Citations Summary
Jun 2022 – May 202611 Inspections Conducted
6
No citations found
55% of all inspections
5
Resulted in citations
45% of all inspections
40 Total Citations — state avg: 41
Issued across those 5 inspections
29Standard Health
11Life Safety Code
Severity of Citations
How serious were those 40 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
In plain language
- Across 11 inspections in the current reporting window, 6 found no citations at all; inspectors issued 40 citations in total.
- Of those, 29 were standard health citations (quality of care) and 11 were related to the Life Safety Code (fire protection).
- The state logged 108 complaints about this facility; 16 led to on-site inspections.
- The state has 1 formal enforcement action (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
2750306N
County
Monroe
Phone
(585) 442-7960
Operated By
The Meadows at Westfall, Inc. (Not for Profit)
DOH Regional Office
Western NY
Occupancy Rate
95%
Staff Flu Vaccination
82%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Reporting Of Alleged Violations
Standard Health Citation — quality of care
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Personal Privacy/confidentiality Of Records
Standard Health Citation — quality of care
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Quality Of Care
Standard Health Citation — quality of care
Life Safety Code Citations
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
Gas And Vacuum Piped Systems - Information An
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
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
Infection Prevention & Control
Standard Health Citation — quality of care
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Resident/family Group And Response
Standard Health Citation — quality of care
Standards Of Construction For New Nh
Standard Health Citation — quality of care
Life Safety Code Citations
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Electrical Equipment - Testing And Maintenanc
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Elevators
Life Safety Code Citation — NFPA requirements
Vertical Openings - Enclosure
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Resident Records - Identifiable Information
Standard Health Citation — quality of care
▼
Standard Health Citations
Reporting - National Health Safety Network
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 79.6 complaints per 100 beds vs. a statewide rate of 57.4. 8 citations resulted from those complaints (5.9 per 100 beds vs. 5.3 statewide).
Total Complaints
108
55,669 statewide
Per 100 Occupied Beds
79.6
57.4 state avg
On-Site Inspections
16
7,566 statewide
Citations Issued
8
5.9 per 100 beds · avg 5.3
Facility-Reported Incidents
78%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 0 |
| Dietary Services | 1 |
| Other Services | 3 |
| Physical Environment | 1 |
| Quality of Care | 3 |
| Resident Rights | 3 |
| Total | 11 |
Enforcement & Fines
Jun 2016 – May 20261 enforcement action totaling $2,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
December 6, 2021
$2,000
Stipulation & Order #NH-22-024 · Signed January 25, 2022
Reason: Quality of Care
Reason: Quality of Care