Inspection Reports for
MVHS Rehabilitation and Nursing Center

1650 Champlin Avenue, Utica, NY, 13502

Back to Facility Profile

Deficiencies (last 4 years)

Deficiencies (over 4 years) 8.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

67% worse than New York average
New York average: 5.1 deficiencies/year

Deficiencies per year

24 18 12 6 0
2021
2022
2023
2025

Inspection Report

Annual Inspection
Census: 39 Capacity: 202 Deficiencies: 6 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.

Deficiencies (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 Census: 39 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
NameTitleContext
Manager of Social Services #9Manager of Social ServicesInterviewed regarding grievance process and PASARR screening
Admissions Coordinator #23Admissions CoordinatorInterviewed regarding admission documentation and PASARR screening
Director of NursingDirector of NursingInterviewed regarding PASARR screening compliance
Certified Nurse Aide #17Certified Nurse AideInterviewed regarding grievance forms availability
Licensed Practical Nurse #25Licensed Practical NurseInterviewed regarding staffing levels and call bell response times
Registered Nurse Unit Manager #15Registered Nurse Unit ManagerInterviewed regarding staffing levels and meal service
Food Service ManagerFood Service ManagerInterviewed regarding food service and walk-in cooler temperatures
Housekeeper #7HousekeeperObserved and interviewed regarding infection control and cleaning practices
Certified Nurse Aide #9Certified Nurse AideObserved and interviewed regarding infection control and meal delivery
Registered Nurse/ Infection Preventionist #10Registered Nurse/ Infection PreventionistInterviewed regarding infection control policies
Housekeeping Supervisor #8Housekeeping SupervisorInterviewed regarding cleaning protocols for isolation rooms
Registered Nurse Unit Manager #11Registered Nurse Unit ManagerInterviewed regarding infection control understanding

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 15 Date: Jul 22, 2025

Visit Reason
Multiple standard health and life safety code citations including food procurement sanitation, grievances, infection control, electrical systems, fire alarm, gas equipment, HVAC, sprinkler system, and utilities.

Findings
Multiple standard health and life safety code citations including food procurement sanitation, grievances, infection control, electrical systems, fire alarm, gas equipment, HVAC, sprinkler system, and utilities.

Deficiencies (15)
Food procurement,store/prepare/serve-sanitary
Grievances
Infection prevention & control
Pasarr screening for md & id
Resident allergies, preferences, substitutes
Sufficient nursing staff
Electrical systems - essential electric syste
Fire alarm system - testing and maintenance
Gas equipment - cylinder and container storag
Hvac
Multiple occupancies - contiguous non-health
Sprinkler system - maintenance and testing
Stairways and smokeproof enclosures
Subsistence needs for staff and patients
Utilities - gas and electric

Inspection Report

Abbreviated Survey
Deficiencies: 1 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.

Deficiencies (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
NameTitleContext
RN #1Registered NurseCompleted admission assessment and obtained orders
LPN #2Licensed Practical NurseProvided colostomy care documentation and interview statements
CNA #3Certified Nurse AideProvided care for urinary catheter and colostomy, documented drainage
RN Manager #6RN ManagerProvided interview on care planning and order responsibilities

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Nov 14, 2023

Visit Reason
One isolated standard health citation for quality of care, corrected as of December 1, 2023.

Findings
One isolated standard health citation for quality of care, corrected as of December 1, 2023.

Deficiencies (1)
Quality of care

Inspection Report

Annual Inspection
Deficiencies: 0 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

Complaint Investigation
Capacity: 60 Deficiencies: 2 Date: Oct 25, 2023

Visit Reason
Two isolated standard life safety code citations for gas and vacuum piped systems and hazardous areas, both corrected as of November 8, 2023.

Findings
Two isolated standard life safety code citations for gas and vacuum piped systems and hazardous areas, both corrected as of November 8, 2023.

Deficiencies (2)
Gas and vacuum piped systems - information an
Hazardous areas - enclosure

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 2 Date: Jun 17, 2022

Visit Reason
Two isolated standard health citations for investigating/preventing alleged violations and treatment to prevent/heal pressure ulcers, corrected as of August 16, 2022.

Findings
Two isolated standard health citations for investigating/preventing alleged violations and treatment to prevent/heal pressure ulcers, corrected as of August 16, 2022.

Deficiencies (2)
Investigate/prevent/correct alleged violation
Treatment/svcs to prevent/heal pressure ulcer

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Apr 28, 2022

Visit Reason
One isolated standard health citation for free from abuse and neglect with actual harm, corrected as of June 15, 2022.

Findings
One isolated standard health citation for free from abuse and neglect with actual harm, corrected as of June 15, 2022.

Deficiencies (1)
Free from abuse and neglect

Inspection Report

Complaint Investigation
Capacity: 60 Deficiencies: 1 Date: Nov 22, 2021

Visit Reason
One widespread standard health citation for reporting to national health safety network.

Findings
One widespread standard health citation for reporting to national health safety network.

Deficiencies (1)
Reporting - national health safety network

Inspection Report

Annual Inspection
Deficiencies: 5 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.

Deficiencies (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
NameTitleContext
CNA #22Certified Nurse AideNamed in abuse allegation involving Resident #56
RN Manager #24Registered Nurse ManagerInterviewed regarding supervision and care restrictions for Resident #56
PTA #26Physical Therapy AssistantReported resident's complaint of rough care by CNA #22
DONDirector of NursingInterviewed regarding abuse allegation and supervision issues
Operations Manager 2Operations ManagerInterviewed regarding food service and equipment issues
Food Service Supervisor #17Food Service SupervisorInterviewed regarding food temperature and equipment
Food Service Worker #18Food Service WorkerInterviewed regarding nourishment room cleanliness and equipment

Viewing

Loading inspection reports...