Citations Summary
Jun 2022 – May 202615 Inspections Conducted
3
No citations found
20% of all inspections
12
Resulted in citations
80% of all inspections
62 Total Citations — state avg: 41
Issued across those 12 inspections
42Standard Health
20Life Safety Code
Severity of Citations
How serious were those 62 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 15 inspections in the current reporting window, 3 found no citations at all; inspectors issued 62 citations in total.
- Of those, 42 were standard health citations (quality of care) and 20 were related to the Life Safety Code (fire protection).
- The state logged 77 complaints about this facility; 16 led to on-site inspections.
- The state has 3 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
5220301N
County
Sullivan
Phone
(845) 292-8640
Operated By
County of Sullivan (Public)
DOH Regional Office
Hudson Valley
Occupancy Rate
68%
Staff Flu Vaccination
82%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
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
▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
▼
Standard Health Citations
Responsibilities Of Medical Director
Standard Health Citation — quality of care
▼
Standard Health Citations
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
Sufficient/competent Staff-behav Health Needs
Standard Health Citation — quality of care
▼
Standard Health Citations
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Nutritive Value/appear, Palatable/prefer Temp
Standard Health Citation — quality of care
Physician Visits - Review Care/notes/order
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Respiratory/tracheostomy Care And Suctioning
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Self-determination
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Life Safety Code Citations
Building Construction Type And Height
Life Safety Code Citation — NFPA requirements
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Corridor - Doors
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
Elevators
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
Hvac
Life Safety Code Citation — NFPA requirements
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
▼
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
▼
Standard Health Citations
Cardio-pulmonary Resuscitation (cpr)
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Increase/prevent Decrease In Rom/mobility
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Notice Of Bed Hold Policy Before/upon Trnsfr
Standard Health Citation — quality of care
Qualified Dietary Staff
Standard Health Citation — quality of care
Resident Allergies, Preferences, Substitutes
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
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Life Safety Code Citations
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Development Of Ep Policies And Procedures
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Ep Testing Requirements
Life Safety Code Citation — NFPA requirements
Fire Drills
Life Safety Code Citation — NFPA requirements
Hazardous Areas - Enclosure
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
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
▼
Standard Health Citations
Free From Abuse And Neglect
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
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
Jun 2022 – May 2026Above state average. This facility received 71.0 complaints per 100 beds vs. a statewide rate of 57.4. 25 citations resulted from those complaints (23.1 per 100 beds vs. 5.3 statewide).
Total Complaints
77
55,669 statewide
Per 100 Occupied Beds
71.0
57.4 state avg
On-Site Inspections
16
7,566 statewide
Citations Issued
25
23.1 per 100 beds · avg 5.3
Facility-Reported Incidents
47%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 2 |
| Dietary Services | 2 |
| Other Services | 2 |
| Physical Environment | 1 |
| Quality of Care | 8 |
| Resident Rights | 6 |
| Total | 21 |
Enforcement & Fines
Jun 2016 – May 20263 enforcement actions totaling $32,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
September 27, 2024
$20,000
Stipulation & Order #NH-25-028 · Signed July 10, 2025
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies
July 7, 2023
$10,000
Stipulation & Order #NH-23-102 · Signed October 26, 2023
Reason: Resident Rights
Reason: Resident Rights
January 5, 2023
$2,000
Stipulation & Order #NH-23-065 · Signed July 5, 2023
Reason: Infection Control
Reason: Infection Control