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 Utica during CMS and state inspections, most recent first.
A wastewater backup in the kitchen led to contaminated water being tracked throughout food prep and storage areas, with staff continuing to prepare and serve food during the incident. The facility failed to properly clean, sanitize, or monitor kitchen equipment, and both the dish machine and 3-bay sink lacked adequate sanitizer levels. Staff were not trained on required sanitation procedures, and contaminated wastewater was improperly disposed of, resulting in Immediate Jeopardy for all residents.
The facility did not ensure that food and drink were served at appetizing temperatures or with adequate flavor during two observed lunch meals. Several residents reported that their meals were cold, bland, or undercooked, and observations confirmed that both hot and cold foods were not at appropriate serving temperatures. Staff interviews revealed a lack of knowledge regarding required food temperatures, and reheating food in microwaves was a common response to complaints.
A resident with significant mental health diagnoses was not allowed to return to their previous room or the facility in a timely manner after hospital clearance, due to the facility's insistence on a psychiatric admission and a private room, despite hospital documentation that the resident was stable and appropriate for LTC placement. The delay persisted until the Department of Health intervened, and there was a lack of proper documentation and communication regarding the readmission process.
A resident with a right femur fracture and moderately impaired cognition was not invited to participate in their comprehensive care plan meeting, and there was no documentation of care plan meeting attendance or communication with the resident or family regarding discharge planning. Staff interviews confirmed that required care plan meetings were not scheduled or documented, and the resident reported not being informed about their discharge plan.
A resident with a history of UTI and neuromuscular bladder dysfunction, requiring substantial assistance with bathing and hygiene, was repeatedly observed with unwashed hair and inadequate genital care. Staff and documentation confirmed that prescribed hygiene interventions, including twice-daily cleansing of the genital area, were not consistently completed, despite no refusal of care by the resident.
A resident with chronic respiratory conditions did not receive prescribed BiPAP therapy for an extended period because the device was broken. Staff documented the issue but did not promptly notify the physician or respiratory therapy, and there was no interim plan for respiratory support. The resident experienced a decline in condition and required hospitalization as a result.
The facility failed to provide timely care and assessments for three residents after falls, leading to significant deficiencies. A resident experienced an unwitnessed fall, and the medical provider was not notified promptly, resulting in a hospital transfer where the resident expired due to asphyxiation from choking on dentures. Another resident had unwitnessed falls without neurological assessments, and a third resident with a head injury did not receive continued neurological checks. These oversights indicate a failure to adhere to protocols, compromising resident safety.
Immediate Jeopardy: Failure to Maintain Kitchen Sanitation After Wastewater Backup
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Following a wastewater backup from the grease trap and drains that flooded the main kitchen, the facility did not adequately address the cleanup, monitoring, evaluation, or sanitization of cooking equipment and appliances. Staff continued to prepare and serve food during the wastewater backup, and contaminated water was tracked throughout the kitchen, including into walk-in coolers and food preparation areas. The cleaning process involved only a no-rinse floor cleaner, which was not a sanitizer or disinfectant, and there was no containment of aerosolization or spread of wastewater during cleanup. Observations revealed ongoing issues with the kitchen's sanitation equipment. The dish machine was not reaching the required sanitizing temperatures, and when chemical sanitization was used, there was no detectable level of sanitizer. Staff were not aware of the required sanitizer levels or how to check them, and logs showed inconsistent or missing documentation of temperature and sanitizer checks. The 3-bay sink also failed to maintain proper sanitizer levels, with test strips showing either no sanitizer or levels above the recommended range. Staff lacked training on how to properly check and maintain sanitizer concentrations, and there was no evidence of routine monitoring prior to the survey. The facility's policies required clean and sanitary conditions, proper equipment maintenance, and specific sanitizer concentrations, but these were not followed. Wastewater was squeegeed out of the kitchen into the parking lot, and racks were hosed down outside over a storm drain, further violating sanitation protocols. The Director of Nutritional Services and other staff acknowledged that the grease trap was not maintained as recommended, and that the kitchen, equipment, and dishware may not have been properly sanitized. The DON, Medical Director, and Infection Control Nurse were not informed of the incident at the time, and food prepared during the period of contamination was not immediately discarded.
Failure to Serve Palatable and Properly Tempered Food and Drink
Penalty
Summary
Surveyors found that the facility failed to provide food and drink that was palatable, flavorful, and at an appetizing temperature during two observed lunch meals. Multiple residents reported dissatisfaction with the quality and temperature of the food, describing it as cold, bland, undercooked, or not matching their requests. Observations confirmed that food items served to residents were not at appropriate temperatures, with hot foods measured between 114 and 132.9 degrees Fahrenheit and cold foods between 55 and 63 degrees Fahrenheit, which did not meet the standards stated by the Food Service Director. Staff interviews revealed uncertainty about the required serving temperatures for hot and cold foods, and it was common practice to reheat food in microwaves when residents complained. The Food Service Director acknowledged that the temperatures recorded during test tray observations were unacceptable and explained that while plate warmers and immediate delivery to units were used, there was no control over how quickly staff served the food after arrival. The deficiency was identified for two consecutive lunch meals, and six residents specifically voiced concerns about the food's taste, temperature, and preparation, with one resident relying on family to supplement their meals due to dissatisfaction.
Failure to Timely Readmit Resident Following Hospital Clearance
Penalty
Summary
A deficiency occurred when the facility failed to allow a resident to return to their previous room or to the facility in a timely manner after being cleared for discharge from the hospital. The resident, who had a history of bipolar disorder, schizoaffective disorder, intermittent explosive disorder, and other mental health conditions, was sent to the hospital due to aggressive behavior and assaulting staff. The facility's own policies required that residents sent to an acute care setting be permitted to return unless their needs could not be met, with documentation required to support any discharge decision. However, after the hospital determined the resident was stable and cleared for discharge, the facility delayed the resident's return, citing the need for a psychiatric admission and the unavailability of a private room. The medical record and hospital documentation indicated that the resident did not meet criteria for psychiatric admission and was appropriate for long-term placement. Despite this, the facility's Medical Director and admissions team refused to accept the resident back until a psychiatric admission was completed, which the hospital repeatedly stated was not indicated. Communication between the hospital and the facility was inconsistent, with the hospital case manager and liaison making multiple attempts to coordinate the resident's return. The facility also filled the resident's bed during the hospital stay and insisted on a private room for the resident upon return, further delaying the process. Interviews with facility staff revealed a lack of documentation regarding communication with the hospital and the decision-making process for readmission. The Administrator and Director of Admissions confirmed that the resident was not accepted back until the Department of Health intervened and instructed the facility to readmit the resident. The delay in readmission was not supported by clinical documentation indicating the facility could not meet the resident's needs, and the resident was ultimately returned to the facility after an extended hospital stay.
Failure to Involve Resident in Care Plan Development and Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident participated in the development of their comprehensive care plan or was invited to attend the initial care plan meeting, as required by facility policy and federal regulations. The resident, who was admitted with a right femur fracture and had moderately impaired cognition, required partial assistance with most activities of daily living and had an active discharge plan to return to the community. Despite documentation in the care plan and therapy notes indicating discharge planning and the resident's preferences, there was no evidence of a care plan meeting invitation, attendance sheet, or documented conversations with the resident or their family regarding the plan of care or discharge goals. Interviews with staff revealed that the process for scheduling and documenting care plan meetings was not consistently followed. The social worker responsible for scheduling care plan meetings stated that invitations were typically hand-delivered to residents and families were called, with attendance sheets signed at meetings. However, in this case, the social worker acknowledged that conversations with the resident about discharge planning were not documented, and no care plan or discharge meeting had been held or scheduled for the resident. The Director of Social Work and the Minimum Data Set Coordinator both confirmed that the resident had not been scheduled for a care plan meeting within the required timeframe due to a failure to enter the review date into the system. The resident reported not attending a care plan meeting, not knowing when they would be discharged, and not receiving information about their discharge plan despite asking staff daily. Staff interviews confirmed that while the resident was discussed in Utilization Review meetings, this information was not communicated to the resident or their family, and required documentation and resident participation in care planning did not occur as per facility policy.
