Williamsville Suburban LLC

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.
31 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.
29.9 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.
49.0% 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.
49 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.
3.4 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.
0 This Facility
Dietary Services
The number of complaint-related deficiencies pertaining to dietary services.
5 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.
8 This Facility
Quality of Care
The number of complaint-related deficiencies pertaining to quality of care.
20 This Facility
Resident Rights
The number of complaint-related deficiencies pertaining to resident rights.
6 This Facility
Total Complaints-Related Citations
The total number of citations during the reporting period resulting directly from complaints made against the facility.
39 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.
56 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
60 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.
2 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 13 inspections. There were also 24 inspections resulting in no citations.

Inspections (with citations)
13
Inspections (no citations)
24
Total citations
60

Citation Details

May 7, 2025 — Complaint Survey — Health: 2 — LSC: 0

May 7, 2025 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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 June 25, 2025
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 June 25, 2025
October 28, 2024 — Complaint Survey — Health: 10 — LSC: 22

October 28, 2024 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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 December 18, 2024
Antibiotic stewardship program
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. Corrected as of December 18, 2024
Bowel/bladder incontinence, catheter, uti
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 18, 2024
Infection control
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 December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Label/store drugs and biologicals
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 18, 2024
Reporting of alleged violations
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 18, 2024
Required postings
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Routine/emergency dental srvcs in nfs
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 18, 2024
Sufficient nursing staff
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. Corrected as of December 18, 2024

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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Corridors - construction of walls
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 December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Electrical systems - other
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 December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Fire alarm 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 December 18, 2024
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Gas equipment - cylinder and container storag
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 December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Illumination of means of egress
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 December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Means of egress requirements - other
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 December 18, 2024
Plan based on all hazards risk assessment
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 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Portable fire extinguishers
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 December 18, 2024
Primary/alternate means for communication
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 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
Smoking regulations
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 December 18, 2024
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 December 18, 2024
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 December 18, 2024
Stairways and smokeproof enclosures
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 December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of December 18, 2024
July 24, 2024 — Complaint Survey — Health: 1 — LSC: 0

July 24, 2024 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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 September 5, 2024
February 9, 2024 — Complaint Survey — Health: 2 — LSC: 0

February 9, 2024 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 3
Actual harm has occurred, resulting in a negative outcome compromising the resident's ability to reach the highest practicable level of functioning.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 19, 2024
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 19, 2024
January 24, 2024 — Complaint Survey — Health: 1 — LSC: 0

January 24, 2024 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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.
👤Isolated
Isolated
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of March 4, 2024
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.
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.
August 7, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

August 7, 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.
June 12, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

June 12, 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.
May 2, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

May 2, 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.
March 17, 2023 — Complaint Survey — Health: 9 — LSC: 10

March 17, 2023 Complaint Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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 May 1, 2023
Binding arbitration agreements
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 May 1, 2023
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 May 1, 2023
Encoding/transmitting resident assessments
Standard Health Inspection Citation: pertains to quality of care, e.g., resident care, staff/resident interaction, environment, and record-keeping.
Level 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 1, 2023
Entering into binding arbitration agreements
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 May 1, 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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 1, 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 May 1, 2023
Nutritive value/appear, palatable/prefer temp
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 May 1, 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 May 1, 2023

Standard Life Safety Code Citations 

Deficiency Severity Scope SQC Corrected
Alcohol based hand rub dispenser (abhr)
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 May 8, 2023
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 1, 2023
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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 8, 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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 15, 2023
Ep testing requirements
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 1
No actual harm done, but potential to cause minimal harm with minor negative impacts on residents.
👤👤👤👤👤Widespread
Widespread
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 8, 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 May 8, 2023
Gas equipment - cylinder and container storag
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 May 8, 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.
👤👤👤Pattern
Pattern
Deficiency does not indicate severe, systemic problems in quality of care. Corrected as of May 8, 2023
Portable space heaters
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 May 8, 2023
Stairways and smokeproof enclosures
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 May 8, 2023
January 9, 2023 — Covid-19 Survey — Health: 1 — LSC: 0

January 9, 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.
January 14, 2022 — Covid-19 Survey — Health: 1 — LSC: 0

January 14, 2022 Covid-19 Survey

Standard Health Citations 

Deficiency Severity Scope SQC Corrected
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 February 22, 2022

Enforcement

November 1, 2015 through October 31, 2025

Survey DateDetails
February 9, 2024
  • Stipulation & Order #: NH-24-038
  • Stipulation and Order date: June 24, 2024
  • Fine: $10,000
  • Description: Quality of Care
January 14, 2022
  • Stipulation & Order #: NH-22-075
  • Stipulation and Order date: May 17, 2022
  • Fine: $8,000
  • Description: Quality of Care
October 5, 2021
  • Stipulation & Order #: NH-22-029
  • Stipulation and Order date: January 25, 2022
  • Fine: $10,000
  • Description: Quality of Care
January 21, 2021
  • Stipulation & Order #: NH-21-115
  • Stipulation and Order date: June 2, 2021
  • Fine: $8,000
  • Description: Multiple Deficiencies
November 2, 2020
  • Stipulation & Order #: Nh-21-001
  • Stipulation and Order date: January 5, 2021
  • Fine: $2,000
  • Description: Quality of Care
June 1, 2020
  • Stipulation & Order #: NH-20-098
  • Stipulation and Order date: December 28, 2020
  • Fine: $6,000
  • Description: Quality of Care