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

The Enclave At Rye Rehab And Nursing Ctr

Port Chester, NY · 160 certified beds · Last Life Safety survey January 29, 2020

CMS Certification Number 335312 · first certified November 1979

Ownership

Operated by CARERITE CENTERS · For profit - Limited Liability company

Ownership changed July 1, 2016 (change of ownership)to THE ENCLAVE AT PORT CHESTER REHABILITATION AND NURSING CENTER from RWB CORPORATION

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NY

16 citations — more than 61% 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

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

The latest survey found 2 citations; the earlier surveys in the window averaged 7. 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 (July 2021 to March 2022), and past the point by which nine in ten NY facilities have been surveyed. This facility’s last Life Safety survey was January 2020. 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

6 of the 16 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)

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 16 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-0880 Provide and implement an infection prevention and control program.

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.

Citations on file over three years, compared
Measure	Citations
This facility	16
Median facility in NY	13
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
January 9, 2017	3
May 31, 2018	11
January 29, 2020	2

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2020-01-29
E-0039	Conduct testing and exercise requirements.	1	2018-05-31
E-0041	Implement emergency and standby power systems.	1	2018-05-31
E-0018	Establish procedures for tracking staff and patients during an emergency.	1	2018-05-31
K-0200	Meet other general requirements.	1	2020-01-29
K-0920	Ensure proper usage of power strips and extension cords.	1	2018-05-31
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	1	2018-05-31
E-0015	Address subsistence needs for staff and patients.	1	2018-05-31

What the citations cover

Citations by CMS category

Emergency Preparedness Deficiencies 6
Smoke Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 3
Egress Deficiencies 1
Other 1

Citations by CMS category
Category	Citations
Emergency Preparedness Deficiencies	6
Smoke Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	3
Egress Deficiencies	1
Services Deficiencies	1

Every citation on file

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

January 29, 2020 — 2 citations

Citations issued on January 29, 2020
Tag	What the surveyor checks	Status
K-0200	Meet other general requirements.	Deficient, Provider has date of correction (March 26, 2020)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (March 26, 2020)

May 31, 2018 — 11 citations

Citations issued on May 31, 2018
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (August 2, 2018)
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (August 2, 2018)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (August 2, 2018)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (August 2, 2018)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (August 2, 2018)
E-0041	Implement emergency and standby power systems.	Deficient, Provider has date of correction (August 2, 2018)
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 (August 2, 2018)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 2, 2018)
K-0541	Install properly constructed and protected linen or trash chutes.	Deficient, Provider has date of correction (August 2, 2018)
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	Deficient, Provider has date of correction (August 2, 2018)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (August 2, 2018)

January 9, 2017 — 3 citations

Citations issued on January 9, 2017
Tag	What the surveyor checks	Status
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 17, 2017)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (February 17, 2017)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (February 17, 2017)

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