Citations Summary
Jun 2022 – May 20266 Inspections Conducted
2
No citations found
33% of all inspections
4
Resulted in citations
67% of all inspections
56 Total Citations — state avg: 41
Issued across those 4 inspections
33Standard Health
23Life Safety Code
Severity of Citations
How serious were those 56 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 6 inspections in the current reporting window, 2 found no citations at all; inspectors issued 56 citations in total.
- Of those, 33 were standard health citations (quality of care) and 23 were related to the Life Safety Code (fire protection).
- The state logged 46 complaints about this facility; 9 led to on-site inspections.
- The state has 1 formal enforcement action (fines or stipulations) on record.
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
2701365N
County
Monroe
Phone
(585) 342-5540
Operated By
AGA Operating LLC (For Profit)
DOH Regional Office
Western NY
Occupancy Rate
11%
Staff Flu Vaccination
91%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
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
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Standards Of Construction For New Existing Nh
Standard Health Citation — quality of care
Life Safety Code Citations
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
Vertical Openings - Enclosure
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Bedrooms Assure Full Visual Privacy
Standard Health Citation — quality of care
Care Plan Timing And Revision
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Menus Meet Resident Nds/prep In Adv/followed
Standard Health Citation — quality of care
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Resident Records - Identifiable Information
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Life Safety Code Citations
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Maintains Effective Pest Control Program
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
▼
Standard Health Citations
Dialysis
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free From Unnec Psychotropic Meds/prn Use
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Infection Control
Standard Health Citation — quality of care
Notice Of Bed Hold Policy Before/upon Trnsfr
Standard Health Citation — quality of care
Qaa Committee
Standard Health Citation — quality of care
Rn 8 Hrs/7 Days/wk, Full Time Don
Standard Health Citation — quality of care
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
Standards Of Construction For New Existing Nh
Standard Health Citation — quality of care
Life Safety Code Citations
Egress Doors
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Ep Training Program
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
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 2026Above state average. This facility received 193.6 complaints per 100 beds vs. a statewide rate of 57.4. 11 citations resulted from those complaints (46.3 per 100 beds vs. 5.3 statewide).
Total Complaints
46
55,669 statewide
Per 100 Occupied Beds
193.6
57.4 state avg
On-Site Inspections
9
7,566 statewide
Citations Issued
11
46.3 per 100 beds · avg 5.3
Facility-Reported Incidents
28%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 1 |
| Dietary Services | 2 |
| Other Services | 3 |
| Physical Environment | 3 |
| Quality of Care | 3 |
| Resident Rights | 3 |
| Total | 15 |
Enforcement & Fines
Jun 2016 – May 20261 enforcement action totaling $14,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
May 21, 2021
$14,000
Stipulation & Order #NH-21-181 · Signed October 15, 2021
Reason: Quality of Care
Reason: Quality of Care