Failure to Provide Required Assistance with Personal Hygiene and Grooming
Penalty
Summary
A deficiency was identified when a resident with diagnoses including urinary tract infection and neuromuscular dysfunction of the bladder did not receive necessary assistance with activities of daily living, specifically in the areas of grooming and personal hygiene. The resident required substantial to maximal assistance with showering, bathing, and toileting hygiene, as documented in their care plan and physician orders. Despite these documented needs, the resident was observed multiple times over several days with greasy, unwashed hair and white flakes near the scalp, and reported not being cleaned up for the day or recalling their last shower. Review of treatment administration records revealed that prescribed genital care, including cleansing the foreskin twice daily with soap and water, was not completed on multiple occasions across several months. Observations and interviews confirmed that the resident's genital area had significant white buildup and the suprapubic catheter site had brown buildup, indicating a lack of proper hygiene. Certified nurse aides and nursing staff acknowledged that the resident's hair and genital area appeared unclean and that care was not consistently provided as required. Documentation showed that the resident did not refuse care, and facility policy required notification of supervisors if care was refused, which did not occur. Staff interviews confirmed that the expected standard of care, including regular washing of hair and genital area, was not met. The failure to provide these services was not in accordance with the resident's care plan, physician orders, or facility policy, resulting in the identified deficiency.
Failure to Provide Prescribed BiPAP Therapy Due to Broken Equipment and Lack of Timely Notification
Penalty
Summary
A resident with chronic respiratory failure, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD) was ordered to receive bilevel positive airway pressure (BiPAP) therapy at bedtime, along with continuous oxygen. The resident's care plan and physician orders specified the use of BiPAP and regular checks of the device. However, from mid to late February, the BiPAP device was not administered as it was documented as broken, and the resident did not receive the prescribed therapy during this period. During this time, the resident experienced a decline in condition, including lethargy, slow response, shortness of breath, bradycardia, and hypoxia. The nurse practitioner was informed that the resident had not used the BiPAP device in recent days due to it being broken, and subsequently ordered a hospital transfer for evaluation. Hospital records confirmed the resident had not used the BiPAP device for three days and was admitted with an acute exacerbation of COPD, sepsis, and lower respiratory tract infection. Interviews revealed that staff, including nursing and purchasing, were aware of the broken device but did not promptly notify the physician or respiratory therapy. The DON confirmed there was no plan in place for the resident in the absence of the BiPAP device, and the physician was not informed until after the resident's condition had worsened. The respiratory therapy director and physician both stated they should have been notified immediately to address the interruption in care.
Failure to Conduct Timely Neurological Checks and Notify Medical Providers
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for three residents, leading to significant deficiencies. One resident experienced an unwitnessed fall, and the medical provider was not notified in a timely manner. Neurological checks were not implemented, and the resident's condition deteriorated, resulting in a hospital transfer where the resident expired due to asphyxiation from choking on dentures. The facility's delay in notifying Emergency Medical Services and the lack of immediate response to the resident's change in condition contributed to the adverse outcome. Another resident had unwitnessed falls, but neurological assessments were not initiated or completed. Despite the resident's ability to communicate, the facility's policy required neurological checks for unwitnessed falls, which were not conducted. This oversight indicates a failure to adhere to established protocols for monitoring residents after falls, potentially compromising their safety and well-being. A third resident sustained a fall with a head injury, but neurological assessments were not continued after the initial evaluation. The resident, who had severe cognitive impairment, was initially assessed, and a hematoma was noted. However, there was no documentation of ongoing neurological checks or attempts to complete them, despite the resident's refusal to be transported to the hospital. This lack of follow-up care highlights a deficiency in the facility's response to falls and head injuries, putting residents at risk.
Removal Plan
- 93% of nursing staff were educated on calling the medical provider after a change in condition, completing neurological checks, immediacy of calling Emergency Medical Services after receiving an order to send to the hospital, and completing assessments including checking the airway.
- The facility had a plan to educate the remaining staff prior to the start of their next shift.
- Post-tests were issued and reviewed.
- Staff education sign in sheets were reviewed and compared to the current nursing staff list and no discrepancies were identified.
- 100% of nursing staff received education.
- Staff education was verified during an onsite visit, multiple nursing staff on multiple units were interviewed.
- Staff were able to report content of education and confirmed the facility staff who presented the education (Assistant Directors of Nursing or Educator).
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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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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 Pines At Utica Center For Nursing And Rehab | 0.3 mi | ★★★★★ | 1 | 0 |
| Oneida Center For Rehabilitation And Nursing | 0.7 mi | ★★★★★ | 1 | 0 |
| Mvhs Rehabilitation And Nursing Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Utica Rehabilitation & Nursing Center | 1.2 mi | ★★★★★ | 9 | 0 |
| Charles T Sitrin Health Care Center Inc | 2.9 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.