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

UPSTATE UNIVERSITY HOSP AT COMMUNITY GENERAL T C U

SYRACUSE, NY · 20 certified beds · Last Life Safety survey July 25, 2025

CMS Certification Number 335870 · first certified July 2014

Ownership

Independently operated (no chain recorded by CMS) · Government - State

No change of ownership on CMS record since January 1, 2016, when the records begin.

13
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
2
Tags cited more than once
Across separate surveys
3
Inspection & testing records
Of the citations on file

Position within NY

13 citations — more than 46% 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

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

The latest survey found 6 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was July 2025. 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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Which alerts

Emergency preparedness

1 of the 13 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)

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 13 Life Safety citations above. The Physical Environment Index

  • 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.

This facility13NY median13National median11
Citations on file over three years, compared
MeasureCitations
This facility13
Median facility in NY13
Median facility nationally11

Survey history

Citations at each Life Safety survey
32021-1242024-0362025-07
Citations at each Life Safety survey
Survey dateCitations
December 29, 20213
March 13, 20244
July 25, 20256

Most-cited tags

Most-cited tags at this facility
K-09012K-05312K-03511K-09211K-05111K-03241E-00371K-09161
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.22025-07-25
K-0531Have elevators that firefighters can control in the event of a fire.22025-07-25
K-0351Install an approved automatic sprinkler system.12024-03-13
K-0921Ensure that testing and maintenance of electrical equipment is performed.12025-07-25
K-0511Have properly installed electrical wiring and gas equipment.12025-07-25
K-0324Provide properly protected cooking facilities.12024-03-13
E-0037Establish staff and initial training requirements.12024-03-13
K-0916Have a battery powered remote alarm panel in a location accessible by operating personnel.12021-12-29

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 3
  • Services Deficiencies 3
  • Construction Deficiencies 2
  • Gas, Vacuum, and Electrical Systems Deficiencies 2
  • Other 3
Citations by CMS category
CategoryCitations
Smoke Deficiencies3
Services Deficiencies3
Construction Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies2
Electrical Deficiencies2
Emergency Preparedness Deficiencies1

Every citation on file

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

July 25, 2025 — 6 citations

Citations issued on July 25, 2025
TagWhat the surveyor checksStatus
K-0131Meet requirements for sections of health care facilities separated by fire resistive construction.Deficient, Provider has date of correction (October 3, 2025)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (October 3, 2025)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (October 3, 2025)
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (October 3, 2025)
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Deficient, Provider has date of correction (October 3, 2025)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (December 19, 2025)

March 13, 2024 — 4 citations

Citations issued on March 13, 2024
TagWhat the surveyor checksStatus
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (May 15, 2024)
K-0133Install a two-hour-resistant firewall separation.Deficient, Provider has date of correction (May 2, 2024)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (May 2, 2024)
K-0351Install an approved automatic sprinkler system.Deficient, Provider has date of correction (May 12, 2024)

December 29, 2021 — 3 citations

Citations issued on December 29, 2021
TagWhat the surveyor checksStatus
K-0531Have elevators that firefighters can control in the event of a fire.Deficient, Provider has date of correction (January 24, 2022)
K-0901Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.Deficient, Provider has date of correction (February 14, 2022)
K-0916Have a battery powered remote alarm panel in a location accessible by operating personnel.Deficient, Provider has date of correction (January 24, 2022)

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