Citations Summary
Jun 2022 – May 202614 Inspections Conducted
5
No citations found
36% of all inspections
9
Resulted in citations
64% of all inspections
113 Total Citations — state avg: 41
Issued across those 9 inspections
63Standard Health
50Life Safety Code
Severity of Citations
How serious were those 113 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 14 inspections in the current reporting window, 5 found no citations at all; inspectors issued 113 citations in total.
- Of those, 63 were standard health citations (quality of care) and 50 were related to the Life Safety Code (fire protection).
- The state logged 166 complaints about this facility; 24 led to on-site inspections.
- The state has 6 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
2701352N
County
Monroe
Phone
(585) 241-2100
Operated By
Wesley Gardens Corporation (Not for Profit)
DOH Regional Office
Western NY
Occupancy Rate
61%
Staff Flu Vaccination
88%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Administration
Standard Health Citation — quality of care
Baseline Care Plan
Standard Health Citation — quality of care
Behavioral Health Services
Standard Health Citation — quality of care
Essential Equipment, Safe Operating Condition
Standard Health Citation — quality of care
Free From Misappropriation/exploitation
Standard Health Citation — quality of care
Increase/prevent Decrease In Rom/mobility
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
License/comply W/ Fed/state/locl Law/prof Std
Standard Health Citation — quality of care
Medicaid/medicare Coverage/liability Notice
Standard Health Citation — quality of care
Notice Requirements Before Transfer/discharge
Standard Health Citation — quality of care
Pain Management
Standard Health Citation — quality of care
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Request/refuse/dscntnue Trmnt;formlte Adv Dir
Standard Health Citation — quality of care
Requirements Before Submitting A Request For
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
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Right To Survey Results/advocate Agency Info
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Standards Of Construction For New Nh
Standard Health Citation — quality of care
Treatment/devices To Maintain Hearing/vision
Standard Health Citation — quality of care
Life Safety Code Citations
Aisle, Corridor, Or Ramp Width
Life Safety Code Citation — NFPA requirements
Building Construction Type And Height
Life Safety Code Citation — NFPA requirements
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Develop Ep Plan, Review And Update Annually
Life Safety Code Citation — NFPA requirements
Development Of Ep Policies And Procedures
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
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Elevators
Life Safety Code Citation — NFPA requirements
Emergency Lighting
Life Safety Code Citation — NFPA requirements
Ep Testing Requirements
Life Safety Code Citation — NFPA requirements
Fire Drills
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
Hvac
Life Safety Code Citation — NFPA requirements
Integrated Ep Program
Life Safety Code Citation — NFPA requirements
Ltc And Icf/iid Sharing Plan With Patients
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
Portable Fire Extinguishers
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
▼
Standard Health Citations
Accounting And Records Of Personal Funds
Standard Health Citation — quality of care
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Care Plan Timing And Revision
Standard Health Citation — quality of care
Drug Regimen Review, Report Irregular, Act On
Standard Health Citation — quality of care
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Standards Of Construction For New Nh
Standard Health Citation — quality of care
Life Safety Code Citations
Building Construction Type And Height
Life Safety Code Citation — NFPA requirements
Cooking Facilities
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
Hvac
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Investigate/prevent/correct Alleged Violation
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
▼
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 2026Above state average. This facility received 121.8 complaints per 100 beds vs. a statewide rate of 57.4. 37 citations resulted from those complaints (27.2 per 100 beds vs. 5.3 statewide).
Total Complaints
166
55,669 statewide
Per 100 Occupied Beds
121.8
57.4 state avg
On-Site Inspections
24
7,566 statewide
Citations Issued
37
27.2 per 100 beds · avg 5.3
Facility-Reported Incidents
38%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 1 |
| Dietary Services | 0 |
| Other Services | 2 |
| Physical Environment | 1 |
| Quality of Care | 2 |
| Resident Rights | 4 |
| Total | 10 |
Enforcement & Fines
Jun 2016 – May 20266 enforcement actions totaling $34,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
September 18, 2021
$2,000
Stipulation & Order #NH-21-226 · Signed December 3, 2021
Reason: Quality of Care
Reason: Quality of Care
April 23, 2021
$6,000
Stipulation & Order #NH-21-130 · Signed June 25, 2021
Reason: Quality of Care
Reason: Quality of Care
November 21, 2020
$10,000
Stipulation & Order #NH-21-052 · Signed March 9, 2021
Reason: Quality of Care
Reason: Quality of Care
August 22, 2019
$4,000
Stipulation & Order #NH-20-014 · Signed March 24, 2020
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
May 21, 2018
$2,000
Stipulation & Order #NH-18-048 · Signed November 29, 2018
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
April 18, 2016
$10,000
Stipulation & Order #NH-17-015 · Signed January 4, 2017
Reason: Quality of Care
Reason: Quality of Care