Cayuga Nursing and Rehabilitation Center

Inspection Reports

Complaints

Nursing Home Complaints, November 1, 2021 to October 31, 2025

Number of Complaints
The total number of complaints received about the facility during the reporting period.
8 This Facility
51,680 Statewide
Number of Complaints per 100 Occupied Beds
This rate demonstrates the number of complaints and incidents received per 100 occupied beds during the reporting period. Occupied beds are approximated by taking the daily occupancy rate data from the most recent year's audited Nursing Home Cost Report. This rate allows the user to compare a specific facility's complaint experience with that of other homes or a statewide average.
14.0 This Facility
50.0 Statewide
Percentage of Complaints Representing Facility-Reported Incidents
Facilities are required to report certain kinds of incidents to the Department of Health whenever they occur, and these are included in the complaint count. This measure shows the percentage of complaints that represents such facility-reported incidents.
50.0% This Facility
54.0% Statewide
All Complaint-Related On-Site Inspections
The number of complaint-related inspections at the facility completed by the Department of Health during the reporting period. Not all inspections necessarily result in deficiencies being cited.
23 This Facility
7,360 Statewide
Citations
The total number of complaints-related citations during the reporting period.
7 This Facility
4,035 Statewide
Citations per 100 Occupied Beds
This rate demonstrates the number of citations per 100 occupied beds during the reporting period. Occupied beds are approximated by taking the daily occupancy rate data from the most recent year's audited Nursing Home Cost Report. This rate allows the user to compare a specific facility's complaint experience with that of other homes or a statewide average.
6.1 This Facility
3.9 Statewide

Complaints-Related Citations by Category, November 1, 2021 to October 31, 2025

Administration
The number of complaint-related deficiencies pertaining to administrative issues.
1 This Facility
Dietary Services
The number of complaint-related deficiencies pertaining to dietary services.
1 This Facility
Other Services
The number of complaint-related deficiencies pertaining to other issues, i.e., those that cannot be categorized under administration, quality of care, resident rights, diet, or physical environment.
0 This Facility
Physical Environment
The number of complaint-related deficiencies pertaining to the physical environment of the facility.
0 This Facility
Quality of Care
The number of complaint-related deficiencies pertaining to quality of care.
8 This Facility
Resident Rights
The number of complaint-related deficiencies pertaining to resident rights.
4 This Facility
Total Complaints-Related Citations
The total number of citations during the reporting period resulting directly from complaints made against the facility.
14 This Facility

Citations

Citations from October 1, 2021 through September 30, 2025

Citations Summary

Standard Health Citations
The number of citations falling into the category of standard health deficiencies, which pertain to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
26 This Facility
18 State Average
Life Safety Code Citations
The number of citations falling into the category of Life Safety Code deficiencies, which pertain to a wide range of requirements established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
4 This Facility
11 State Average
Total Citations
The total number of citations of any kind received by the nursing home during the reporting period
30 This Facility
29 State Average
Citations Related to Actual Harm or Immediate Jeopardy
The number of citations involving defiencies in which actual harm to a resident occurred, as opposed to deficiencies that only created the potential to cause such harm.
1 This Facility
1 State Average
Percentage of Citations Related to Actual Harm or Immediate Jeopardy
The percentage of citations received for deficiencies resulting in actual resident harm, as opposed to those that only created the potential for harm.
3.3% This Facility
2.0% State Average

The citations above resulted from a total of 16 inspections.

Total citations
30

Citation Details

January 24, 2025 — Complaint Survey — Health: 10 — LSC: 8

January 24, 2025 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Admission physician orders for immediate care
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Coordination of pasarr and assessments
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Dialysis
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Discharge planning process
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Food procurement,store/prepare/serve-sanitary
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Free of accident hazards/supervision/devices
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 4
Immediate jeopardy to resident health or safety requiring immediate action. An event has caused or is likely to cause serious injury, harm, impairment, or death.
👤Isolated
Isolated

Substandard quality of care: a severe, systemic deficiency.
Free of medication error rts 5 prcnt or more
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Investigate/prevent/correct alleged violation
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Quality of care
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Resident/family group and response
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025

