Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BAPTIST HEALTH NURSING AND REHABILITATION CENTER
SCOTIA, NY · 262 certified beds · Last Life Safety survey October 24, 2023
CMS Certification Number 335612 · first certified November 1977
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
15 citations — more than 56% 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 5 citations; the earlier surveys in the window averaged 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 (April 2025 to December 2025), and past the point by which nine in ten NY facilities have been surveyed. This facility’s last Life Safety survey was October 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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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 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
1 of the 15 citations on file is 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)
6 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 15 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.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 | 15 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 18, 2019 | 7 |
| August 10, 2021 | 3 |
| October 24, 2023 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-10-24 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2021-08-10 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2021-08-10 |
| K-0907 | Ensure medical gas and vacuum systems have documented maintenance programs. | 1 | 2023-10-24 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2019-06-18 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2019-06-18 |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | 1 | 2023-10-24 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2023-10-24 |
What the citations cover
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 2
- Emergency Preparedness Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 24, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (November 20, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 22, 2023) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0907 | Ensure medical gas and vacuum systems have documented maintenance programs. | Deficient, Provider has date of correction (November 28, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 7, 2023) |
August 10, 2021 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 13, 2021) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (September 3, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 17, 2021) |
June 18, 2019 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (August 17, 2019) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 17, 2019) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 17, 2019) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 17, 2019) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (August 17, 2019) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (August 17, 2019) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 17, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.