Citations Summary
Jun 2022 – May 202631 Total Citations — state avg: 41
Issued in the reporting period
20Standard Health
11Life Safety Code
Severity of Citations
How serious were those 31 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 4 inspections in the current reporting window, 1 found no citations at all; inspectors issued 31 citations in total.
- Of those, 20 were standard health citations (quality of care) and 11 were related to the Life Safety Code (fire protection).
- The state logged 18 complaints about this facility; 5 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
5905303N
County
Westchester
Phone
(914) 941-7300
Operated By
Bethel Nursing Home Company, Inc (Not for Profit)
DOH Regional Office
Hudson Valley
Occupancy Rate
88%
Staff Flu Vaccination
91%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Covid-19 Immunization
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Free From Misappropriation/exploitation
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Free Of Medication Error Rts 5 Prcnt Or More
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
Nutrition/hydration Status Maintenance
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Reasonable Accommodations Needs/preferences
Standard Health Citation — quality of care
Life Safety Code Citations
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Ep Training Program
Life Safety Code Citation — NFPA requirements
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Hvac
Life Safety Code Citation — NFPA requirements
Ltc And Icf/iid Sharing Plan With Patients
Life Safety Code Citation — NFPA requirements
Policies/procedures-volunteers And Staffing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
▼
Standard Health Citations
Discharge Planning Process
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
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
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
Nutrition/hydration Status Maintenance
Standard Health Citation — quality of care
Right To Be Free From Physical Restraints
Standard Health Citation — quality of care
Life Safety Code Citations
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Subsistence Needs For Staff And Patients
Life Safety Code Citation — NFPA requirements
Vertical Openings - Enclosure
Life Safety Code Citation — NFPA requirements
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 51.4 complaints per 100 beds vs. a statewide rate of 57.4. 7 citations resulted from those complaints (20.0 per 100 beds vs. 5.3 statewide).
Total Complaints
18
55,669 statewide
Per 100 Occupied Beds
51.4
57.4 state avg
On-Site Inspections
5
7,566 statewide
Citations Issued
7
20.0 per 100 beds · avg 5.3
Facility-Reported Incidents
39%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 1 |
| Dietary Services | 1 |
| Other Services | 2 |
| Physical Environment | 2 |
| Quality of Care | 3 |
| Resident Rights | 2 |
| Total | 11 |
Enforcement & Fines
Jun 2016 – May 20262 enforcement actions totaling $4,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
June 30, 2023
$2,000
Stipulation & Order #NH-23-104 · Signed October 26, 2023
Reason: Infection Control
Reason: Infection Control
July 27, 2022
$2,000
Stipulation & Order #NH-22-171 · Signed December 19, 2022
Reason: Quality of Care
Reason: Quality of Care