Citations Summary
Jun 2022 – May 202694 Total Citations — state avg: 41
Issued in the reporting period
64Standard Health
30Life Safety Code
Severity of Citations
How serious were those 94 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 6 inspections in the current reporting window; inspectors issued 94 citations in total.
- Of those, 64 were standard health citations (quality of care) and 30 were related to the Life Safety Code (fire protection).
- The state logged 26 complaints about this facility; 3 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
4350301N
County
Rockland
Phone
(845) 268-9339
Operated By
Tolstoy Foundation Rehabilitation and Nursing Center Inc (Not for Profit)
DOH Regional Office
Hudson Valley
Occupancy Rate
59%
Staff Flu Vaccination
94%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Administration
Standard Health Citation — quality of care
Cardio-pulmonary Resuscitation (cpr)
Standard Health Citation — quality of care
Criminal History Record Check Process
Standard Health Citation — quality of care
Discharge Process
Standard Health Citation — quality of care
Governing Body
Standard Health Citation — quality of care
Grievances
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
Medicaid/medicare Coverage/liability Notice
Standard Health Citation — quality of care
Pharmacy Srvcs/procedures/pharmacist/records
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
Residents Are Free Of Significant Med Errors
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
Discharge From Exits
Life Safety Code Citation — NFPA requirements
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
Electrical Systems - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
Elevators
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
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Methods For Sharing Information
Life Safety Code Citation — NFPA requirements
Physical Environment
Life Safety Code Citation — NFPA requirements
Policies/procedures-volunteers And Staffing
Life Safety Code Citation — NFPA requirements
Smoking Regulations
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Care Plan Timing And Revision
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Free From Abuse And Neglect
Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Right To Be Free From Physical Restraints
Standard Health Citation — quality of care
Treatment/svcs To Prevent/heal Pressure Ulcer
Standard Health Citation — quality of care
▼
Standard Health Citations
Free From Abuse And Neglect
Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
▼
Standard Health Citations
Baseline Care Plan
Standard Health Citation — quality of care
Comprehensive Assessments & Timing
Standard Health Citation — quality of care
Covid-19 Immunization
Standard Health Citation — quality of care
Department Criminal History Review
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
Infection Preventionist Qualifications/role
Standard Health Citation — quality of care
Notice Of Bed Hold Policy Before/upon Trnsfr
Standard Health Citation — quality of care
Notice Requirements Before Transfer/discharge
Standard Health Citation — quality of care
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
Nurse Aide Peform Review-12 Hr/yr In-service
Standard Health Citation — quality of care
Pasarr Screening For Md & Id
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
Required In-service Training For Nurse Aides
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Life Safety Code Citations
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Testing And Maintenanc
Life Safety Code Citation — NFPA requirements
Ep Program Patient Population
Life Safety Code Citation — NFPA requirements
Exit Signage
Life Safety Code Citation — NFPA requirements
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
Fundamentals - Building System Categories
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
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Number Of Exits - Corridors
Life Safety Code Citation — NFPA requirements
Physical Environment
Life Safety Code Citation — NFPA requirements
Portable Fire Extinguishers
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
Standards Of Construction For New Existing Nh
Life Safety Code Citation — NFPA requirements
▼
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 2026Below state average. This facility received 37.4 complaints per 100 beds vs. a statewide rate of 57.4. 21 citations resulted from those complaints (30.2 per 100 beds vs. 5.3 statewide).
Total Complaints
26
55,669 statewide
Per 100 Occupied Beds
37.4
57.4 state avg
On-Site Inspections
3
7,566 statewide
Citations Issued
21
30.2 per 100 beds · avg 5.3
Facility-Reported Incidents
27%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 1 |
| Dietary Services | 0 |
| Other Services | 1 |
| Physical Environment | 1 |
| Quality of Care | 2 |
| Resident Rights | 3 |
| Total | 8 |
Enforcement & Fines
Jun 2016 – May 20261 enforcement action totaling $14,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
September 2, 2025
$14,000
Stipulation & Order #NH-26-004 · Signed January 8, 2026
Reason: Other Services
Reason: Other Services