Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Sprain Brook Manor Rehab
Scarsdale, NY · 121 certified beds · Last Life Safety survey May 14, 2024
CMS Certification Number 335320 · first certified November 1973
Ownership
Independently operated (no chain recorded by CMS) · For profit - Partnership
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NY
23 citations — more than 79% of the 592 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 8 citations; the earlier surveys on file averaged 7.5. 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 (November 2025 to June 2026), and past the point by which nine in ten NY facilities have been surveyed. This facility’s last Life Safety survey was May 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 21), measured over 520 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 about three years in Virginia. How the window is measured
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2 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 cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 23 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)
1 physical-environment citation 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 23 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.
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 | 23 |
| Median facility in NY | 14 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 19, 2019 | 7 |
| June 2, 2021 | 8 |
| May 14, 2024 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2024-05-14 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 3 | 2024-05-14 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2024-05-14 |
| E-0033 | Establish methods for sharing information. | 1 | 2021-06-02 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2021-06-02 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2021-06-02 |
| K-0331 | Construct fire resistant interior walls. | 1 | 2024-05-14 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2024-05-14 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Miscellaneous Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 14, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (June 28, 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 (June 28, 2024) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 28, 2024) |
June 2, 2021 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0033 | Establish methods for sharing information. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 29, 2021) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (July 29, 2021) |
February 19, 2019 — 7 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 (April 16, 2019) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (April 16, 2019) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (April 16, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 16, 2019) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (April 16, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 16, 2019) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (April 16, 2019) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.