Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BISHOP REHABILITATION AND NURSING CENTER
SYRACUSE, NY · 440 certified beds · Last Life Safety survey May 5, 2026
CMS Certification Number 335338 · first certified November 1971
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
- Ownership changed December 15, 2017 (change of ownership)to CLINTON SQUARE NURSING AND REHABILITATION from RIVER MEADOWS, LLC
Position within NY
42 citations — more than 98% 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 20 citations; the earlier surveys in the window averaged 7.3. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2027 — about 13 months from now. This facility’s last Life Safety survey was May 2026. 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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5 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
2 of the 42 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)
8 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 42 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-0880 Provide and implement an infection prevention and control program.
- F-0908 Keep all essential equipment working safely.
- 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 | 42 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 13, 2023 | 1 |
| December 20, 2024 | 11 |
| May 16, 2025 | 10 |
| May 5, 2026 | 20 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2026-05-05 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 3 | 2026-05-05 |
| K-0161 | Use approved construction type or materials. | 3 | 2026-05-05 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 2 | 2026-05-05 |
| 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 | 2026-05-05 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2026-05-05 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2026-05-05 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2026-05-05 |
What the citations cover
- Smoke Deficiencies 18
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Construction Deficiencies 5
- Services Deficiencies 5
- Other 9
| Category | Citations |
|---|---|
| Smoke Deficiencies | 18 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Construction Deficiencies | 5 |
| Services Deficiencies | 5 |
| Egress Deficiencies | 4 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 5, 2026 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (July 13, 2026) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 13, 2026) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (July 1, 2026) |
| 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 (July 13, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 13, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 13, 2026) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 12, 2026) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (July 1, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (July 13, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (July 1, 2026) |
May 16, 2025 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0133 | Install a two-hour-resistant firewall separation. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (June 24, 2025) |
| 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 24, 2025) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0364 | Install properly constructed windows in hallway walls or doors. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 24, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Deficient, Provider has date of correction (June 24, 2025) |
December 20, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0161 | Use approved construction type or materials. | Fire Safety Evaluation Survey (February 13, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 5, 2025) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (February 13, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (February 13, 2025) |
October 13, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 22, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.