Inspection Reports for
MVHS Rehabilitation and Nursing Center
1650 Champlin Avenue, Utica, NY, 13502
Back to Facility Profile5 Reports
Inspection Report — Jul 22, 2025
State
Date: Jul 22, 2025
Visit Reason
State-compiled facility profile showing 5 inspections from 2022 to 2025 with deficiency history, complaint investigations, and enforcement actions.
Complaint Details
The state logged 65 complaints about this facility; 9 led to on-site inspections.
Findings
Across 5 inspections, 21 citations were issued including 9 standard health and 12 Life Safety Code citations. The facility had 65 complaints with 9 on-site inspections and 1 enforcement action recorded.
Citations (21)
Standard Health Citation — quality of care: Food Procurement, store/prepare/serve-sanitary was cited for deficiencies.
Standard Health Citation — quality of care: Grievances were cited with widespread scope.
Standard Health Citation — quality of care: Infection Prevention & Control deficiencies noted.
Standard Health Citation — quality of care: Pasarr Screening For Md & Id deficiencies found.
Standard Health Citation — quality of care: Resident Allergies, Preferences, Substitutes were deficient.
Standard Health Citation — quality of care: Sufficient Nursing Staff was cited for deficiencies.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System had widespread deficiencies.
Life Safety Code Citation — NFPA requirements: Electrical Systems - Essential Electric System repeated widespread deficiencies.
Life Safety Code Citation — NFPA requirements: Fire Alarm System - Testing And Maintenance was deficient.
Life Safety Code Citation — NFPA requirements: Gas Equipment - Cylinder And Container Storage had pattern deficiencies.
Life Safety Code Citation — NFPA requirements: Hvac had pattern deficiencies.
Life Safety Code Citation — NFPA requirements: Multiple Occupancies - Contiguous Non-health was deficient.
Life Safety Code Citation — NFPA requirements: Sprinkler System - Maintenance And Testing had pattern deficiencies.
Life Safety Code Citation — NFPA requirements: Stairways And Smokeproof Enclosures had pattern deficiencies.
Life Safety Code Citation — NFPA requirements: Subsistence Needs For Staff And Patients was deficient.
Life Safety Code Citation — NFPA requirements: Utilities - Gas And Electric had pattern deficiencies.
Standard Health Citation — quality of care: Quality Of Care was cited.
Life Safety Code Citation — NFPA requirements: Gas And Vacuum Piped Systems - Information And was deficient.
Life Safety Code Citation — NFPA requirements: Hazardous Areas - Enclosure was deficient.
Standard Health Citation — quality of care: Investigate/prevent/correct Alleged Violation was cited.
Standard Health Citation — quality of care: Treatment/svcs To Prevent/heal Pressure Ulcer was deficient.
Report Facts
Inspections on page: 5
Total violations/deficiencies cited: 21
Inspections with violations: 4
Inspections without violations: 1
Plan of correction counts: Not explicitly stated
Total fines: 10000
Number of enforcement actions: 1
Total complaints: 65
On-site complaint inspections: 9
Citations from complaints: 3
Inspection Report — Jul 22, 2025
Annual Inspection CMS
Date: Jul 22, 2025
Visit Reason
The inspection was a recertification survey conducted from 7/16/2025 to 7/22/2025 to assess compliance with regulatory requirements for nursing home operations.
Findings
The facility was found deficient in multiple areas including grievance process accessibility, preadmission screening compliance, nursing staffing levels, food service practices, food storage temperatures, and infection prevention and control practices.
Citations (6)
F 0585: The facility did not ensure residents had access to grievance forms or an anonymous grievance process, and residents were unaware of how to file grievances or the grievance officer's identity.
F 0645: The facility failed to ensure preadmission screening and resident review (PASARR) was completed prior to admission for 1 of 35 residents reviewed.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs, resulting in prolonged call bell response times and delayed care for several residents.
F 0806: The facility did not provide hot beverages as specified on meal tickets for 12 of 18 residents reviewed, impacting hydration and resident preferences.
F 0812: The meat and dairy walk-in cooler did not maintain required temperatures below 41°F, with multiple food items measured above safe limits, risking foodborne illness.
F 0880: The facility failed to implement infection prevention and control measures for a resident on enteric pathogen precautions, with staff not wearing required personal protective equipment and improper hand hygiene.
