Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
GHENT REHABILITATION & NURSING CENTER
GHENT, NY · 120 certified beds · Last Life Safety survey September 1, 2023
CMS Certification Number 335766 · first certified November 1992
Ownership
Operated by PERSONAL HEALTHCARE MANAGEMENT · For profit - Corporation
- Ownership changed January 1, 2020 (change of ownership)to GHENT REHABILITATION AND NURSING CENTER from HUDSON VALLEY CARE CENTERS INC
Position within NY
14 citations — more than 52% of the 593 certified nursing homes in NY. Compared within NY 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
The latest survey found 3 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2025 to October 2025), and past the point by which nine in ten NY facilities have been surveyed. This facility’s last Life Safety survey was September 2023. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 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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1 inspection-and-testing tag has 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 14 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)
3 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 14 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-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 22, 2019 | 6 |
| June 9, 2021 | 5 |
| September 1, 2023 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2023-09-01 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2021-06-09 |
| E-0024 | Establish policies and procedures for volunteers. | 1 | 2019-05-22 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2021-06-09 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2019-05-22 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-09-01 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2023-09-01 |
| E-0035 | Provide family notifications of emergency plan. | 1 | 2019-05-22 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Smoke Deficiencies 4
- Emergency Preparedness Deficiencies 3
- Miscellaneous Deficiencies 2
- Other 1
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 1, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (September 10, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 16, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (September 10, 2023) |
June 9, 2021 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 5, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (August 5, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 5, 2021) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (August 5, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 5, 2021) |
May 22, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (June 28, 2019) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (July 28, 2019) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (June 21, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 28, 2019) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (June 21, 2019) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (June 21, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.