Standard Life Safety Code Citations 

Deficiency Severity Scope SQC Corrected
Cooking facilities
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Corridor - doors
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Electrical equipment - power cords and extens
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Exit signage
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Hazardous areas - enclosure
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Sprinkler system - installation
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Sprinkler system - maintenance and testing
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
Utilities - gas and electric
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 25, 2025
March 11, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

March 11, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
February 20, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

February 20, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
February 12, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

February 12, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
February 6, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

February 6, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
January 30, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

January 30, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
January 22, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

January 22, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
January 8, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

January 8, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
January 2, 2024 — Covid-19 Survey — Health: 1 — LSC: 0

January 2, 2024 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
December 26, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

December 26, 2023 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
December 18, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

December 18, 2023 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
December 11, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

December 11, 2023 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
November 20, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

November 20, 2023 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Reporting - national health safety network
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care.
October 18, 2023 — Complaint Survey — Health: 1 — LSC: 0

October 18, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Therapeutic diet prescribed by physician
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 17, 2023
June 8, 2023 — Complaint Survey — Health: 14 — LSC: 11

June 8, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Activities meet interest/needs each resident
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
ADL care provided for dependent residents
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Department criminal history review
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 0
👤Scope
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Develop/implement comprehensive care plan
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Food procurement,store/prepare/serve-sanitary
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Free of accident hazards/supervision/devices
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Grievances
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Infection prevention & control
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Influenza and pneumococcal immunizations
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Nutrition/hydration status maintenance
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Resident call system
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Respiratory/tracheostomy care and suctioning
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Right to participate in planning care
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023
Safe/clean/comfortable/homelike environment
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 7, 2023

Standard Life Safety Code Citations 

Deficiency Severity Scope SQC Corrected
Electrical equipment - testing and maintenanc
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Electrical systems - essential electric syste
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Electrical systems - essential electric syste
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Fire alarm system - testing and maintenance
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Hazardous areas - enclosure
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Means of egress - general
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Multiple occupancies - construction type
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Sprinkler system - installation
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Sprinkler system - maintenance and testing
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Subdivision of building spaces - smoke barrie
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
Vertical openings - enclosure
Standard Life Safety Code Citation: pertains to a wide range of life safety code requirements as established by the National Fire Protection Agency (NFPA), including construction, protection and operational features designed to provide safety from fire, smoke, and panic.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of August 6, 2023
May 26, 2023 — Complaint Survey — Health: 2 — LSC: 0

May 26, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
Free from abuse and neglect
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of July 21, 2023
Investigate/prevent/correct alleged violation
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 2
No actual harm or immediate jeopardy, but has caused minor discomfort and has the potential to cause more than minimal harm.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of July 21, 2023

Enforcement

November 1, 2015 through October 31, 2025

Survey DateDetails
January 24, 2025
  • Stipulation & Order #: NH-25-057
  • Stipulation and Order date: September 17, 2025
  • Fine: $10,000
  • Description: Physical Environment
June 8, 2023
  • Stipulation & Order #: NH-23-105
  • Stipulation and Order date: October 30, 2023
  • Fine: $2,000
  • Description: Infection Control
March 18, 2021
  • Stipulation & Order #: NH-22-015
  • Stipulation and Order date: January 11, 2022
  • Fine: $10,000
  • Description: Quality of Care
July 30, 2021
  • Stipulation & Order #: NH-21-171
  • Stipulation and Order date: October 12, 2021
  • Fine: $2,000
  • Description: Quality of Care
October 2, 2020
  • Stipulation & Order #: NH-21-009
  • Stipulation and Order date: January 12, 2021
  • Fine: $10,000
  • Description: Quality of Care
August 17, 2016
  • Stipulation & Order #: NH-17-021
  • Stipulation and Order date: March 20, 2017
  • Fine: $10,000
  • Description: Multiple Deficiencies
Date not yet available
  • Stipulation & Order #: NH-16-169
  • Stipulation and Order date: June 6, 2016
  • Fine: $16,000
  • Description: Multiple Deficiencies
November 18, 2014
  • Stipulation & Order #: NH-16-119
  • Stipulation and Order date: March 9, 2016
  • Fine: $10,000
  • Description: Multiple Deficiencies