Citations Summary
Feb 2022 – Jan 202619 Inspections Conducted
13
No citations found
68% of all inspections
6
Resulted in citations
32% of all inspections
35 Total Citations — state avg: 23
Issued across those 6 inspections
28Standard Health
7Life Safety Code
Severity of Citations
How serious were those 35 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Activities Meet Interest/needs Each Resident
Standard Health Citation — quality of care
Administration
Standard Health Citation — quality of care
Care Plan Timing And Revision
Standard Health Citation — quality of care
Care Plan Timing And Revision
Standard Health Citation — quality of care
Competent Nursing Staff
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Dispose Garbage And Refuse Properly
Standard Health Citation — quality of care
Drug Regimen Is Free From Unnecessary Drugs
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free From Abuse And Neglect
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Free Of Medication Error Rts 5 Prcnt Or More
Standard Health Citation — quality of care
Grievances
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Infection Preventionist Qualifications/role
Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Notice Of Bed Hold Policy Before/upon Trnsfr
Standard Health Citation — quality of care
Nutrition/hydration Status Maintenance
Standard Health Citation — quality of care
Pasarr Screening For Md & Id
Standard Health Citation — quality of care
Personal Food Policy
Standard Health Citation — quality of care
Qaa Committee
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Resident Records - Identifiable Information
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Resident Self-admin Meds-clinically Approp
Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
Respiratory/tracheostomy Care And Suctioning
Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Right To Survey Results/advocate Agency Info
Standard Health Citation — quality of care
Rn 8 Hrs/7 Days/wk, Full Time Don
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Transfer And Discharge Requirements
Standard Health Citation — quality of care
Life Safety Code Citations
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Discharge From Exits
Life Safety Code Citation — NFPA requirements
Doors With Self-closing Devices
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Power Cords And Extens
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Ep Testing Requirements
Life Safety Code Citation — NFPA requirements
Ep Training Program
Life Safety Code Citation — NFPA requirements
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
Horizontal Exits
Life Safety Code Citation — NFPA requirements
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Organization And Administration
Life Safety Code Citation — NFPA requirements
Plan Based On All Hazards Risk Assessment
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Lab Srvcs Physician Order/notify Of Results
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Laboratory Services
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Resident Records - Identifiable Information
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Facility Assessment
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Routine/emergency Dental Srvcs In Snfs
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Treatment/svcs To Prevent/heal Pressure Ulcer
Standard Health Citation — quality of care
▼
Standard Health Citations
Right To Access/purchase Copies Of Records
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Drug Regimen Review, Report Irregular, Act On
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Maintains Effective Pest Control Program
Standard Health Citation — quality of care
Provide/obtain Specialized Rehab Services
Standard Health Citation — quality of care
Resident Allergies, Preferences, Substitutes
Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Training Requirements
Standard Health Citation — quality of care
Life Safety Code Citations
Ep Testing Requirements
Life Safety Code Citation — NFPA requirements
Ep Training Program
Life Safety Code Citation — NFPA requirements
Multiple Occupancies
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Accuracy Of Assessments
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Resident Records - Identifiable Information
Standard Health Citation — quality of care
Respiratory/tracheostomy Care And Suctioning
Standard Health Citation — quality of care
Severity Scale Reference
Level 0 — No Harm Potential
Level 2 — Minor Potential Harm
Level 3 — Actual Harm
Level 4 — Immediate Jeopardy
Complaints
Feb 2022 – Jan 2026Above state average. This facility received 151.7 complaints per 100 beds vs. a statewide rate of 55.0. 24 citations resulted from those complaints (20.3 per 100 beds vs. 3.0 statewide).
Total Complaints
179
55,221 statewide
Per 100 Occupied Beds
151.7
55.0 state avg
On-Site Inspections
23
8,103 statewide
Citations Issued
24
20.3 per 100 beds · avg 3.0
Facility-Reported Incidents
8%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 4 |
| Dietary Services | 9 |
| Other Services | 0 |
| Physical Environment | 11 |
| Quality of Care | 58 |
| Resident Rights | 24 |
| Total | 106 |
Enforcement & Fines
Feb 2016 – Jan 20264 enforcement actions totaling $34,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
February 3, 2023
$2,000
Stipulation & Order #NH-23-059 · Signed May 17, 2023
Reason: Infection Control
Reason: Infection Control
February 22, 2021
$12,000
Stipulation & Order #NH-21-072 · Signed April 23, 2021
Reason: Quality of Care
Reason: Quality of Care
April 20, 2017
$6,000
Stipulation & Order #NH-18-003 · Signed February 1, 2018
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
October 25, 2013
$14,000
Stipulation & Order #NH-16-115 · Signed March 9, 2016
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies