Citations Summary
Feb 2022 – Jan 202612 Total Citations — state avg: 23
Issued in the reporting period
8Standard Health
4Life Safety Code
Severity of Citations
How serious were those 12 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Baseline Care Plan
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Infection Control
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Right To Survey Results/advocate Agency Info
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Life Safety Code Citations
Physical Environment
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
Residents Are Free Of Significant Med Errors
Standard Health Citation — quality of care
▼
Standard Health Citations
Bowel/bladder Incontinence, Catheter, Uti
Standard Health Citation — quality of care
Care Plan Timing And Revision
Standard Health Citation — quality of care
Drug Regimen Is Free From Unnecessary Drugs
Standard Health Citation — quality of care
Drug Regimen Review, Report Irregular, Act On
Standard Health Citation — quality of care
Encoding/transmitting Resident Assessments
Standard Health Citation — quality of care
Free From Unnec Psychotropic Meds/prn Use
Standard Health Citation — quality of care
Free From Unnec Psychotropic Meds/prn Use
Standard Health Citation — quality of care
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
Notify Of Changes (injury/decline/room, Etc. )
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Life Safety Code Citations
Doors With Self-closing Devices
Life Safety Code Citation — NFPA requirements
Egress Doors
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
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Other Laws, Codes, Rules And Regulations.
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Accuracy Of Assessments
Standard Health Citation — quality of care
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Free Of Accident Hazards/supervision/devices
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
Feb 2022 – Jan 2026Below state average. This facility received 40.1 complaints per 100 beds vs. a statewide rate of 55.0. 7 citations resulted from those complaints (3.6 per 100 beds vs. 3.0 statewide).
Total Complaints
77
55,221 statewide
Per 100 Occupied Beds
40.1
55.0 state avg
On-Site Inspections
5
8,103 statewide
Citations Issued
7
3.6 per 100 beds · avg 3.0
Facility-Reported Incidents
73%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 0 |
| Dietary Services | 1 |
| Other Services | 0 |
| Physical Environment | 2 |
| Quality of Care | 6 |
| Resident Rights | 2 |
| Total | 11 |
Enforcement & Fines
Feb 2016 – Jan 20262 enforcement actions totaling $20,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
March 7, 2025
$10,000
Stipulation & Order #NH-25-063 · Signed October 8, 2025
Reason: Quality of Care
Reason: Quality of Care
October 31, 2022
$10,000
Stipulation & Order #NH-23-020 · Signed February 15, 2023
Reason: Quality of Care
Reason: Quality of Care