Citations Summary
Jun 2022 – May 202612 Inspections Conducted
7
No citations found
58% of all inspections
5
Resulted in citations
42% of all inspections
31 Total Citations — state avg: 41
Issued across those 5 inspections
18Standard Health
13Life 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 12 inspections in the current reporting window, 7 found no citations at all; inspectors issued 31 citations in total.
- Of those, 18 were standard health citations (quality of care) and 13 were related to the Life Safety Code (fire protection).
- The state logged 132 complaints about this facility; 27 led to on-site inspections.
- The state has 3 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
1467301N
County
Erie
Phone
(716) 684-3000
Operated By
Niagara Lutheran Development, Inc (Not for Profit)
DOH Regional Office
Western NY
Occupancy Rate
96%
Staff Flu Vaccination
74%
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Reporting Of Alleged Violations
Standard Health Citation — quality of care
▼
Standard Health Citations
Bowel/bladder Incontinence, Catheter, Uti
Standard Health Citation — quality of care
Department Criminal History Review
Standard Health Citation — quality of care
Entering Into Binding Arbitration Agreements
Standard Health Citation — quality of care
Infection Control
Standard Health Citation — quality of care
Parenteral/iv Fluids
Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Right To Be Free From Chemical Restraints
Standard Health Citation — quality of care
Life Safety Code Citations
Fire Alarm System - Testing And Maintenance
Life Safety Code Citation — NFPA requirements
Hvac
Life Safety Code Citation — NFPA requirements
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Soiled Linen And Trash Containers
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Antibiotic Stewardship Program
Standard Health Citation — quality of care
Free From Abuse And Neglect
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
Personal Privacy/confidentiality Of Records
Standard Health Citation — quality of care
Responsibilities Of Providers; Required Notif
Standard Health Citation — quality of care
Right To Be Free From Physical Restraints
Standard Health Citation — quality of care
Life Safety Code Citations
Cooking Facilities
Life Safety Code Citation — NFPA requirements
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Fire Drills
Life Safety Code Citation — NFPA requirements
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Soiled Linen And Trash Containers
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Investigate/prevent/correct Alleged Violation
Standard Health Citation — quality of care
▼
Standard Health Citations
Cardio-pulmonary Resuscitation (cpr)
Standard Health Citation — quality of care
Notify Of Changes (injury/decline/room, Etc. )
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 87.7 complaints per 100 beds vs. a statewide rate of 57.4. 6 citations resulted from those complaints (4.0 per 100 beds vs. 5.3 statewide).
Total Complaints
132
55,669 statewide
Per 100 Occupied Beds
87.7
57.4 state avg
On-Site Inspections
27
7,566 statewide
Citations Issued
6
4.0 per 100 beds · avg 5.3
Facility-Reported Incidents
83%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 1 |
| Dietary Services | 0 |
| Other Services | 2 |
| Physical Environment | 1 |
| Quality of Care | 3 |
| Resident Rights | 5 |
| Total | 12 |
Enforcement & Fines
Jun 2016 – May 20263 enforcement actions totaling $20,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
January 3, 2023
$10,000
Stipulation & Order #NH-23-046 · Signed April 4, 2023
Reason: Quality of Care
Reason: Quality of Care
January 7, 2021
$4,000
Stipulation & Order #NH-21-043 · Signed March 1, 2021
Reason: Quality of Care
Reason: Quality of Care
September 30, 2020
$6,000
Stipulation & Order #NH-20-075 · Signed December 1, 2020
Reason: Multiple Deficiencies
Reason: Multiple Deficiencies