea, and bowel incontinence was on enteric pathogen precautions requiring gown, gloves, and soap-and-water hand hygiene. A housekeeper entered the room and cleaned without the required PPE, and a CNA delivered a meal tray without gown, gloves, or hand hygiene before continuing to pass trays to other residents. Staff interviews showed inconsistent understanding of when PPE was required.
Grievance Process and Anonymous Complaint Access Not Available
Penalty
Summary
The facility did not ensure a process was in place for residents to have grievances addressed appropriately for all 190 residents. During the recertification survey, information on how to file a grievance and grievance forms were not available to residents, and the facility did not have a process for residents to file an anonymous grievance. The facility policy on Complaint Management, revised 11/18, stated grievance officer posters were located by the elevators and that staff were to report complaints to their immediate supervisor, who would initiate a complaint form at the request of a resident, resident representative, interested family, visitor, or advocate. The policy did not include a process for filing an anonymous grievance. During the resident group meeting, 8 of 8 anonymous residents stated they did not know how to obtain grievance forms, how to file a grievance anonymously, or who the grievance official was. Staff interviews and observations confirmed grievance forms were not available at the nurse's station, in the lobby, or in other resident-accessible areas, and no grievance drop boxes were observed in the lobby areas or by the elevators. Multiple staff members stated residents should go to the Unit Manager, Social Work, or a supervisor if they had a concern, while the Manager of Social Services stated the facility had specific grievance forms but they were not out for people to complete and were kept on the intranet and in unit filing cabinets. The Manager of Social Services also stated the facility did not have an anonymous grievance policy and was not sure whether residents knew who the grievance official was.
Failure to Provide Hot Beverages Listed on Meal Tickets
Penalty
Summary
The facility did not ensure that residents received food and beverages that matched their meal tickets and preferences during breakfast meal service. During observations on 7/18/2025 and 7/21/2025, 12 of 18 reviewed residents were listed for hot beverages such as coffee, tea, or hot chocolate on their meal tickets but were not provided those items. The affected residents included Residents #3, #17, #47, #56, #67, #86, #110, #117, #146, #150, #158, and #187. The facility policy stated that food had to be delivered in a safe, accurate, effective, and timely manner, and that licensed nurses or CNAs were responsible for checking trays for missing items. The Clinical Nutrition Manager stated that meal profiles were based on resident preferences and that all items listed on the ticket, including hot cocoa, hot tea, and coffee, should be offered. Staff interviews showed confusion about responsibility for pouring drinks, with nursing and dietary both described as sharing the task, and one CNA stated that if coffee was on the ticket they asked the resident because most did not want it. A RN Unit Manager stated that everything on the meal ticket should be provided because it was part of the resident’s nutritional plan. During the interview, Resident #86 requested coffee with cream and sugar, but the hot coffee listed on the ticket was not provided.
Improper Refrigeration of Food Items in Meat and Dairy Cooler
Penalty
Summary
The meat and dairy walk-in cooler in the main kitchen did not maintain food temperatures below 41 degrees Fahrenheit during the recertification survey. During an observation with the Food Service Director, the cooler’s outside analog thermometer read 50.0 degrees Fahrenheit while the inside thermometer read 39-40 degrees Fahrenheit, but multiple food items in the cooler were measured above acceptable temperatures, including butter at 45.0 degrees Fahrenheit, pickles at 45.0 degrees Fahrenheit, feta cheese at 55 degrees Fahrenheit, bologna at 52.7 degrees Fahrenheit, and milk at 45 degrees Fahrenheit. The Food Service Director stated the foods should not have been out of temperature for more than 2 hours and that the temperatures were not acceptable. During a later interview, the Food Service Manager stated 40 degrees Fahrenheit was considered acceptable for the cooler and that staff relied on the thermometer hanging inside the cooler because the external thermometer was old and not accurate. Staff stated internal food temperatures were only checked if there was a suspicion of a problem and that recent internal temperature checks had not been performed. When the cooler was rechecked, additional foods were found out of temperature, including cottage cheese at 52 degrees Fahrenheit, coleslaw dressing at 50 degrees Fahrenheit, provolone cheese at 53 degrees Fahrenheit, tzatziki at 51 degrees Fahrenheit, sour cream at 48 degrees Fahrenheit, liquid eggs at 46-49 degrees Fahrenheit, string cheese at 48 degrees Fahrenheit, ham at 51-53 degrees Fahrenheit, and bologna at 51 degrees Fahrenheit. The Food Service Manager later stated the items were discarded and that staff were unaware how long the food had been out of temperature.
Missing PASRR Screening Before Admission
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed for one resident prior to admission. The resident had diagnoses including encounter for orthopedic after care and osteomyelitis, and the 12/8/2024 MDS documented that the resident was admitted from an acute hospital, was cognitively intact, did not require a Level II PASRR, and needed extensive assistance with most activities of daily living. There was no documented evidence that a Level I Preadmission Screening and Resident Review had been completed by a qualified screener before admission as required by facility policy and state regulation. During the survey, the Manager of Social Services stated chart audits for PASRR forms were typically done but had not been completed because of increased job duties, and that the form often did not appear in the facility chart system until two to three days after admission. The Admissions Coordinator stated they printed admission information from the hospital computer system and provided it to the unit, but for this resident they printed two separate documents labeled Patient Review Instrument and Screen, neither of which included the required DOH-695 PASRR screen form. The DON stated the facility did not have the PASRR form for the resident and that the screening was supposed to be reviewed before the resident was accepted for admission.
Insufficient Nursing Staffing and Delayed Call Bell Response
Penalty
Summary
The facility did not provide sufficient nursing staff each day to meet resident needs or ensure a licensed nurse was in charge on each shift. During the recertification survey, residents, staff, and observations showed repeated short staffing on the unit, with staffing levels below what was described in the facility assessment and staffing plan. The unit had a census of 39 residents, including one resident requiring one-to-one supervision, yet staffing sheets showed shifts with only 1 licensed nurse and 2 to 3 certified nurse aides at times, and the staffing sheets did not reflect the resident assigned to one-to-one supervision. During a confidential resident group meeting, 8 of 8 anonymous residents said the facility was frequently short staffed, especially during mealtimes and when staff had to assist residents requiring one-to-one supervision. Residents reported that each unit had about 36 to 38 residents and only 2 CNAs, and that there was no extra staff to assist with wandering residents. One resident stated there was not enough staff to go around, that they often waited at least an hour to use the bathroom, and that if the call bell was not answered timely they became incontinent and soaked through their clothes. Another resident stated staff sometimes took a long time to help them to bed and that they became frustrated waiting. Survey observations documented prolonged call bell response times for two residents. One resident’s call bell was observed on for 30 minutes and answered after 41 minutes, and later the same resident’s call light was on for 33 minutes and answered after 35 minutes. Another resident’s call bell was observed on for 78 minutes, and the resident stated they had rung for help to use the bathroom and had been incontinent while waiting. Staff interviews confirmed that the unit was often short staffed, that call bell response times were longer when staffing was low, and that toileting, showers, repositioning, and other resident care were delayed when only 2 aides were available. Staff also stated that the minimum staffing on the unit was 1 nurse and 3 CNAs for about 40 residents, but that the unit often did not have enough staff to care for resident needs.
Failure to Follow Enteric Pathogen Precautions
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program for Resident #91, who had active clostridium difficile, moderate cognitive impairment, and was always incontinent of bowel. The resident’s care plan included contact isolation, and the physician documented active diarrhea with clostridium difficile likely recurring, with testing planned and oral vancomycin started. Facility policy required enteric pathogen precautions, including a sign outside the room, a PPE caddy at the door, gown and gloves for entry, and hand washing with soap and water when exiting the room. During observation, Housekeeper #7 entered the resident’s room without a gown and cleaned the room without the required PPE, then exited without changing gloves and entered the shower room next door. The housekeeper stated they usually wore gowns in enteric pathogen rooms but forgot that day, and later washed hands in a chemical sink in the janitor room. During another observation, Certified Nurse Aide #9 entered the room and delivered the resident’s lunch tray without a gown, gloves, or hand hygiene, then exited and continued passing trays to other resident rooms. Staff interviews showed differing understanding of the precautions, with one CNA stating PPE was only needed for hands-on care and a unit manager stating precautions were not needed for food delivery.
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Illustrative
What surveyors actually found near you
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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.
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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 | 0.9 mi | ★★★★★ | 0 | 0 |
| Utica Rehabilitation & Nursing Center | 1.1 mi | ★★★★★ | 9 | 0 |
| The Pines At Utica Center For Nursing And Rehab | 1.2 mi | ★★★★★ | 1 | 0 |
| Oneida Center For Rehabilitation And Nursing | 1.6 mi | ★★★★★ | 1 | 0 |
| Charles T Sitrin Health Care Center Inc | 3.7 mi | ★★★★★ | 0 | 0 |
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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.