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

Tolstoy Foundation Rehabilitation And Nrsg Center

Valley Cottage, NY · 96 certified beds · Last Life Safety survey September 2, 2025

CMS Certification Number 335311 · first certified October 1970

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.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NY

43 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

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

The latest survey found 13 citations; the earlier surveys in the window averaged 15. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens February 2027 — about 5 months from now. This facility’s last Life Safety survey was September 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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6 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

9 of the 43 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)

5 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 43 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.

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.

Citations on file over three years, compared
Measure	Citations
This facility	43
Median facility in NY	13
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
June 15, 2021	17
June 4, 2024	13
September 2, 2025	13

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	3	2025-09-02
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	3	2025-09-02
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2025-09-02
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	2	2025-09-02
K-0363	Install corridor and hallway doors that block smoke.	2	2024-06-04
K-0271	Have exits that are accessible at all times.	2	2025-09-02
E-0007	Address patient/client population and determine types of services needed.	2	2024-06-04
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	2	2024-06-04

What the citations cover

Citations by CMS category

Smoke Deficiencies 13
Gas, Vacuum, and Electrical Systems Deficiencies 11
Emergency Preparedness Deficiencies 9
Egress Deficiencies 5
Other 5

Citations by CMS category
Category	Citations
Smoke Deficiencies	13
Gas, Vacuum, and Electrical Systems Deficiencies	11
Emergency Preparedness Deficiencies	9
Egress Deficiencies	5
Miscellaneous Deficiencies	2
Services Deficiencies	2
Electrical Deficiencies	1

Every citation on file

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

September 2, 2025 — 13 citations

Citations issued on September 2, 2025
Tag	What the surveyor checks	Status
E-0024	Establish policies and procedures for volunteers.	Deficient, Provider has date of correction (October 24, 2025)
E-0033	Establish methods for sharing information.	Deficient, Provider has date of correction (October 24, 2025)
K-0271	Have exits that are accessible at all times.	Deficient, Provider has date of correction (October 24, 2025)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (October 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 (October 24, 2025)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (October 24, 2025)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 7, 2025)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (December 18, 2025)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (November 21, 2025)
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 (October 24, 2025)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (December 22, 2025)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (October 24, 2025)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (October 24, 2025)

June 4, 2024 — 13 citations

Citations issued on June 4, 2024
Tag	What the surveyor checks	Status
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (July 8, 2024)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (July 8, 2024)
K-0252	Provide at least two remote exits on each floor or fire section of the building.	Deficient, Provider has date of correction (July 8, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (July 8, 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 (July 8, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 8, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (June 18, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (July 8, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (July 8, 2024)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (July 8, 2024)
K-0901	Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.	Deficient, Provider has date of correction (July 8, 2024)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (July 8, 2024)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (July 8, 2024)

June 15, 2021 — 17 citations

Citations issued on June 15, 2021
Tag	What the surveyor checks	Status
E-0006	Conduct risk assessment and an All-Hazards approach.	Deficient, Provider has date of correction (August 10, 2021)
E-0007	Address patient/client population and determine types of services needed.	Deficient, Provider has date of correction (August 10, 2021)
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (August 10, 2021)
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (August 10, 2021)
E-0035	Provide family notifications of emergency plan.	Deficient, Provider has date of correction (August 10, 2021)
K-0271	Have exits that are accessible at all times.	Waiver has been granted (September 10, 2021)
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 (August 10, 2021)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (August 10, 2021)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (August 10, 2021)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 10, 2021)
K-0371	Have properly sized and located compartments to protect residents from smoke.	Deficient, Provider has date of correction (September 14, 2021)
K-0531	Have elevators that firefighters can control in the event of a fire.	Deficient, Provider has date of correction (August 10, 2021)
K-0911	Meet requirements for the installation and maintenance of electrical systems.	Deficient, Provider has date of correction (August 10, 2021)
K-0917	Ensure electrical receptacles or cover plates have distinctive color or marking.	Deficient, Provider has date of correction (August 10, 2021)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (August 10, 2021)
K-0921	Ensure that testing and maintenance of electrical equipment is performed.	Deficient, Provider has date of correction (August 10, 2021)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (August 10, 2021)

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