Citations Summary

Feb 2022 โ€“ Jan 2026
13 Total Citations โ€” state avg: 23
Issued in the reporting period
11Standard Health
2Life Safety Code
Severity of Citations
How serious were those 13 citations?
0
Minor potential harm
All corrected โœ“
0
No actual harm
Free from involuntary seclusion ยท July 23, 2025 ยท Not yet corrected

Inspection Details

Surveys with Citations Only
July 23, 2025 Complaint Survey 11 Health 0 LSC
โ–ผ
Standard Health Citations
Accuracy Of Assessments
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated Not yet corrected
Free From Abuse And Neglect
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern Not yet corrected
Free From Involuntary Seclusion
Standard Health Citation โ€” quality of care
Level 3 ยท Actual Harm ๐Ÿ‘ค Isolated Not yet corrected
Infection Prevention & Control
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated Not yet corrected
Investigate/prevent/correct Alleged Violation
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated Not yet corrected
Qapi/qaa Improvement Activities
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern Not yet corrected
Quality Of Care
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern Not yet corrected
Reporting Of Alleged Violations
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern Not yet corrected
Resident Rights/exercise Of Rights
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated Not yet corrected
Residents Are Free Of Significant Med Errors
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated Not yet corrected
Sufficient Nursing Staff
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern Not yet corrected
August 30, 2024 Complaint Survey 5 Health 0 LSC
โ–ผ
Standard Health Citations
Physician Visits - Review Care/notes/order
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated October 29, 2024
Qapi Prgm/plan, Disclosure/good Faith Attmpt
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated October 29, 2024
Residents Are Free Of Significant Med Errors
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern October 29, 2024
Services Provided Meet Professional Standards
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern October 29, 2024
Sufficient Nursing Staff
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated October 29, 2024
July 13, 2023 Complaint Survey 1 Health 0 LSC
โ–ผ
Standard Health Citations
Free From Abuse And Neglect
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated August 29, 2023
January 26, 2023 Certification/Complaint Survey 6 Health 8 LSC
โ–ผ
Standard Health Citations
Develop/implement Comprehensive Care Plan
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated March 27, 2023
Drug Regimen Review, Report Irregular, Act On
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated March 27, 2023
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated March 27, 2023
Free Of Accident Hazards/supervision/devices
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated March 27, 2023
Grievances
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated March 27, 2023
Infection Prevention & Control
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated March 27, 2023
Life Safety Code Citations
Electrical Systems - Essential Electric Syste
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern February 28, 2023
Emergency Lighting
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated February 28, 2023
Hvac
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern February 28, 2023
Smoke Detection
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Pattern February 28, 2023
Sprinkler System - Installation
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated February 28, 2023
Standards Of Construction For New Existing Nh
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated February 28, 2023
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated February 28, 2023
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation โ€” NFPA requirements
Level 2 ยท Minor potential harm ๐Ÿ‘ค Isolated February 28, 2023
May 30, 2022 Covid-19 Survey 1 Health 0 LSC
โ–ผ
Standard Health Citations
Reporting - National Health Safety Network
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Widespread Not yet corrected
April 18, 2022 Covid-19 Survey 1 Health 0 LSC
โ–ผ
Standard Health Citations
Reporting - National Health Safety Network
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Widespread Not yet corrected
March 7, 2022 Covid-19 Survey 1 Health 0 LSC
โ–ผ
Standard Health Citations
Reporting - National Health Safety Network
Standard Health Citation โ€” quality of care
Level 2 ยท Minor potential harm ๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค๐Ÿ‘ค Widespread Not yet corrected
Severity Scale Reference
Level 0 โ€” No Harm Potential Level 2 โ€” Minor Potential Harm Level 3 โ€” Actual Harm Level 4 โ€” Immediate Jeopardy

Complaints

Feb 2022 โ€“ Jan 2026
Below state average. This facility received 33.6 complaints per 100 beds vs. a statewide rate of 55.0. 15 citations resulted from those complaints (11.7 per 100 beds vs. 3.0 statewide).
Total Complaints
43
55,221 statewide
Per 100 Occupied Beds
33.6
55.0 state avg
On-Site Inspections
5
8,103 statewide
Citations Issued
15
11.7 per 100 beds ยท avg 3.0
Facility-Reported Incidents
44%
55% statewide
Citations by CategoryThis Facility
Administration1
Dietary Services0
Other Services0
Physical Environment0
Quality of Care7
Resident Rights1
Total9

Enforcement & Fines

Feb 2016 โ€“ Jan 2026
3 enforcement actions totaling $16,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
July 21, 2025
$2,000
Stipulation & Order #NH-26-008 ยท Signed January 15, 2026
Reason: Resident Rights
January 26, 2023
$2,000
Stipulation & Order #NH-23-042 ยท Signed April 14, 2023
Reason: Infection Control
March 19, 2013
$12,000
Stipulation & Order #NH-16-175 ยท Signed June 28, 2016
Reason: Multiple Deficiencies