Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
The Grand Rehabilitation and Nursing At Pawling
PAWLING, NY · 122 certified beds · Last Life Safety survey April 13, 2023
CMS Certification Number 335458 · first certified October 1976
Ownership
Operated by THE GRAND HEALTHCARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
28 citations — more than 90% 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 8. 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 (October 2024 to May 2025), and past the point by which nine in ten NY facilities have been surveyed. This facility’s last Life Safety survey was April 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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3 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
10 of the 28 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 28 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.
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 | 28 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 16, 2018 | 10 |
| October 15, 2019 | 6 |
| April 13, 2023 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-04-13 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2023-04-13 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-04-13 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2018-01-16 |
| K-0161 | Use approved construction type or materials. | 1 | 2023-04-13 |
| E-0039 | Conduct testing and exercise requirements. | 1 | 2018-01-16 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2018-01-16 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2023-04-13 |
What the citations cover
- Emergency Preparedness Deficiencies 10
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 2
- Other 4
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 10 |
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 2 |
| Electrical Deficiencies | 1 |
| Egress Deficiencies | 1 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
April 13, 2023 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0022 | Establish policies and procedures for sheltering. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (June 2, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (May 30, 2023) |
| K-0161 | Use approved construction type or materials. | Waiver has been granted (July 21, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 9, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 9, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 1, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 9, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (May 17, 2023) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (May 21, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 21, 2023) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 18, 2023) |
October 15, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (December 26, 2019) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 26, 2019) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 26, 2019) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (December 26, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 26, 2019) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (December 26, 2019) |
January 16, 2018 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (March 29, 2018) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 29, 2018) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (March 29, 2018) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (March 29, 2018) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (March 29, 2018) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 29, 2018) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 29, 2018) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (April 13, 2018) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 29, 2018) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (March 29, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.