Citations Summary
Jun 2022 – May 202623 Inspections Conducted
16
No citations found
70% of all inspections
7
Resulted in citations
30% of all inspections
85 Total Citations — state avg: 41
Issued across those 7 inspections
31Standard Health
54Life Safety Code
Severity of Citations
How serious were those 85 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 23 inspections in the current reporting window, 16 found no citations at all; inspectors issued 85 citations in total.
- Of those, 31 were standard health citations (quality of care) and 54 were related to the Life Safety Code (fire protection).
- The state logged 234 complaints about this facility; 27 led to on-site inspections.
- The state has 5 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
3620301N
County
Orleans
Phone
(585) 589-3225
Operated By
Comprehensive at Orleans, LLC (For Profit)
DOH Regional Office
Western NY
Occupancy Rate
100%
Staff Flu Vaccination
94%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
▼
Standard Health Citations
Department Criminal History Review
Standard Health Citation — quality of care
Department Criminal History Review
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
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
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Nurse Aide Peform Review-12 Hr/yr In-service
Standard Health Citation — quality of care
Physical Environment
Standard Health Citation — quality of care
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Request/refuse/dscntnue Trmnt;formlte Adv Dir
Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif
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
Life Safety Code Citations
Alcohol Based Hand Rub Dispenser (abhr)
Life Safety Code Citation — NFPA requirements
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Discharge From Exits
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
General Requirements - Other
Life Safety Code Citation — NFPA requirements
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Portable Fire Extinguishers
Life Safety Code Citation — NFPA requirements
Portable Space Heaters
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
Transfer And Discharge Requirements
Standard Health Citation — quality of care
▼
Standard Health Citations
Reporting Of Alleged Violations
Standard Health Citation — quality of care
▼
Standard Health Citations
Compliance And Ethics Program
Standard Health Citation — quality of care
Request/refuse/dscntnue Trmnt;formlte Adv Dir
Standard Health Citation — quality of care
▼
Standard Health Citations
Discharge Summary
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Infection Control
Standard Health Citation — quality of care
Menus Meet Resident Nds/prep In Adv/followed
Standard Health Citation — quality of care
Nutritive Value/appear, Palatable/prefer Temp
Standard Health Citation — quality of care
Qualified Dietary Staff
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Life Safety Code Citations
Alcohol Based Hand Rub Dispenser (abhr)
Life Safety Code Citation — NFPA requirements
Building Rehabilitation
Life Safety Code Citation — NFPA requirements
Discharge From Exits
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
Exit Signage
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
Illumination Of Means Of Egress
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
Smoke Detection
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Free From Abuse And Neglect
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 200.9 complaints per 100 beds vs. a statewide rate of 57.4. 12 citations resulted from those complaints (10.3 per 100 beds vs. 5.3 statewide).
Total Complaints
234
55,669 statewide
Per 100 Occupied Beds
200.9
57.4 state avg
On-Site Inspections
27
7,566 statewide
Citations Issued
12
10.3 per 100 beds · avg 5.3
Facility-Reported Incidents
79%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 2 |
| Dietary Services | 2 |
| Other Services | 2 |
| Physical Environment | 1 |
| Quality of Care | 4 |
| Resident Rights | 5 |
| Total | 16 |
Enforcement & Fines
Jun 2016 – May 20265 enforcement actions totaling $60,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
January 12, 2024
$10,000
Stipulation & Order #NH-24-067 · Signed October 29, 2024
Reason: Quality of Care
Reason: Quality of Care
September 24, 2021
$2,000
Stipulation & Order #NH-21-183 · Signed October 21, 2021
Reason: Quality of Care
Reason: Quality of Care
April 28, 2021
$18,000
Stipulation & Order #NH-21-236 · Signed December 16, 2021
Reason: Quality of Care
Reason: Quality of Care
May 9, 2020
$20,000
Stipulation & Order #NH-20-018 · Signed June 29, 2020
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
February 21, 2018
$10,000
Stipulation & Order #NH-18-022 · Signed May 14, 2018
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies