Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Grand Rehabilitation And Nursing At Mohawk during CMS and state inspections, most recent first.
A resident with a history of aspiration pneumonia, hyperphagia, and dysphagia, who required 1:1 supervision and aspiration precautions during meals, was left unattended in the dining room. The resident accessed inappropriate food consistency from another plate, began choking, and showed signs of distress that were not recognized or acted upon by staff. The resident was later found unresponsive and was pronounced deceased after resuscitation was attempted. Staff interviews revealed gaps in communication and documentation regarding the resident's supervision needs.
A resident with a Full Code status was found unresponsive and pulseless in the dining room. Staff did not begin CPR immediately at the scene, instead moving the resident to their room before starting chest compressions. The delay in initiating basic life support was confirmed by staff interviews and surveillance footage, and the resident was later pronounced deceased after EMS arrival.
A resident with multiple medical conditions requiring substantial toileting assistance was left unattended in the dining room for over three hours after lunch, without being checked or provided incontinence care as required by their care plan. Staff interviews and surveillance video confirmed that scheduled two-hourly checks and changes were not performed, resulting in the resident remaining in soiled conditions until found unresponsive.
Several residents who required assistance with daily living activities did not receive care as outlined in their care plans, including missed showers, lack of shaving, unclean fingernails, and inadequate help during meals. Staff were often unaware of care requirements or failed to document and provide necessary services, resulting in unmet needs for nutrition, hygiene, and personal dignity.
The facility failed to maintain acceptable hot water temperatures on the second and third floors, and clean linen supplies on the second, third, and fourth floors were stained. Staff and residents reported ongoing issues with the lack of hot water, preventing proper care such as showers and nighttime care. The stained linens raised concerns about cleanliness, compromising the residents' right to a safe, clean, comfortable, and homelike environment.
Failure to Provide Adequate Supervision and Aspiration Precautions During Meals
Penalty
Summary
A deficiency occurred when a resident with a history of aspiration pneumonia, hyperphagia, and dysphagia, who was on aspiration precautions and required 1:1 supervision during meals, was left unattended in the dining room. The resident's care plan and Kardex did not fully document the required aspiration precautions or specialized feeding techniques, and staff were not consistently informed or aware of the specific supervision and assistance needed. The resident was served a ground diet with honey thick liquids, but was able to access inappropriate food consistency from another resident's plate due to lack of supervision. During the meal, there were no licensed nurses present in the dining room, and certified nurse aides did not provide the required 1:1 supervision. The resident was observed on surveillance video reaching for and consuming food from a neighboring plate, then displaying signs of distress, including waving arms and banging on the chest, which went unnoticed by staff present in the dining room. Dietary and housekeeping staff saw the resident in distress but did not intervene or notify nursing staff. The resident remained unattended for an extended period, and was later found unresponsive. Interviews with staff revealed confusion and lack of communication regarding responsibility for supervision and the specific needs of the resident. The speech language pathologist had documented and verbally communicated the need for 1:1 supervision and specialized feeding strategies, but these were not incorporated into the care plan or visible to all staff. The lack of adequate supervision and failure to follow aspiration precautions directly led to the resident choking and subsequently being pronounced deceased after resuscitation efforts.
Removal Plan
- All staff were educated on Aspiration Precautions, Dining Supervision, and Notification of Change in Condition.
- The facility attestation documented 87% of staff were educated with a plan to educate the remaining staff prior to the beginning of their next work assignment.
- Staff interviews verified understanding and retention of education provided.
Failure to Initiate Immediate CPR for Unresponsive Resident
Penalty
Summary
The facility failed to provide immediate basic life support, including CPR, to a resident who was found unresponsive and without a pulse in the dining room. Surveillance footage showed that after the resident was discovered, staff did not initiate CPR at the scene. Instead, a certified nurse aide alerted a licensed practical nurse, who then left the dining room to check for the resident's code status. Upon confirming the resident was a Full Code, staff decided to move the resident from the dining room to their room before starting chest compressions. During this time, other staff members were observed entering the dining room, making phone calls, and retrieving the crash cart. Emergency Medical Services were called and arrived several minutes later, at which point the resident was pronounced deceased. The facility's policy required immediate initiation of CPR by certified staff unless a do not resuscitate order was present, which was not the case for this resident. Interviews with staff and the Director of Nursing confirmed that CPR should have been started immediately at the point of care, but this did not occur. The delay in initiating CPR was due to staff leaving the area to check documentation and moving the resident to another location before starting resuscitation efforts.
