Citations Summary
Jun 2022 – May 20268 Inspections Conducted
2
No citations found
25% of all inspections
6
Resulted in citations
75% of all inspections
63 Total Citations — state avg: 41
Issued across those 6 inspections
48Standard Health
15Life Safety Code
Severity of Citations
How serious were those 63 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 8 inspections in the current reporting window, 2 found no citations at all; inspectors issued 63 citations in total.
- Of those, 48 were standard health citations (quality of care) and 15 were related to the Life Safety Code (fire protection).
- The state logged 123 complaints about this facility; 19 led to on-site inspections.
- The state has 1 formal enforcement action (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
3429304N
County
Ontario
Phone
(585) 396-4340
Operated By
Ontario Operations Associates, LLC (For Profit)
DOH Regional Office
Western NY
Occupancy Rate
94%
Staff Flu Vaccination
94%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Accuracy Of Assessments
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
Discharge Process
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Infection Prevention & Control
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
Qrtly Assessment At Least Every 3 Months
Standard Health Citation — quality of care
Request/refuse/dscntnue Trmnt;formlte Adv Dir
Standard Health Citation — quality of care
Resident Call System
Standard Health Citation — quality of care
Resident Records - Identifiable Information
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
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Services Provided Meet Professional Standards
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
Emergency Lighting
Life Safety Code Citation — NFPA requirements
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
Fire Drills
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
Accounting And Records Of Personal Funds
Standard Health Citation — quality of care
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Administration
Standard Health Citation — quality of care
Bowel/bladder Incontinence, Catheter, Uti
Standard Health Citation — quality of care
Free From Abuse And Neglect
Standard Health Citation — quality of care
Grievances
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
Notice Requirements Before Transfer/discharge
Standard Health Citation — quality of care
Physical Environment
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Requirements Before Submitting A Request For
Standard Health Citation — quality of care
Resident Call System
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Treatment/svcs To Prevent/heal Pressure Ulcer
Standard Health Citation — quality of care
Life Safety Code Citations
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
▼
Standard Health Citations
Notice Of Bed Hold Policy Before/upon Trnsfr
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
▼
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
Develop/implement Comprehensive Care Plan
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
Menus Meet Resident Nds/prep In Adv/followed
Standard Health Citation — quality of care
Nutrition/hydration Status Maintenance
Standard Health Citation — quality of care
Pharmacy Srvcs/procedures/pharmacist/records
Standard Health Citation — quality of care
Safe/functional/sanitary/comfortable Environ
Standard Health Citation — quality of care
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
Standards Of Construction For New Existing Nh
Standard Health Citation — quality of care
Life Safety Code Citations
Development Of Communication Plan
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
Ep Training Program
Life Safety Code Citation — NFPA requirements
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
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 133.1 complaints per 100 beds vs. a statewide rate of 57.4. 25 citations resulted from those complaints (27.0 per 100 beds vs. 5.3 statewide).
Total Complaints
123
55,669 statewide
Per 100 Occupied Beds
133.1
57.4 state avg
On-Site Inspections
19
7,566 statewide
Citations Issued
25
27.0 per 100 beds · avg 5.3
Facility-Reported Incidents
20%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 4 |
| Dietary Services | 1 |
| Other Services | 3 |
| Physical Environment | 3 |
| Quality of Care | 4 |
| Resident Rights | 3 |
| Total | 18 |
Enforcement & Fines
Jun 2016 – May 20261 enforcement action totaling $84,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
January 31, 2025
$84,000
Stipulation & Order #NH-26-033 · Signed March 31, 2026
Reason: Quality of Care
Reason: Quality of Care