Citations Summary
Jun 2022 – May 20269 Inspections Conducted
5
No citations found
56% of all inspections
4
Resulted in citations
44% of all inspections
29 Total Citations — state avg: 41
Issued across those 4 inspections
15Standard Health
14Life Safety Code
Severity of Citations
How serious were those 29 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 9 inspections in the current reporting window, 5 found no citations at all; inspectors issued 29 citations in total.
- Of those, 15 were standard health citations (quality of care) and 14 were related to the Life Safety Code (fire protection).
- The state logged 33 complaints about this facility; 12 led to on-site inspections.
- The state lists no formal enforcement actions against this facility.
A citation is a rule violation noted by a state inspector. Most are corrected through a plan of correction; the sections below show each citation, its severity, and how the facility compares with the statewide average.
Provider Information
Type
Nursing Home
Operating Certificate
2725301N
County
Monroe
Phone
(585) 377-4000
Operated By
CPR Associates, LLC (For Profit)
DOH Regional Office
Western NY
Occupancy Rate
94%
Staff Flu Vaccination
97%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Bedrails
Standard Health Citation — quality of care
Free Of Medication Error Rts 5 Prcnt Or More
Standard Health Citation — quality of care
Infection Control
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Life Safety Code Citations
Egress Doors
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
Gas And Vacuum Piped Systems - Information An
Life Safety Code Citation — NFPA requirements
Number Of Exits - Corridors
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Resident Records - Identifiable Information
Standard Health Citation — quality of care
▼
Standard Health Citations
Baseline Care Plan
Standard Health Citation — quality of care
Department Criminal History Review
Standard Health Citation — quality of care
Free Of Medication Error Rts 5 Prcnt Or More
Standard Health Citation — quality of care
Infection Control
Standard Health Citation — quality of care
Personal Privacy/confidentiality Of Records
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Life Safety Code Citations
Electrical Equipment - Testing And Maintenanc
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Gas And Vacuum Piped Systems - Maintenance Pr
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Number Of Exits - Corridors
Life Safety Code Citation — NFPA requirements
Rubbish Chutes, Incinerators, And Laundry Chu
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Request/refuse/dscntnue Trmnt;formlte Adv Dir
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
Jun 2022 – May 2026Below state average. This facility received 25.8 complaints per 100 beds vs. a statewide rate of 57.4. 6 citations resulted from those complaints (4.7 per 100 beds vs. 5.3 statewide).
Total Complaints
33
55,669 statewide
Per 100 Occupied Beds
25.8
57.4 state avg
On-Site Inspections
12
7,566 statewide
Citations Issued
6
4.7 per 100 beds · avg 5.3
Facility-Reported Incidents
67%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 0 |
| Dietary Services | 0 |
| Other Services | 2 |
| Physical Environment | 1 |
| Quality of Care | 2 |
| Resident Rights | 3 |
| Total | 8 |