Citations Summary
Jun 2022 – May 20269 Inspections Conducted
4
No citations found
44% of all inspections
5
Resulted in citations
56% of all inspections
40 Total Citations — state avg: 41
Issued across those 5 inspections
27Standard Health
13Life Safety Code
Severity of Citations
How serious were those 40 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
Tube feeding mgmt/restore eating skills · April 22, 2026 · Not yet corrected
In plain language
- Across 9 inspections in the current reporting window, 4 found no citations at all; inspectors issued 40 citations in total.
- Of those, 27 were standard health citations (quality of care) and 13 were related to the Life Safety Code (fire protection).
- The state logged 145 complaints about this facility; 18 led to on-site inspections.
- The state has 8 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
2753302N
County
Monroe
Phone
(585) 247-7880
Operated By
Westgate Operations Associates, LLC (For Profit)
DOH Regional Office
Western NY
Occupancy Rate
95%
Staff Flu Vaccination
86%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Administration
Standard Health Citation — quality of care
Qaa Committee
Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Tube Feeding Mgmt/restore Eating Skills
Standard Health Citation — quality of care
▼
Standard Health Citations
Accuracy Of Assessments
Standard Health Citation — quality of care
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Comprehensive Assessments & Timing
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
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
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Nutrition/hydration Status Maintenance
Standard Health Citation — quality of care
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Resident/family Group And Response
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
Soiled Linen And Trash Containers
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Parenteral/iv Fluids
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Comprehensive Assessments & Timing
Standard Health Citation — quality of care
Develop/implement Abuse/neglect Policies
Standard Health Citation — quality of care
Food In Form To Meet Individual Needs
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Request/refuse/dscntnue Trmnt;formlte Adv Dir
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
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
Electrical Equipment - Power Cords And Extens
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Elevators
Life Safety Code Citation — NFPA requirements
Ep Testing Requirements
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
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
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
Vertical Openings - Enclosure
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
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 121.5 complaints per 100 beds vs. a statewide rate of 57.4. 15 citations resulted from those complaints (12.6 per 100 beds vs. 5.3 statewide).
Total Complaints
145
55,669 statewide
Per 100 Occupied Beds
121.5
57.4 state avg
On-Site Inspections
18
7,566 statewide
Citations Issued
15
12.6 per 100 beds · avg 5.3
Facility-Reported Incidents
21%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 1 |
| Dietary Services | 1 |
| Other Services | 3 |
| Physical Environment | 1 |
| Quality of Care | 5 |
| Resident Rights | 2 |
| Total | 13 |
Enforcement & Fines
Jun 2016 – May 20268 enforcement actions totaling $62,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
October 31, 2023
$2,000
Stipulation & Order #NH-24-012 · Signed January 19, 2024
Reason: Resident Rights
Reason: Resident Rights
November 5, 2020
$10,000
Stipulation & Order #NH-21-015 · Signed January 22, 2021
Reason: Quality of Care
Reason: Quality of Care
October 5, 2020
$6,000
Stipulation & Order #NH-21-176 · Signed October 14, 2021
Reason: Quality of Care
Reason: Quality of Care
June 29, 2020
$4,000
Stipulation & Order #NH-20-055 · Signed September 29, 2020
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
April 24, 2020
$16,000
Stipulation & Order #NH-20-022 · Signed July 8, 2020
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
June 5, 2019
$12,000
Stipulation & Order #NH-19-040 · Signed September 16, 2019
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
January 5, 2018
$10,000
Stipulation & Order #NH-18-045 · Signed October 5, 2018
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
Date not yet available
$2,000
Stipulation & Order #NH-17-040 · Signed July 6, 2017
Reason: Other Services
Reason: Other Services