Report Facts
Residents affected: 190
Residents affected: 35
Residents affected: 8
Residents affected: 2
Licensed beds: 202
Residents affected: 12
Food temperatures: 50
Food temperatures: 45
Food temperatures: 55
Food temperatures: 52.7
Food temperatures: 45
Food temperatures: 37.7
Food temperatures: 36.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Manager of Social Services #9 | Manager of Social Services | Interviewed regarding grievance process and PASARR screening |
| Admissions Coordinator #23 | Admissions Coordinator | Interviewed regarding admission documentation and PASARR screening |
| Director of Nursing | Director of Nursing | Interviewed regarding PASARR screening compliance |
| Certified Nurse Aide #17 | Certified Nurse Aide | Interviewed regarding grievance forms availability |
| Licensed Practical Nurse #25 | Licensed Practical Nurse | Interviewed regarding staffing levels and call bell response times |
| Registered Nurse Unit Manager #15 | Registered Nurse Unit Manager | Interviewed regarding staffing levels and meal service |
| Food Service Manager | Food Service Manager | Interviewed regarding food service and walk-in cooler temperatures |
| Housekeeper #7 | Housekeeper | Observed and interviewed regarding infection control and cleaning practices |
| Certified Nurse Aide #9 | Certified Nurse Aide | Observed and interviewed regarding infection control and meal delivery |
| Registered Nurse/ Infection Preventionist #10 | Registered Nurse/ Infection Preventionist | Interviewed regarding infection control policies |
| Housekeeping Supervisor #8 | Housekeeping Supervisor | Interviewed regarding cleaning protocols for isolation rooms |
| Registered Nurse Unit Manager #11 | Registered Nurse Unit Manager | Interviewed regarding infection control understanding |
Inspection Report — Nov 14, 2023
Abbreviated Survey CMS
Date: Nov 14, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with professional standards of care related to treatment and care of a resident with a urinary catheter, colostomy, and PICC line.
Findings
The facility failed to ensure that physician orders were implemented and comprehensive care plans developed for the resident's urinary catheter, colostomy, and PICC line. There were delays and omissions in scheduling follow-up infectious disease consults and obtaining stool specimens for C-Diff testing, resulting in inadequate care and potential harm.
Citations (1)
F 0684: The facility did not implement physician orders on admission for urinary catheter, colostomy, and PICC line care. No comprehensive care plan was developed for these devices. Follow-up infectious disease appointments and stool specimen collection for C-Diff were not timely scheduled or documented.
Report Facts
Residents Affected: 1
Duration of IV antibiotics: 50
Temperature: 102.9
Blood pressure: 10256
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Completed admission assessment and obtained orders |
| LPN #2 | Licensed Practical Nurse | Provided colostomy care documentation and interview statements |
| CNA #3 | Certified Nurse Aide | Provided care for urinary catheter and colostomy, documented drainage |
| RN Manager #6 | RN Manager | Provided interview on care planning and order responsibilities |
Inspection Report — Oct 25, 2023
Annual Inspection CMS
Date: Oct 25, 2023
Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Mvhs Rehabilitation and Nursing Center.
Findings
No health deficiencies were found during the inspection.
Inspection Report — May 28, 2021
Annual Inspection CMS
Date: May 28, 2021
Visit Reason
The survey was conducted as a recertification and abbreviated survey from 5/24/21 to 5/28/21 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to implement corrective measures after an abuse allegation, inadequate supervision leading to resident accidents, food safety issues including improper food temperatures and unsafe food storage, and failure to maintain mechanical and food service equipment in safe operating condition.
Citations (5)
F 0610: The facility failed to implement corrective measures after an allegation of abuse involving CNA #22 and Resident #56, including lack of documentation and continued care by the accused CNA.
F 0689: The facility did not ensure adequate supervision to prevent accidents for Residents #12 and #95, including failure to reassess wandering risk, report incidents, and prevent access to unsafe areas.
F 0804: The facility did not ensure food and drinks were served at safe and palatable temperatures during multiple meals, with cold foods served too warm and hot foods losing temperature.
F 0812: The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, including unsafe cooling of pork roasts, debris on floors, outdated food, unclean equipment, broken refrigeration, and uncovered cups in nourishment rooms.
F 0908: The facility did not maintain all mechanical and patient care equipment in safe operating condition, including steam tables left on in unlocked nourishment rooms and missing knobs on equipment.
Report Facts
Date of survey completion: May 28, 2021
Temperature of pork roast: 138
Temperature of pork roast: 104
Temperature of pork roast: 69
Temperature of chef salad: 65
Temperature of provolone cheese: 68
Temperature of lemon mousse: 63
Temperature of yogurt: 53
Temperature of turkey and cheese sandwich: 59
Temperature of French fries: 99
Temperature of tossed salad: 55
Temperature of milk: 55
Temperature of coleslaw: 49
Temperature of nourishment room refrigerator: 52
Temperature of nourishment preparation room refrigerator: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #22 | Certified Nurse Aide | Named in abuse allegation involving Resident #56 |
| RN Manager #24 | Registered Nurse Manager | Interviewed regarding supervision and care restrictions for Resident #56 |
| PTA #26 | Physical Therapy Assistant | Reported resident's complaint of rough care by CNA #22 |
| DON | Director of Nursing | Interviewed regarding abuse allegation and supervision issues |
| Operations Manager 2 | Operations Manager | Interviewed regarding food service and equipment issues |
| Food Service Supervisor #17 | Food Service Supervisor | Interviewed regarding food temperature and equipment |
| Food Service Worker #18 | Food Service Worker | Interviewed regarding nourishment room cleanliness and equipment |
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