Citations Summary
Jun 2022 – May 202630 Total Citations — state avg: 41
Issued in the reporting period
19Standard Health
11Life Safety Code
Severity of Citations
How serious were those 30 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; inspectors issued 30 citations in total.
- Of those, 19 were standard health citations (quality of care) and 11 were related to the Life Safety Code (fire protection).
- The state logged 42 complaints about this facility; 7 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
2701339N
County
Monroe
Phone
(585) 546-8400
Operated By
Church Home of the Protestant Episcopal Church (Not for Profit)
DOH Regional Office
Western NY
Occupancy Rate
79%
Staff Flu Vaccination
83%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Increase/prevent Decrease In Rom/mobility
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Influenza And Pneumococcal Immunizations
Standard Health Citation — quality of care
Resident Self-admin Meds-clinically Approp
Standard Health Citation — quality of care
Life Safety Code Citations
Corridor - Openings
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
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Reporting - National Health Safety Network
Standard Health Citation — quality of care
▼
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
Develop/implement Abuse/neglect Policies
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Pain Management
Standard Health Citation — quality of care
Life Safety Code Citations
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
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
▼
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 2026Below state average. This facility received 29.6 complaints per 100 beds vs. a statewide rate of 57.4. 5 citations resulted from those complaints (3.5 per 100 beds vs. 5.3 statewide).
Total Complaints
42
55,669 statewide
Per 100 Occupied Beds
29.6
57.4 state avg
On-Site Inspections
7
7,566 statewide
Citations Issued
5
3.5 per 100 beds · avg 5.3
Facility-Reported Incidents
95%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 0 |
| Dietary Services | 1 |
| Other Services | 2 |
| Physical Environment | 1 |
| Quality of Care | 2 |
| Resident Rights | 2 |
| Total | 8 |