Citations Summary
Feb 2022 – Jan 20267 Inspections Conducted
4
No citations found
57% of all inspections
3
Resulted in citations
43% of all inspections
17 Total Citations — state avg: 23
Issued across those 3 inspections
13Standard Health
4Life Safety Code
Severity of Citations
How serious were those 17 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period
Inspection Details
Surveys with Citations Only▼
Standard Health Citations
Develop/implement Comprehensive Care Plan
Standard Health Citation — quality of care
Infection Control
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
Right To Survey Results/advocate Agency Info
Standard Health Citation — quality of care
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Sufficient Nursing Staff
Standard Health Citation — quality of care
Life Safety Code Citations
Alcohol Based Hand Rub Dispenser (abhr)
Life Safety Code Citation — NFPA requirements
Discharge From Exits
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
Encoding/transmitting Resident Assessments
Standard Health Citation — quality of care
Increase/prevent Decrease In Rom/mobility
Standard Health Citation — quality of care
Respect, Dignity/right To Have Prsnl Property
Standard Health Citation — quality of care
Life Safety Code Citations
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Means Of Egress - General
Life Safety Code Citation — NFPA requirements
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
▼
Standard Health Citations
Care Plan Timing And Revision
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
Reporting Of Alleged Violations
Standard Health Citation — quality of care
Reporting Of Reasonable Suspicion Of A Crime
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 17.7 complaints per 100 beds vs. a statewide rate of 55.0. 6 citations resulted from those complaints (2.5 per 100 beds vs. 3.0 statewide).
Total Complaints
42
55,221 statewide
Per 100 Occupied Beds
17.7
55.0 state avg
On-Site Inspections
10
8,103 statewide
Citations Issued
6
2.5 per 100 beds · avg 3.0
Facility-Reported Incidents
60%
55% statewide
| Citations by Category | This Facility |
|---|---|
| Administration | 0 |
| Dietary Services | 0 |
| Other Services | 0 |
| Physical Environment | 1 |
| Quality of Care | 8 |
| Resident Rights | 3 |
| Total | 12 |
Enforcement & Fines
Feb 2016 – Jan 20261 enforcement action totaling $4,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
September 9, 2022
$4,000
Stipulation & Order #NH-23-004 · Signed January 9, 2023
Reason: Quality of Care
Reason: Quality of Care