Citations Summary
Jun 2022 – May 20268 Inspections Conducted
2
No citations found
25% of all inspections
6
Resulted in citations
75% of all inspections
35 Total Citations — state avg: 41
Issued across those 6 inspections
19Standard Health
16Life Safety Code
Severity of Citations
How serious were those 35 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 8 inspections in the current reporting window, 2 found no citations at all; inspectors issued 35 citations in total.
- Of those, 19 were standard health citations (quality of care) and 16 were related to the Life Safety Code (fire protection).
- The state logged 59 complaints about this facility; 11 led to on-site inspections.
- The state has 2 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
5901308N
County
Westchester
Phone
(914) 737-8400
Operated By
West Ledge Op, LLC (For Profit)
DOH Regional Office
Hudson Valley
Occupancy Rate
95%
Staff Flu Vaccination
94%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Accuracy Of Assessments
Standard Health Citation — quality of care
Encoding/transmitting Resident Assessments
Standard Health Citation — quality of care
Infection Prevention & Control
Standard Health Citation — quality of care
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
▼
Standard Health Citations
Drug Regimen Is Free From Unnecessary Drugs
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
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
Pharmacy Srvcs/procedures/pharmacist/records
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
Treatment/svcs To Prevent/heal Pressure Ulcer
Standard Health Citation — quality of care
Life Safety Code Citations
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Power Cords And Extens
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
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
Illumination Of Means Of Egress
Life Safety Code Citation — NFPA requirements
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Organization And Administration
Life Safety Code Citation — NFPA requirements
Rubbish Chutes, Incinerators, And Laundry Chu
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
Stairways And Smokeproof Enclosures
Life Safety Code Citation — NFPA requirements
Standards Of Construction For New Existing Nh
Life Safety Code Citation — NFPA requirements
Vertical Openings - Enclosure
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
▼
Standard Health Citations
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
▼
Standard Health Citations
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
▼
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
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 67.8 complaints per 100 beds vs. a statewide rate of 57.4. 7 citations resulted from those complaints (8.0 per 100 beds vs. 5.3 statewide).
Total Complaints
59
55,669 statewide
Per 100 Occupied Beds
67.8
57.4 state avg
On-Site Inspections
11
7,566 statewide
Citations Issued
7
8.0 per 100 beds · avg 5.3
Facility-Reported Incidents
51%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 0 |
| Dietary Services | 0 |
| Other Services | 1 |
| Physical Environment | 2 |
| Quality of Care | 5 |
| Resident Rights | 3 |
| Total | 11 |
Enforcement & Fines
Jun 2016 – May 20262 enforcement actions totaling $12,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
August 28, 2024
$10,000
Stipulation & Order #NH-25-007 · Signed January 22, 2025
Reason: Quality of Care
Reason: Quality of Care
December 22, 2021
$2,000
Stipulation & Order #NH-22-050 · Signed March 25, 2022
Reason: Quality of Care
Reason: Quality of Care