Citations Summary
Jun 2022 – May 202615 Inspections Conducted
11
No citations found
73% of all inspections
4
Resulted in citations
27% of all inspections
60 Total Citations — state avg: 41
Issued across those 4 inspections
47Standard Health
13Life Safety Code
Severity of Citations
How serious were those 60 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 15 inspections in the current reporting window, 11 found no citations at all; inspectors issued 60 citations in total.
- Of those, 47 were standard health citations (quality of care) and 13 were related to the Life Safety Code (fire protection).
- The state logged 379 complaints about this facility; 51 led to on-site inspections.
- The state has 2 formal enforcement actions (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
2701353N
County
Monroe
Phone
(585) 271-5413
Operated By
St John's Health Care Corporation (Not for Profit)
DOH Regional Office
Western NY
Occupancy Rate
89%
Staff Flu Vaccination
97%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Assistive Devices - Eating Equipment/utensils
Standard Health Citation — quality of care
Bowel/bladder Incontinence, Catheter, Uti
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Discharge Process
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
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Reasonable Accommodations Needs/preferences
Standard Health Citation — quality of care
Reporting Of Alleged Violations
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
Life Safety Code Citations
Egress Doors
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
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
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Infection Control
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
License/comply W/ Fed/state/locl Law/prof Std
Standard Health Citation — quality of care
Qrtly Assessment At Least Every 3 Months
Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
Respect, Dignity/right To Have Prsnl Property
Standard Health Citation — quality of care
Respiratory/tracheostomy Care And Suctioning
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
Life Safety Code Citations
Electrical Equipment - Power Cords And Extens
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Testing And Maintenanc
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Rubbish Chutes, Incinerators, And Laundry Chu
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Reporting - National Health Safety Network
Standard Health Citation — quality of care
▼
Standard Health Citations
Reporting - National Health Safety Network
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 2026Above state average. This facility received 100.7 complaints per 100 beds vs. a statewide rate of 57.4. 16 citations resulted from those complaints (4.2 per 100 beds vs. 5.3 statewide).
Total Complaints
379
55,669 statewide
Per 100 Occupied Beds
100.7
57.4 state avg
On-Site Inspections
51
7,566 statewide
Citations Issued
16
4.2 per 100 beds · avg 5.3
Facility-Reported Incidents
86%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 2 |
| Dietary Services | 2 |
| Other Services | 2 |
| Physical Environment | 1 |
| Quality of Care | 2 |
| Resident Rights | 2 |
| Total | 11 |
Enforcement & Fines
Jun 2016 – May 20262 enforcement actions totaling $32,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
June 9, 2025
$18,000
Stipulation & Order #NH-26-011 · Signed January 13, 2026
Reason: Quality of Care
Reason: Quality of Care
December 13, 2023
$14,000
Stipulation & Order #NH-24-024 · Signed March 24, 2024
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies