Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Sullivan County Adult Care Center
Liberty, NY · 146 certified beds · Last Life Safety survey September 27, 2024
CMS Certification Number 335628 · first certified April 1978
Ownership
Independently operated (no chain recorded by CMS) · Government - County
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
32 citations — more than 94% 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 12 citations; the earlier surveys in the window averaged 10. 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: March 2026 to November 2026. This facility’s last Life Safety survey was September 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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4 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
7 of the 32 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)
5 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 32 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.
- F-0880 Provide and implement an infection prevention and control program.
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 | 32 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 4, 2019 | 13 |
| January 5, 2023 | 7 |
| September 27, 2024 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-09-27 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-09-27 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2023-01-05 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2024-09-27 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-01-05 |
| K-0281 | Install proper backup exit lighting. | 2 | 2024-09-27 |
| E-0013 | Develop Emergency Preparedness policies and procedures. | 2 | 2023-01-05 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-09-27 |
What the citations cover
- Smoke Deficiencies 9
- Emergency Preparedness Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Services Deficiencies 3
- Other 8
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Emergency Preparedness Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 3 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Electrical Deficiencies | 1 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 27, 2024 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (October 13, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 1, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 26, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 9, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 4, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 9, 2024) |
January 5, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (March 5, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 5, 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 (March 5, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 5, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 5, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 5, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 5, 2023) |
September 4, 2019 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (October 24, 2019) |
| E-0034 | Provide a means of sharing information on occupancy/needs. | Deficient, Provider has date of correction (October 24, 2019) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (October 24, 2019) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (October 24, 2019) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (October 24, 2019) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (October 24, 2019) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (October 24, 2019) |
| 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 (October 24, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 24, 2019) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (October 24, 2019) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 24, 2019) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (October 24, 2019) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (October 24, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.