Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Father Baker Manor
Orchard Park, NY · 160 certified beds · Last Life Safety survey November 6, 2024
CMS Certification Number 335777 · first certified June 1994
Ownership
Independently operated (no chain recorded by CMS) · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
13 citations — more than 46% 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 6 citations; the earlier surveys in the window averaged 3.5. 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 December 2026. 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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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.
Physical environment (health survey)
2 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 13 Life Safety citations above. The Physical Environment Index
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 | 13 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 4, 2020 | 0 |
| November 15, 2022 | 7 |
| November 6, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-11-06 |
| 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 | 2024-11-06 |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | 1 | 2022-11-15 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-11-06 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2022-11-15 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2022-11-15 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-11-06 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2022-11-15 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 6, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 31, 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 (December 31, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (December 31, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 31, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 31, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (December 31, 2024) |
November 15, 2022 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (January 13, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 13, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (January 13, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 13, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (January 13, 2023) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (January 13, 2023) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (January 13, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.