Citations Summary
Feb 2022 – Jan 202613 Inspections Conducted
6
No citations found
46% of all inspections
7
Resulted in citations
54% of all inspections
29 Total Citations — state avg: 23
Issued across those 7 inspections
22Standard Health
7Life Safety Code
Severity of Citations
How serious were those 29 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Dialysis
Standard Health Citation — quality of care
Drug Regimen Review, Report Irregular, Act On
Standard Health Citation — quality of care
Free From Abuse And Neglect
Standard Health Citation — quality of care
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
Life Safety Code Citations
Building Construction Type And Height
Life Safety Code Citation — NFPA requirements
Egress Doors
Life Safety Code Citation — NFPA requirements
Elevators
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Hvac
Life Safety Code Citation — NFPA requirements
Portable Fire Extinguishers
Life Safety Code Citation — NFPA requirements
Portable Space Heaters
Life Safety Code Citation — NFPA requirements
Stairways And Smokeproof Enclosures
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Infection Prevention & Control
Standard Health Citation — quality of care
▼
Standard Health Citations
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Free From Abuse And Neglect
Standard Health Citation — quality of care
Increase/prevent Decrease In Rom/mobility
Standard Health Citation — quality of care
Maintains Effective Pest Control Program
Standard Health Citation — quality of care
Physical Environment
Standard Health Citation — quality of care
Resident Allergies, Preferences, Substitutes
Standard Health Citation — quality of care
Right To Be Free From Physical Restraints
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
Building Construction Type And Height
Life Safety Code Citation — NFPA requirements
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Ep Program Patient Population
Life Safety Code Citation — NFPA requirements
Ep Testing Requirements
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
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Maintenance, Inspection & Testing - Doors
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
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free From Abuse And Neglect
Standard Health Citation — quality of care
Free From Unnec Psychotropic Meds/prn Use
Standard Health Citation — quality of care
Physical Environment
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Resident Call System
Standard Health Citation — quality of care
Standards Of Construction For New Nh
Standard Health Citation — quality of care
Life Safety Code Citations
Alcohol Based Hand Rub Dispenser (abhr)
Life Safety Code Citation — NFPA requirements
Building Construction Type And Height
Life Safety Code Citation — NFPA requirements
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Doors With Self-closing Devices
Life Safety Code Citation — NFPA requirements
Egress Doors
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 Program Patient Population
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
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Portable Space Heaters
Life Safety Code Citation — NFPA requirements
Roles Under A Waiver Declared By Secretary
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Essential Equipment, Safe Operating Condition
Standard Health Citation — quality of care
Life Safety Code Citations
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Fire Alarm System - Out Of Service
Life Safety Code Citation — NFPA requirements
Sprinkler System - Out Of Service
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Quality Of Care
Standard Health Citation — quality of care
▼
Standard Health Citations
Reporting Of Alleged Violations
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
Feb 2022 – Jan 2026Above state average. This facility received 165.6 complaints per 100 beds vs. a statewide rate of 55.0. 9 citations resulted from those complaints (9.7 per 100 beds vs. 3.0 statewide).
Total Complaints
154
55,221 statewide
Per 100 Occupied Beds
165.6
55.0 state avg
On-Site Inspections
16
8,103 statewide
Citations Issued
9
9.7 per 100 beds · avg 3.0
Facility-Reported Incidents
61%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 0 |
| Dietary Services | 2 |
| Other Services | 0 |
| Physical Environment | 8 |
| Quality of Care | 14 |
| Resident Rights | 2 |
| Total | 26 |
Enforcement & Fines
Feb 2016 – Jan 20266 enforcement actions totaling $40,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
May 11, 2022
$12,000
Stipulation & Order #NH-22-122 · Signed August 9, 2022
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
November 5, 2021
$2,000
Stipulation & Order #NH-22-085 · Signed May 25, 2022
Reason: Quality of Care
Reason: Quality of Care
December 23, 2020
$8,000
Stipulation & Order #NH-21-047 · Signed March 13, 2021
Reason: Quality of Care
Reason: Quality of Care
January 24, 2017
$6,000
Stipulation & Order #NH-17-038 · Signed June 19, 2017
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
June 17, 2013
$10,000
Stipulation & Order #NH-16-187 · Signed August 9, 2017
Reason: Quality of Care
Reason: Quality of Care
Date not yet available
$2,000
Stipulation & Order #NH-18-042 · Signed September 24, 2018
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies