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

NORTHEAST CTR FOR REHABILITATION AND BRAIN INJURY

LAKE KATRINE, NY · 280 certified beds · Last Life Safety survey November 21, 2024

CMS Certification Number 335845 · first certified July 2004

Ownership

Operated by UPSTATE SERVICES GROUP · For profit - Limited Liability company

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

22
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
3
Tags cited more than once
Across separate surveys
7
Inspection & testing records
Of the citations on file

Position within NY

22 citations — more than 78% 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

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

The latest survey found 12 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window is open now: May 2026 to January 2027. This facility’s last Life Safety survey was November 2024. 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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Which alerts

Emergency preparedness

1 of the 22 citations on file is 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)

7 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 22 Life Safety citations above. The Physical Environment Index

  • 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.
  • 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-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

How that compares

Citations on file over three years

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

This facility22NY median13National median11
Citations on file over three years, compared
MeasureCitations
This facility22
Median facility in NY13
Median facility nationally11

Survey history

Citations at each Life Safety survey
62019-0242022-05122024-11
Citations at each Life Safety survey
Survey dateCitations
February 7, 20196
May 25, 20224
November 21, 202412

Most-cited tags

Most-cited tags at this facility
K-09203K-09012K-02252K-02111K-09211K-02811K-07121K-03631
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0920Ensure proper usage of power strips and extension cords.32024-11-21
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.22024-11-21
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.22024-11-21
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.12019-02-07
K-0921Ensure that testing and maintenance of electrical equipment is performed.12019-02-07
K-0281Install proper backup exit lighting.12022-05-25
K-0712Have simulated fire drills held at unexpected times.12024-11-21
K-0363Install corridor and hallway doors that block smoke.12019-02-07

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 6
  • Gas, Vacuum, and Electrical Systems Deficiencies 6
  • Egress Deficiencies 4
  • Electrical Deficiencies 2
  • Other 4
Citations by CMS category
CategoryCitations
Smoke Deficiencies6
Gas, Vacuum, and Electrical Systems Deficiencies6
Egress Deficiencies4
Electrical Deficiencies2
Services Deficiencies2
Miscellaneous Deficiencies1
Emergency Preparedness Deficiencies1

Every citation on file

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

November 21, 2024 — 12 citations

Citations issued on November 21, 2024
TagWhat the surveyor checksStatus
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (January 23, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (January 23, 2025)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (January 8, 2025)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has no plan of correction
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (January 23, 2025)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (January 23, 2025)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has no plan of correction
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (December 27, 2024)
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Deficient, Provider has date of correction (January 23, 2025)
K-0915Have proper power supply for life support equipment.Deficient, Provider has date of correction (January 23, 2025)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (January 23, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (January 23, 2025)

May 25, 2022 — 4 citations

Citations issued on May 25, 2022
TagWhat the surveyor checksStatus
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (July 1, 2022)
K-0281Install proper backup exit lighting.Deficient, Provider has date of correction (July 1, 2022)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (July 1, 2022)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (July 1, 2022)

February 7, 2019 — 6 citations

Citations issued on February 7, 2019
TagWhat the surveyor checksStatus
E-0009Include a process for Emergency Preparedness collaboration.Deficient, Provider has date of correction (March 22, 2019)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (March 22, 2019)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (March 22, 2019)
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Deficient, Provider has date of correction (March 22, 2019)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (March 22, 2019)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (March 22, 2019)

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