Failure to Implement Scheduled Toileting and Care Plan Interventions
Penalty
Summary
A deficiency occurred when staff failed to implement a comprehensive, person-centered care plan for a resident with diagnoses including aspiration pneumonia, progressive hyperphagia, and dysphagia. The resident required substantial to maximal assistance with toileting and was on a scheduled toileting program, as documented in the care plan and facility policies. Despite these documented interventions, surveillance video and staff interviews revealed that after lunch, the resident was left unattended in the dining room from 12:10 PM to 3:15 PM without being checked or provided with incontinence care as required every two hours. Documentation did not reflect that the resident was toileted or checked during this period, contrary to the care plan and physician orders. Staff interviews confirmed that the resident was last assisted with toileting around 11:45 AM and was not provided further care after lunch, as staff were occupied with other duties or residents. The resident was eventually found unresponsive at 3:15 PM, and there was no evidence that the required two-hourly checks and changes were performed between 12:10 PM and 3:15 PM. This failure to follow the care plan and facility policy resulted in the resident remaining in soiled conditions for an extended period, as observed and documented by surveyors.
Failure to Provide Required Assistance with Activities of Daily Living
Penalty
Summary
Multiple residents who were unable to perform activities of daily living did not receive the necessary care and assistance as required by their care plans and facility policies. One resident with a fractured left hand and wrist, who required substantial assistance with showering and personal hygiene, was observed with long, untrimmed facial hair and reported not receiving regular showers or shaving. Documentation confirmed missed showers on scheduled days and inconsistent recording of personal hygiene care, with staff interviews revealing that care not documented was likely not provided. Staff were unaware of refusals or missed care, and the resident did not reject care according to assessments. Another resident with limited mobility and requiring supervision for personal hygiene was repeatedly observed with unclean fingernails over several days, including during meals. Although care logs indicated that personal hygiene assistance was provided, staff admitted to not checking or cleaning the resident's nails as required. The unit manager confirmed that nail care should be performed weekly and as needed, emphasizing the importance of clean nails for hygiene and dignity, but this was not consistently done. A third resident with severe cognitive impairment and at risk for nutritional decline was not provided with the full assistance at meals as outlined in their care plan. The resident was observed unable to access their meal tray due to poor positioning and received no staff assistance during multiple meals, resulting in uneaten food and drinks. Staff interviews revealed a lack of awareness of the resident's care plan requirements, with some staff relying on personal knowledge rather than documented instructions. This led to the resident not receiving the necessary support to maintain adequate nutrition and dignity during meals.
Facility Fails to Maintain Acceptable Hot Water Temperatures and Clean Linen Supplies
Penalty
Summary
The facility failed to ensure residents had access to a safe, clean, comfortable, and homelike environment. Specifically, the hot water on the second and third floors was not maintained at acceptable temperatures, and clean linen supplies on the second, third, and fourth floors were stained. The facility's Safety of Water Temperature policy required maintenance to conduct periodic tap water temperature checks and record the temperatures in a safety log. However, the daily water readings form did not include the specific rooms or floors where the temperatures were taken, and the recorded temperatures were within the acceptable range of 90 to 120 degrees Fahrenheit. Despite this, actual measurements taken during the survey revealed that the hot water temperatures in various rooms on the second and third floors were significantly below the acceptable range, with temperatures as low as 67 degrees Fahrenheit. Staff interviews confirmed that the lack of hot water had been an ongoing issue, preventing them from providing proper care to residents, such as showers and nighttime care. Maintenance staff admitted that they did not record the temperatures measured on the resident floors and only received complaints when there were issues with the boiler. The Administrator acknowledged the problem and stated that adjustments were made to the water system, but the issue persisted. Additionally, the facility failed to provide clean linen supplies that looked clean. During the survey, it was observed that clean linen supplies in various rooms on the second, third, and fourth floors were stained and looked unclean. The Director of Housekeeping and Laundry stated that the town water turned the white linens into an ivory yellow color when washed, and this issue had been ongoing for three years. However, this concern was not communicated to the current Administrator or mentioned during quarterly quality assurance meetings. The Administrator was unaware of the issue and stated that it was important for clean linen supplies to look clean to avoid complaints from residents. Interviews with staff and residents further highlighted the impact of these deficiencies. Certified Nurse Aides and Registered Nurse Managers reported that the lack of hot water prevented them from providing proper care, and they had to resort to alternative methods such as bed baths or using water from the coffee machine. Residents also expressed their dissatisfaction with the lack of hot water, stating that it affected their ability to wash personal care devices and receive showers. The stained linens also raised concerns among staff and residents, as they did not appear clean despite being washed. The facility's failure to address these issues compromised the residents' right to a safe, clean, comfortable, and homelike environment.
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 170 citations issued within 25 miles in the last 12 months — including the 2 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 Ilion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley Health Services Inc | 2.5 mi | ★★★★★ | 26 | 0 |
| Foltsbrook Center For Nursing And Rehabilitation | 3.2 mi | ★★★★★ | 0 | 0 |
| Masonic Care Community Of New York | 8.5 mi | ★★★★★ | 35 | 1 |
| Charles T Sitrin Health Care Center Inc | 9.5 mi | ★★★★★ | 0 | 0 |
| Alpine Rehabilitation And Nursing Center | 10.1 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Grand Rehabilitation And Nursing At Mohawk.
100% money-back within 48 hours.
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.