Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Good Samaritan Society - Syracuse

Syracuse, NE · 88 certified beds · Last Life Safety survey January 16, 2025

CMS Certification Number 285138 · first certified February 1994

Ownership

Operated by GOOD SAMARITAN SOCIETY · Non profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NE

35 citations — more than 93% of the 180 certified nursing homes in NE. Compared within NE rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 13 citations; the earlier surveys in the window averaged 10.7. With 4 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (January 2026 to March 2026), and past the point by which nine in ten NE facilities have been surveyed. This facility’s last Life Safety survey was January 2025. Facilities in NE are typically surveyed 12–14 months after the last one (median 13), measured over 271 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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5 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

3 of the 35 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 35 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.

How that compares

Citations on file over three years

Compared with the median facility in NE, and nationally. Surveyors differ markedly between states, so the NE figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	35
Median facility in NE	15
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
January 9, 2023	12
January 9, 2024	10
January 9, 2024	10
January 16, 2025	13

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0920	Ensure proper usage of power strips and extension cords.	3	2025-01-16
K-0363	Install corridor and hallway doors that block smoke.	3	2025-01-16
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	3	2025-01-16
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	3	2025-01-16
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2024-01-09
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2025-01-16
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	2	2025-01-16
E-0041	Implement emergency and standby power systems.	2	2025-01-16

What the citations cover

Citations by CMS category

Smoke Deficiencies 15
Gas, Vacuum, and Electrical Systems Deficiencies 10
Emergency Preparedness Deficiencies 3
Miscellaneous Deficiencies 3
Other 4

Citations by CMS category
Category	Citations
Smoke Deficiencies	15
Gas, Vacuum, and Electrical Systems Deficiencies	10
Emergency Preparedness Deficiencies	3
Miscellaneous Deficiencies	3
Services Deficiencies	2
Egress Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 16, 2025 — 13 citations

Citations issued on January 16, 2025
Tag	What the surveyor checks	Status
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (February 27, 2025)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (February 27, 2025)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (February 27, 2025)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (April 4, 2025)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (April 4, 2025)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (February 27, 2025)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (April 4, 2025)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (April 4, 2025)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (April 4, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 27, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 27, 2025)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (February 27, 2025)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (February 27, 2025)

January 9, 2024 — 10 citations

Citations issued on January 9, 2024
Tag	What the surveyor checks	Status
E-0001	Establish an Emergency Preparedness Program (EP).	Deficient, Provider has date of correction (February 9, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (February 18, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 18, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (February 18, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 18, 2024)
K-0500	Meet other general requirements that are deficient.	Deficient, Provider has date of correction (February 18, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (February 18, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 18, 2024)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (February 18, 2024)
K-0922	Meet requirements for the use and maintenance of medical gas equipment.	Deficient, Provider has date of correction (February 18, 2024)

January 9, 2023 — 12 citations

Citations issued on January 9, 2023
Tag	What the surveyor checks	Status
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (February 10, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (February 10, 2023)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (February 10, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 10, 2023)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (February 10, 2023)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 10, 2023)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (February 10, 2023)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (February 10, 2023)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (February 10, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 10, 2023)
K-0919	Meet requirements for the use of electrical equipment.	Deficient, Provider has date of correction (February 10, 2023)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (February 10, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.