Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
NYACK RIDGE REHABILITATION AND NURSING CENTER
VALLEY COTTAGE, NY · 160 certified beds · Last Life Safety survey January 14, 2025
CMS Certification Number 335365 · first certified November 1972
Ownership
Independently operated (no chain recorded by CMS) · For profit - Partnership
- Ownership changed January 1, 2018 (change of ownership)from NYACK MANOR NURSING HOME
Position within NY
21 citations — more than 75% 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 12 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: July 2026 to March 2027. This facility’s last Life Safety survey was January 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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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 21 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)
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 21 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-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-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 | 21 |
| Median facility in NY | 13 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 19, 2020 | 3 |
| September 25, 2023 | 6 |
| January 14, 2025 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 2 | 2025-01-14 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-01-14 |
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2025-01-14 |
| 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 | 2025-01-14 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2025-01-14 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2025-01-14 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 1 | 2025-01-14 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2023-09-25 |
What the citations cover
- Smoke Deficiencies 7
- Egress Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 3
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Egress Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 14, 2025 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (March 12, 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 (March 12, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 31, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 12, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (March 12, 2025) |
September 25, 2023 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 1, 2023) |
| K-0227 | Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements. | Deficient, Provider has date of correction (November 1, 2023) |
| 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 (November 1, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 1, 2023) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (November 1, 2023) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (November 1, 2023) |
February 19, 2020 — 3 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 15, 2020) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (April 15, 2020) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 15, 2020) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.